title: Evaluating the Use of Tissue Oximetry to Decrease Intensive Unit Monitoring for Free Flap Breast Reconstruction.
abstract: BACKGROUND
  Postoperative free flap care has historically required intensive monitoring for 24 hours in an intensive care unit. Continuous monitoring with tissue oximetry has allowed earlier detection of vascular compromise, decreasing flap loss and improving salvage. This study aims to identify whether a fast-track postoperative paradigm can be safely used with tissue oximetry to decrease intensive monitoring and costs.
  
  
  METHODS
  All consecutive microsurgical breast reconstructions performed at a single institution were reviewed (2008-2014) and cases requiring return to the operating room were identified. Data evaluated included patient demographics, the take back time course, and complications of flap loss and salvage. A cost-benefit analysis was performed to analyse the utility of a postoperative intensive monitoring setting.
  
  
  RESULTS
  There were 900 flaps performed and 32 required an unplanned return to the operating room. There were 16 flaps that required a reexploration within the first 24 hours; the standard length of intensive unit monitoring. After 4 hours, there were 7 flaps (44%) detected by tissue oximetry for reexploration. After 15 hours of intensive monitoring postoperatively, cost analysis revealed that the majority (15/16; 94%) of failing flaps had been identified and the cost of identifying each subsequent failing flap exceeded the cost of another hour of intensive monitoring.
  
  
  CONCLUSIONS
  The postoperative paradigm for microsurgical flaps has historically required intensive unit monitoring. Using tissue oximetry, a fast-track pathway can reduce time spent in an intensive monitoring setting from 24 to 15 hours with significant cost savings and minimal risk of missing a failing free flap.
authors.affiliation: From the Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston MA.
authors.forename: Joseph A
authors.initials: JA
authors.lastname: Ricci
authors.forename: Christina R
authors.initials: CR
authors.lastname: Vargas
authors.forename: Olivia A
authors.initials: OA
authors.lastname: Ho
authors.forename: Samuel J
authors.initials: SJ
authors.lastname: Lin
authors.forename: Adam M
authors.initials: AM
authors.lastname: Tobias
authors.forename: Bernard T
authors.initials: BT
authors.lastname: Lee
mesh_terms: D000328:Adult; D001943:Breast Neoplasms / Q000601:surgery*; D015331:Cohort Studies; D016208:Databases, Factual; D005260:Female; D005500:Follow-Up Studies; D058752:Free Tissue Flaps / Q000098:blood supply / Q000637:transplantation*; D006084:Graft Rejection / Q000517:prevention & control; D006801:Humans; D007362:Intensive Care Units; D007902:Length of Stay; D016462:Mammaplasty / Q000009:adverse effects / Q000379:methods*; D008408:Mastectomy / Q000379:methods; D008866:Microsurgery / Q000379:methods; D008875:Middle Aged; D008991:Monitoring, Physiologic / Q000379:methods; D010092:Oximetry / Q000706:statistics & numerical data*; D011182:Postoperative Care / Q000379:methods; D012086:Reoperation / Q000706:statistics & numerical data; D012189:Retrospective Studies; D016896:Treatment Outcome