Intensive care unit versus floor admission following lower extremity free flap surgery: Is there a difference in outcomes?

[BACKGROUND] Free tissue transfer (FTT) lower limb salvage requires costly multidisciplinary care. Traditionally, patients who undergo FTT reconstruction for lower extremity (LE) wounds were admitted to the intensive care unit (ICU) in the immediate postoperative period for close monitoring. During the COVID-19 pandemic, our practice shifted toward admitting FTT patients to the floor postoperatively instead of the ICU. The purpose of this study is to compare surgical outcomes in patients admitted to the floor versus ICU immediately following LE free flap reconstruction.

[METHODS] We retrospectively reviewed patients undergoing LE FTT reconstruction from 2011 to 2021. Flap monitoring consisted of an implantable Cook-Swartz Doppler probe for muscle flaps and ViOptix tissue oximetry for fasciocutaneous flaps; clinical exam and hand-held dopplers were not the primary flap monitoring techniques. Patients were divided into two groups depending on whether they went to the ICU or floor postoperatively. To ensure proper comparability between cohorts, we corrected for age, BMI and Charlson Comorbidity Index (CCI) using 1:2 propensity score matching (floor: ICU). Primary outcomes included early postoperative complications, flap takeback and salvage, flap success, and postoperative length of stay (LOS).

[RESULTS] A total of 252 patients were identified. Forty-five patients (17.9%) were admitted to the floor postoperatively and 207 patients (82.1%) to the ICU. Overall, microsurgical success rate was 97.2%, which was similar for floor and ICU patients. Flap takeback and salvage were similar between cohorts. Average postoperative LOS was significantly shorter in floor patients (15.7 vs. 19.1 days, p = 0.043).

[CONCLUSION] Our findings suggest that postoperative floor admission does not decrease flap success rates and should be considered in patients who undergo FTT to LE reconstruction and are otherwise stable. In the ongoing era of health care cost containment, microsurgery centers should consider appropriate floor training to allow medically stable free flap patients to avoid an ICU stay.