Note: last updated before 2015

Supplies

• H&N: have tongue depressors and light source ready, 18g needle if flap check is necessary, check that dressing change supplies are in the room
• Otology: always have a 512Hz tuning fork
• Supplies for a mastoid dressing: 2 Kerlix lite rolls, 10 Kerlix fluffs, bacitracin ointment, Adaptic nonadhesive gauze, scissors. Sometimes Coban is needed for kids. Gantz patients have mastoid dressing replaced daily. Hansen patients have mastoid dressing replaced every other day.

Trach Care

• With trachs in flap patients → NO strap around neck. This could put pressure on the vascular pedicle and can kill the flap. The trach should be sutured in place until the staff will feel enough time has gone by that a strap can be used. Humidifier trach mask neck strap should not be around neck, pin it to gown
• Trach cuffs should be deflated if the patient is not on a ventilator (except if there is a high risk of some fluid going down the trachea like blood or bile or saliva from fistula)
• Trach change: Usually done POD #5.
  • Some staff sew a new trach to the skin and then also put trach ties/ straps. In this case, cut the sutures and ties out the day of the first trach change and secure the trach with velcro straps unless it is a flap, in which case stitch it back in.
  • Usually the Shiley is exchanged for a Jackson of the same size. If it’s a patient who’s gonna have radiation therapy, don’t place a Jackson. The metal will scatter the rays. Replace with a cuffless Shiley instead. If the patient may need to be on the vent again in the near future, change to another cuffed Shiley.
• On discharge, trach patients must have suction machine arranged for taking home, they need trach care teaching, wound care supplies, electrolarynx, tube feeds, VNA as needed.

Staples/stitches

• Most out on POD #7. If irradiated tissue then on POD #14.
• Keep suture lines clean with peroxide and apply bacitrain/vaseline at least bid

Drain Care

• JP should be stripped q2h by nursing and each time you round on the patient to avoid clot formation which renders the drain useless
• Most staff will pull JP drains once output is < 30cc / 24 hours. Pull one drain per day. Ask staff or senior resident prior to pulling any drains, and consult with operating senior on order of drains to be pulled. Some staff are more lenient on drain cares (will send patients home with drains in)
• Penrose drains should be “rolled” i.e. rolled with a Kerlix over the skin toward the penrose using gentle, constant pressure. On free flaps, it’s often: q15 minutes for 1 H, then q30 minutes for 2 H, then qH for 4 H, then q 2H...but you can expect that to change according to how oozy the fellow thinks the neck was intraop. Avoid raking the kerlix over the skin as this creates shear forces between the skin flap and underlying tissues.
• Penroses drains are placed in areas where we don’t want fluid to collect, but we also don’t want a drain sucking on our vessels. Pushing against the tissue around the drain evacuates accumulated fluids. However, if left in there, tissues around the drain will heal and leave persistent a canal. So, to counteract this, we remove the drain slowly over many days to allow it to heal from the inside out. Advancing penrose drains is normally begun when the neck is producing less fluid. They´re advanced 1-2 cm/day, they have to be stitched in each time → put a loop stitch in skin and then stitch the loop to the drain. Trim the penrose afterwards so that around 1.5 cm is sticking out of the neck.

Pain management

• Usually start with Lortab 500/5  1-2 q4-6h PRN, or Lortab elixir 10-15 cc q 4-6H prn if you expect swallowing difficulties
• If Lortab isn’t cutting it, try Percocet 1-2 q4-6h PRN, then Dilaudid 2-4mg po q 4-6 H prn
• PCA- usually start with 1 mg IV morphine q 10 minutes, lock out of 6 mg/H. Never order a basal rate. Use morphine or dilaudid, not fentanyl.
• Neurotology patients who have had intracranial surgery (eg. acoustics) – codeine or T3 only for first 24 hours due to need for neurological monitoring

Antibiotics

• Staff dependent
• In general, Unasyn (3gm IV q8H, sometimes q6H) IV, then transition to Augmentin (875mg PO BID)
• If PCN allergic, Clinda IV (600mg TID) transitioning to Clinda PO (300mg TID)
• If a person has any sort of intranasal pack, must have Staph coverage on board (augmentin, clinda etc) to protect against toxic shock syndrome
• Pagedar clean cases (e.g. thyroidectomy) – no antibiotics needed

Diet

• Most patients (like neck dissections) get a regular diet.
• Trachs get a regular diet. But, because trachea is tethered, they are at risk of dysphagia, so advance slowly and check for signs of aspiration.
• If intraoral, pharynx or larynx operation, the goal will likely be soft diet for 2 weeks or so
• Many (free flaps and people with oral excisions) get a Dobhoff tube placed at time of surgery. For those folks, get a postop abd xray and check that the tip of DHT is in the stomach (doesn’t have to be post-pyloric). Get nutrition consult and start TF regimen after nutrition places recs.
• Many patients with TF get diarrhea. If that’s the case, first test for C. Diff. If negative, ask nutrition to suggest alternative regimen (they often add fiber or change osmolar load of the formula).
• Many of our patients have trouble with swallowing or we expect them to. To address this, consult speech path and request a bedside swallow study (enter an EPIC consult and then call 62292 and let them know). After the bedside swallow (during which patients are given food of various consistencies and observed as they swallow), speech path may request an oropharyngeal motility study (aka OPMS/ modified barium swallow) which is done under fluoroscopic visualization.

