Intraoperative Care
Our intraoperative procedures have been adjusted to adapt to the
COVID-19 pandemic. Changes have been made with the primary goals to
decrease exposure risk for the operating room team and to conserve PPE.
Given the potentially high viral titers on aerodigestive tract mucosal
surfaces, all head and neck free flap cases involving mucosal surfaces
are performed with N95 masks for all operating room staff. We have
reduced the size of the operative team to conserve PPE. These major
cases are performed with 4 surgeons (2 attending surgeons, 2
assistants). Thus, the reconstructive component of the procedure is
performed entirely by the attending and fellow/senior resident. Also,
attending surgeons have agreed upon having no overlapping or concurrent
surgical procedures to ensure operative efficiency.
We have worked to optimize case flow to decrease the total amount of PPE
used during a case. All flap harvest is done concurrently with flap
ablation in a two team approach so that there is no delay in flap
transfer to the defect site after the ablation is completed.
Preoperative communication with the oncologic team regarding the
anticipated defect has allowed us to commit early to our defect for
planning purposes.
The surgical team has decreased the amount of times scrubbing in and out
during a case to conserve PPE, with the goal of remaining scrubbed in
until their portion of the case is completed. Importantly, this also
decreases the amount of times that team members are donning and doffing
PPE, with PPE removal specifically being high risk for
self-contamination3.
Strategies used during tracheostomy to decrease aerosolization are
similar to those published after the SARS outbreak and include using
full muscle relaxant to prevent coughing, holding ventilation prior to
airway entry, and only resuming ventilation once the tracheostomy tube
has been placed with cuff inflated8. The number of
individuals present during the performance of the tracheostomy is
limited to the two otolaryngology surgeons. We are also trying to
utilize tracheostomy judiciously and avoid it in cases in which the
indication is marginal. A recently published airway scoring system
provides a useful framework for determining need for tracheostomy in
these complex cases9.
Our team has noticed subjectively some challenges with prolonged use of
the N95 respirators. There is some evidence that prolonged use alters
pulmonary gas exchange and promotes hypercarbia10.
This can present as a headache or lightheadedness. De novo headache
symptoms have been found to be present in 81% of N95 users in one
recent study11. Several of our providers have noted
these symptoms during the course of these cases. This obviously has the
potential to impact surgical efficiency, performance, and alter decision
making capacity. We recommend strategic team breaks during these
prolonged cases for recovery.
Intraoperatively all free flaps have both an arterial and venous
implantable Doppler sonography probe placed for monitoring due to
changes in our postoperative monitoring plan detailed below.