Postoperative Care

The head and neck surgery team has been restructured to decrease the risk of exposure to the entire team from a single patient or a single team member with COVID-19. After anecdotes of department wide quarantines due to possible COVID-19 exposure, we subdivided our head and neck service into two independent teams. This was initiated at a time when our institutional policy for suspected or confirmed COVID-19 exposure was self-quarantine.
The goal was that if one team had to quarantine the other would be able to continue providing patient care. Each team has at least one ablative and one reconstructive attending, one head and neck fellow, one senior resident, and one intern. We have minimized interactions between teams including separate rounding times and elimination of shared workspaces. As mentioned previously, conferences are now virtual which also eliminates physical interaction between teams. The frequency of team rounding has moved from twice daily to once a day.
One of the biggest changes made in response to COVID-19 from a free flap perspective is the postoperative flap monitoring protocol for intraoral flaps by decreasing the frequency of flap checks. The goals were to limit the use of PPE needed for flap checks and to limit surgical team and nursing staff exposure risk. Our previous flap monitoring protocol had been nursing flap checks every 1 hour for 24 hours (postoperative day (POD) 1), every 2 hours for 48 hours (POD 2-3), every 4 hours for 72 hours (POD 4-6), then every 8 hours until discharge. Resident flap checks were performed 6 hours immediately postoperatively, then every 12 hours for the first 72 hours, then once daily. Flap checks previously included both implantable or external handheld Doppler sonography checks as applicable and clinical examination of the skin paddle.
In our new flap monitoring protocol, nursing checks are performed at the prior timing interval but only include checking the arterial and venous implantable Doppler signals and an external skin paddle if applicable. Importantly, the intraoral skin paddle is only checked every 6 hours or if there is a change in Doppler signal, and requires use of proper PPE for the exam. Resident intraoral skin paddle assessment is now performed once at 6 hours postoperatively and then once daily on morning rounds.
These changes decrease the frequency of skin paddle examinations and force a greater reliance on implantable Doppler sonography. Given this increased reliance, we are now implanting both and arterial and venous probe on all cases as mentioned above. Prior to this change, our division protocol called for continuous implantable venous monitoring for all flaps and clinical assessment of arterial perfusion in flaps with a skin paddle amenable to exam.
Ultimately, our new protocol reduces the dependence on the postoperative physical exam. Given that use of implantable doppler technology as an indicator of flap perfusion is imperfect, it is reasonable to assume that such a change in exam frequency could potentially lead to a slightly higher flap failure rate during this time. As a division, this is a risk we have accepted with the hope of reducing potential viral exposures to our team. The effect of resident postoperative flap monitoring frequency on flap survival rates, however, is unclear and controversial. One recent multi-institutional study showed no difference in flap survival rates with reduced resident monitoring frequency12.