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.