Activity

• In general, OOB to chair POD#0. If it’s not too late and they feel up to it, please have them walk that day, too
• Thereafter, ambulate at least 5x/day
• Every patient with significant risk of perioperative pulmonary complication such as pts. with COPD, overweight, smoker etc. should get an incentive spirometry. (Unless a trach, because it won’t work for them. In their case, encourage deep breathing and frequent coughing.

PT

• Every free flap needs a PT consult placed the day they are transferred to the floor
• All neck dissections get a PT consult for ROM/strength of the ipsilateral arm
• Elderly/debilitated pts with long courses need PT to prevent debilitation
• Sometimes you need OT clearance for discharge on elderly patients/debilitated
• Initiate PT and OT level of care consults as early as possible, often when transferred to floor.

DVT Prophylaxis

• Walk
• If not walking, teds and kendalls
• We do not use sub Q heparin in general. But, be thinking about when it might be appropriate and ask your team. (Person’s surgery was 2 weeks ago, really debilitated, not walking much, etc).

Bowel Regimen

• All patients: Colace 100mg po BID and Senna 1 tab qhs, hold for loose stools
• Add if no BM: 1. double Colace and Senna  2. Milk of Magnesia  3. Dulcolax PR  4. Fleets enema
• Most patients with TF get diarrhea (see diet section)

Discharges

• Know the disposition plans and keep SW updated frequently so placement (SNF, rehab, nursing home), VNA, and home supplies (eg. suction, tube feed machines, IV abx) are ready by the time the patient is medically ready for discharge.
• All patients should have follow-up appt scheduled with attending, even if patient will return sooner to ROD for suture removal.

Rounds

• Presentation:
  • POD#, dx including TNM staging, specific description of operative procedure
  • Abx day #
  • Events overnight
  • Vitals:
    • If fever (T > 38.3) report time and Tcurrent, what workup was done
    • I&O with Uo (if pt in unit) and drain output amount
    • Otherwise, know it, but don’t tell it.
  • Diet
    • NPO, clears, TF at what rate and what is goal, etc
    • Goal is to get them to regular diet or to bolus TF, since continuous feeds at home are difficult to administer
  • Pain control regimen. Goal is to get them to lortab.
  • Studies: new films, cultures results, surgical pathology
  • Labs: any abnormal. H&H for flaps must be at least 10/30 (usually transfuse 1 unit, but ask first). Trend of white count. 
  • PE: 
    • Wound: skin flaps (flat, hematoma; edges alive, necrotic), incision (clean, dry, intact vs. dehiscent, draining, erythematous)
    • Drains: ype of fluid (blood vs. serosanginous vs chyle)?
    • Flaps: Color (pink, purple, white), consistency (soft,  firm), doppler, pin prick, incision line of flap. 
    • Flap donor sites: if STSG, what is percent take? Any fluid collections or exposed tissues? If an arm or leg has a splint, do the fingers/toes have good perfusion and sensation?
    • Neuro: If in the unit, check pupils, following commands. 
    • Trach: size, cuff up/down, secretions (if nurses aren't putting saline down the trach, ask them to.)
  • Plan and disposition
    • Advance diet and activity. Consider PT/OT consults
    • Follow up on pathology and other studies
    • Lots of our patients have to have a visiting nurse or go to a rehab or skilled nursing facility, and this requires coordination by social work (Roxanne, 3JPW pager 4188). 
• Sample presentation
  • This is Mr. Soandso 56 y.o. gentleman POD#4 s/p composite resection of T3N2b SCCa of FOM with bilateral ND and scapula flap reconstruction. He is currently on Unasyn day #5. He did well overnight compared to previous nights with one episode of agitation needing Haldol, with one episode of desaturation requiring suction of his tracheotomy. He is currently on TF at goal boluses, off his PCA and taking Lortab, getting scheduled Ativan with Haldol PRN needing only one dose of Haldol over the past 24 h. On examination his Tmax was 38.1 Tcurrent 37.5, vital signs have been stable and he is saturating 95% on FM with FiO2 of .33. I/O were balanced over the last 24h with tube-feeds being 2.0L, UOP was 1700 cc and JP#1 put out 45cc over the last 24h with 15 cc over the last 8h, JP#2 put out 25cc over the last 24h and 7.5cc over the last 8h and was removed this morning. Lungs are CTA. Flap is soft with good color, + Doppler and BRB to pinprick @ 5 seconds, no dehiscence of suture lines. Donor site is flat with no evidence of hematoma, incisions clean, dry and intact with full ROM of the shoulder. Tracheotomy site is clean with no evidence of infection. Neck is flat, incisions are c/d/i. Plan is to continue antibiotics, encourage ambulation, changing Ativan to PRN, changing his trach to a #6 Jackson tomorrow. Path report says preliminary is available, will call on that today.

Determining level of care for admission

• Duration of stay does not matter
• LOC categories
  • Observation: no invasive procedures
  • Recovery: An invasive procedure was performed with recovery period usually <24 hours though sometimes can be up to 48h
  • Acute: Severity of illness and co-morbidities or complications require active treatment and monitoring