Table of Contents
Lower Extremity Pathway
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.
POD 1:
Advance to diet, begin transition to oral pain meds.
ASA 81 mg and SQH 5000U TID if not yet started. Discuss with Iorio prior to ordering, based on EBL, drains, bleeding risk etc.
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).
5 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.
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
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Remote Vioptix
https://remote.vioptix.com/uchmli/
Troubleshooting:
Email for Tom: Tom Nie niet@vioptix.com, Cell: 708-466-9601
