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Perioperative Management of Pediatric Digital Replantations and Revascularizations: A Best Practice Survey of Hand Surgeons
Elizabeth A Graesser, MD
1, Lindley B Wall, MD
2, Gretchen Maughan-Egbert, MSPH
1, Angela A Wang, MD
1; Brittany N Garcia, MD
1(1)University of Utah Hospital, Salt Lake City, UT, (2)Washington University School of Medicine, St. Louis, MO
IntroductionThere is a paucity of literature and no consensus for the ideal intraoperative and postoperative management of pediatric digital replantation and revascularization surgery. The purpose of this study was to describe the current practices of hand surgeons in North America with respect to perioperative management of pediatric digital replantations and revascularizations (R/R).
Materials & MethodsThis was a cross-sectional survey-based study querying attending surgeons who take hand surgery call and perform pediatric digital R/R's. In addition to collecting data on surgeon demographics, the survey determined preferences of anticoagulation protocols by age, postoperative disposition, neurovascular checks, pain management, interventions for venous congestion, and hospital length of stay. The survey was sent to two pediatric hand surgery email listservs and snowball sampling was used to target academic hand surgery groups and individual hand surgeons. Descriptive statistics were performed.
ResultsSixty-six fellowship-trained hand surgeons completed the survey. Of the respondents, 60.3% have been in practice ?10 years and 86% perform <5 R/R surgeries per year. Ninety-one percent practice in an urban setting in an academic practice. For intraoperative anticoagulation, the majority use a one-time IV heparin bolus for all age groups. For postoperative anticoagulation, the majority use aspirin 81mg daily or a subtherapeutic IV heparin infusion with or without aspirin. Regarding the duration of postoperative anticoagulation, most surgeons keep patients on heparin for 3-5 days and aspirin for 3-4 weeks. In an uncomplicated anastomosis, 63% admit patients to the ICU post-op versus 74% for a tenuous anastomosis. Most surgeons do neurovascular checks (NVC) every 1 hour for 24 hours post-op then liberate thereafter. The most important factors that influence postoperative disposition to an ICU versus a lower acuity unit are the ability to perform frequent NVCs and ability to administer a heparin infusion. Multimodal pain management is used by most surgeons and many surgeons utilize regional anesthesia teams to perform peripheral nerve blocks. Regarding the management of postoperative venous congestion, the majority of surgeons use leech therapy for 3-5 days, and ciprofloxacin is the most used antibiotic prophylaxis. Typical hospital length of stay is 5-7 days.
ConclusionsThis was the first study to report practice patterns of the perioperative management of pediatric digital replantations and revascularizations. The results of this study may be utilized to help create a summary statement of "best practices" for the management of these patients.
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