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KEY POINTS

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KEY POINTS

  1. The success of a free-flap transfer is inversely proportional to flap ischemic time and the time to recognition of complications.

  2. Dextran infusion syndrome should be suspected in patients on low-molecular-weight dextran that develop noncardiogenic pulmonary edema.

  3. The classic triad of fat embolism syndrome is hypoxemia, neurological abnormalities, and petechiae.

  4. Bone cement implantation syndrome is a life-threatening complication of orthopedic surgery characterized by hypoxia, hypotension, pulmonary hypertension, arrhythmias, loss of consciousness, and potentially cardiac arrest.

  5. Cystectomy is an independent risk factor for venous thromboembolism.

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INTRODUCTION

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This chapter discusses specific postoperative complications and management in the intensive care unit (ICU) after ENT, orthopedic, and urology surgery. Radical head and neck surgery with free-flap reconstruction, total hip replacement (THR) and total knee replacement (TKR), radical nephrectomy, and radical cystectomy are discussed.

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ENT SURGERY

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Radical Head and Neck Surgery with Free-Flap Reconstruction

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An estimated 55,000 Americans develop head and neck cancer mainly of the pharynx, larynx, and tongue annually and 12,000 die from the disease.1 Radical head and neck dissection with free-flap reconstruction has evolved over the past 4 decades with free-flap success rates in the 90% to 99% range.

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Otolaryngology patients with tumors of the head and neck undergo radical dissection and free-flap microsurgery. These patients are admitted postoperatively to the ICU for neurologic, free flap, and airway monitoring. Complications include flap failure, infections, postoperative bleeding, acute lung injury (noncardiogenic pulmonary edema), and venous thromboembolism (VTE). In addition to comorbid conditions such as chronic obstructive pulmonary disease (COPD) and diabetes, these patients often have a history of alcohol dependence and smoking, hence close monitoring for encephalopathy and alcohol withdrawal syndrome is warranted.

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Surgical Factors

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Radical head and neck dissection involves en bloc removal of all nodal groups between the mandible and the clavicle with removal of the sternocleidomastoid muscle, internal jugular vein, and spinal accessory nerve.

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The free-flap transfer, also called a free tissue transfer, is an autologous transplantation of vascularized tissues that incorporate a direct cutaneous artery and vein in the base. The free flap may contain skin, muscle, bone, or fascia. Free flaps have a higher complication rate than skin grafts. Indications for free flaps include complex defects of the head and neck regions following tumor resection or chemoradiation, reconstruction in patients failing local or regional flaps, or failure of a prior free flap. Common sites of harvest include the anterolateral thigh, fibula, and iliac crest. Fascio-cutaneous flaps are used to repair superficial lesions; and muscle and myocutaneous flaps are used to repair deeper lesions. To reconstruct mandible and floor of the mouth defects, fibular free flaps with overlying skin, or iliac crest bone flaps are usually used.

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Patient Risk Factors
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Diabetics are at increased risk of flap failure secondary to ...

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