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--- medical_student:lower_extremity_pathway [2020/03/26 15:57] – serafin
+++ medical_student:lower_extremity_pathway [2025/05/19 14:43] (current) – [Remote Vioptix] haley.d
@@ Line 1: / Line 1: @@
-**Lower Extremity Wound Consult Evaluation:**
+==== Lower Extremity Pathway ====
-  * Mechanism of wound
-  * Size of wound
-  * Prior surgeries
-  * Existing hardware?
-  * Current dressing/vac, etc
-  * Weight bearing status
-  * Infection? Osteo versus soft tissue only.
-  * Antibiotics? Follow ALL cultures; know if they are soft tissue versus bone
-  * Has CTA runoff been obtained?
-  * Needs to be on SQH 5000U TID and hold the AM dose if going to OR
-  * Follow up CBCs especially after OR with ortho. If Hct is <28, will transfuse day BEFORE surgery.
-  * If planning for poss free flap, need to T&C 2u RBC.
-  * If going to surgery, need to make NPO, IVF, pre-op abx.
+Dr. Iorio Lower extremity free flap\\
+POD 0:\\
+Vioptix, manual flap checks with Doppler. On ICU arrival: Flap checks q15 minutes x 2 hours, then q30 minutes x 2 hours, then Q1 hr RN flap checks. Checks X2 overnight by crosscover MD.\\
+Discuss ASA 81 and SQH with Iorio—usually hold until POD 1.\\
+Bedrest, elevate extremity, Bair hugger.\\
-**Iorio** Lower ext path:\\
+POD 1: \\
-Prior to OR: transition to heparin at time of consult, eval for CTA vs angio\\
+Advance to diet, begin transition to oral pain meds.\\
-Day of OR: Hct 25-27\\
+ASA 81 mg and SQH 5000U TID if not yet started. Discuss with Iorio prior to ordering, based on EBL, drains, bleeding risk etc.\\
-POD1: Conversation about starting ASA 81, Heparin 5000 SQ TID (usually at night if flap is soft and drain output low). Heparin gtt reserved for special cases.\\
-POD2: Start dangle protocol (unless in frame)\\
-POD3: Out of ICU, Q2hr checks\\
+POD 2:\\
+D/C foley.\\
+WB status? Ortho vs plastics.\\
+Out of bed to chair with assistance. Must have leg elevated. PT/OT.\\
+Consult Case Management if not already involved for dispo (acute rehab).\\
+Begin dangles (or delay to POD 3 if limited by pain or Iorio preference).\\
+minutes TID\\
+Vioptix and manual flap check immediately prior to, during, and after dangle.\\
+ABORT DANGLE AND IMMEDIATELY RE-ELEVATE LEG IF:\\
+  * Vioptix drops more than 20 points from pre-dangle baseline.
+  * Vioptix drops below 30% value.
+  * Flap becomes visibly congested/changes color
+  * If patient has pain, but flap is otherwise fine, okay to abort.
+Important to note why dangle was aborted. Depending on situation, may try again later in the day.
+POD 3-6:\\
+Increase dangles by 5 minute increments each day (10 mins TID/15 mins TID/20 mins TID).\\
+If dangles aborted, depending on reason, may try again later versus reducing the dangle increment by 5 mins (i.e. failed 15 minute dangle due to pain—can try 15 minutes again later. i.e. failed 10 minute dangle due to congestion—might go back to 5 minute attempt).\\
+POD 6 or 7:\\
+Ready for discharge if tolerating 20 minute TID dangles.\\
+No unmonitored dangles in rehab\\
+Can use dangle times for ADLs.\\
+Continue ASA 81 mg daily for 1 month.\\
 Note: Muscle flaps do not accommodate dangles (ie venous return) the same way as skin flaps. Dangles usually start on POD#5 or POD#6.\\
-Denver Health: \\
-**Wong** Lower Extremity Pathway: \\
+==== Wong Lower Extremity Pathway (DH) ====
 - Bedrest with leg elevated for 5 days\\
 - POD5 (or anytime not on the weekend) begin dangle protocol \\
 - Dangle: POD5 5 min TID; POD6 10 min TID; POD7 20 min TID, then home \\
 - No wrapping or compressing of leg during dangle \\
+==== Kaoutzanis Lower Extremity Pathway ====
+<iframe src="https://docs.google.com/document/d/e/2PACX-1vQYpat1xWyuYj2pwOBPFzPfPa4BYh2moMqAb1bNdSQn21viXIdchWaTeJjfSmGEIhaQdrufkwpnEy5U/pub?embedded=true"></iframe>
+==== Remote Vioptix ====
+https://remote.vioptix.com/uchmli/
+\\
+Troubleshooting:\\
+Email for Tom:  Tom Nie <niet@vioptix.com>, Cell: 708-466-9601\\
+{{:medical_student:screenshot_2025-05-19_at_12.40.29_pm.png?600|}}
+{{:medical_student:screenshot_2025-05-19_at_12.40.18_pm.png?600|}}
+{{:medical_student:screenshot_2025-05-19_at_12.40.37_pm.png?600|}}