Admission

• Ensure a tracheostomy box with spare inner tube accompanies the patient
• Manage the patient in a warm environment (patient should be in a side room where possible) aiming for a normal body temperature and keep the flap warm
• Routine clerk-in of patient
• Complete generic ICU admission checklist
• Send ICU admission bloods and check baseline ABG from arterial line
• Prescribe post-over drugs (outlined later in guidelines) in addition to patient's usual medication (where appropriate)
• Fluid management: Prescribe maintenance fluids (and any boluses as clinically indicated), taking care to avoid excess fluid [which can compromise flap] 
• Maintain Hb >8g/dl in most patients (some may have higher transfusion triggers e.g if evidence of ongoing myocardial ischaemia): administer one unit red cells at a time before rechecking Hb to avoid over-transfusion
• Target Mean Arterial Blood Pressure 65-80mmHg unless otherwise specific (it is safer to use vasopressor infusions rather than boluses as high dose vasopressors will decrease blood flow to flap; if hypotensive, consider underlying causes, in particular blood loss)
• Commence PCA with continuous background infusion on admission to critical care if not already started in Recovery. 
• If NG inserted in theatre, confirm this is a safe to use as per 'Checking the Position of Naso-gastric Tubes' guideline on Critical Care section of intranet. 

Post operative Care

• Routine daily bloods
• CXR only if clinically indicated (infection and atelectasis common)
• Daily physiotherapy
• Flap care- see below
• Wound care- see below
• Tracheostomy- see below
• PEG Care- see below
• Commence PEG or NG feeding 24 hours post-op using PEG/NG protocol unless indicated otherwise by surgical team
• Ensure strict mouth care as patient will be more prone to a dry mouth and oral thrush 
• Optimise patient comfort- consider aids such as v pillows for neck support
• Promote patient communication using aids such as note pads, white boards and mobile phone texting

Flap Care

Close monitoring of the flap for the first signs of compromise is imperative

• Successful free flap salvage is most likely within the first 72 hours
• Flap observation should be performed HOURLY for the first 48 hours and then every 4 hours for the next 7 days
• Flap observation should be carried out gently with the aid of good light and suction to ensure the flap is clean and all of the flap is visualised, looking for:

1. Changes in colour of the flap

2. Abnormal capillary refill time

3. Changes in volume of the flap

• Clinical assessment is the gold standard for flap observation. The implantable Doppler is usually placed on the artery; occasionally there may be an additional venous Doppler also; Doppler is only an adjunct to clinical assessment.
• Colour: The colour of the free flap should match the skin contralateral to the donor site. Remember this may be very pale. 

• Venous engorgement is suspected when a flap changes from pale pink to blue-purple. Colour change is not always uniform throughout the flap: some parts can appear normal while one area may seem discoloured. 
• Although venous compromise of a free flap may manifest suddenly as an abrupt colour change, it is usually an insidious process lasting for 1-2 hours, causing clinical uncertainty and frustration. It can be difficult to observe flap colour if there is any bruising, which may occur when the flap is raised, inset or subject to hourly scraping with a tonne depressor. It is generally possible to distinguish venous engorgement from bruising as bruised tissue does not blanche when pressed.

• Capillary Refill time: Check capillary refill of the flap

• In a well-perfused flap, capillary refill should take 1-3 seconds. Inadequate arterial flow results in prolonged capillary refill time, usually >5 seconds. Venous outflow obstruction results in brisk capillary refill, usually <1 second. A very engorged flap may not visibly blanche due to instantaneous refill.

Any changes in colour, capillary refill or volume of the flap should be recorded and the OMFS second on-call (OMFS on-call registrar via switchboard) informed immediately.

Tracheostomy Care

• Nurse in semi-recumbent position- avoid excessive neck extension to minimise tension on wound
• Clean skin and rim of tracheostomy with sterile swabs dampened with sterile saline
• Remove any debris/crusts gently using forceps
• Ensure humidified oxygen to soften crusting/plugs and promote expulsion of these
• Encourage the patient to gently cough regularly
• Suction may be used but care must be taken not to push any debris into the lungs and care also not to damage the tracheal wall
• Cavilon cream (not spray`0 may be applied to protect the surrounding skin
• Tracheostomy box must be at patient's bedside at all times, including during transfer

Wound Care

• Observe neck wound for any swelling or evidence of haematoma
• Daily drainage should be recorded accurately
• Neck drains remain in situ for a minimum of 72 hours; drains are only removed following instruction from the OMFS tea
• Any sudden increase in drainage or large volume drainage should be reported to the OMFS second on-call immediately

PEG Care

Please follow the guidelines as laid out in the NHS Lothian protocol for the Care of Percuraneous Endoscopic Gastrostomy (PEG) Tube

Drugs

• If PEG tube in place- prescribe 20mls of water as flush, twice daily
• IV Pantoprazole 40mg OD if patient on PPI pre-operatively; if not on PPE pre-operatively, IV ranitidine 50mg TDS (BD if renal failure); this should be converted to Lansoprazole or Ranitidine down NG/PEG tube once in use
• Dalteparin 5000 units SC 4 hours after leaving theatre for most patients as long as no evidence of significant bleeding (these patients are at high risk of VTE due to cancer and long surgery); following by regular once-daily dosing usually at 10pm; some patients may have alternative VTE prophylaxis plans but these will be handed over post-operatively after discussion with the OMFS team (for example it may be decided that the dose is altered in patients with a very low or very high BMI. 
• Patients should have Flowtrons on both legs (as long as no contraindication such as significant peripheral vascular disease or recent/current DVT)
• If there is an epidural for a fibula flap it will be managed by Medical staff
• Local anaesthetic infusions are occassionally used for donor site wound infiltration & will be managed by the Medical staff. The Haggis usually infuses 0.5% L-Bupivicaine at 5mls/hr and stays in for 48-72 hours. Any queries should be referred to the pain team or on-call anaesthetist out of hours.
• IV Dexamethasone 6.6mh- usually 3 doses (includes the dose(s) given in theatre
• Antibiotics- Patients receive intravenous antibiotics for a minimum of 72 hours post-surgery while the neck drains remain. Thereafter, antibiotics will be at the request of the OMFS consultant or as per clinical requirement. Details are available on the Antimicrobial section of the intranet. 

Discharge

• Transfer to Level 1 (Ward 19A) or Ward 18 at St John's hospital when patient stable
• Remove invasive monitoring lines before transfer
• Ensure tracheostomy box remains with patient
• Collate results in notes
• Complete discharge letter on TRAK
• Compete Ward watcher (including APACHE from first 24hours) prior to transfer. 

Contact Numbers