|Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.|
| When the patient arrives in the emergency room, antibiotic therapy is begun, usually with a cephalosporin64-65 unless specific sources of contamination dictate modifying the therapy. Unless they are contraindicated, antibiotics are continued for 1 to 2 days.66 An aspirin suppository is given preoperatively.67,68 As soon as the first anastomosis is completed, Dextran-40,69-71 (25 cc/hr) is started and continued for 5 days. Patients with crush injuries are sometimes given heparin,40,41,47 but one must be cautious with anticoagulation therapy, especially if the zone of injury is large or if a flap donor site can result in significant blood loss. If heparin is used, the dosage is adjusted to maintain a partial prothrombin time of one and a half times control and is continued for 7 to 10 days. For vasodilation and mild sedation, chlorpromazine73-75, 10 mg to 25 mg, is given orally three times a day. Other drugs that have been tried 74,76 include procardia77 for vasospasm and vasodilan78-80 for vasodilation.
Bupivacaine81 blocks have been used successfully for relieving pain and reducing vasospasm. These must, however, be used with caution. A wrist block, not a digital block, must be used for digital replants because the needle may injure a digital vessel or the anesthetic solution may compress and occlude the vessel. Nerve blocks may be dangerous in patients receiving heparin; indwelling catheters,82 placed at the time of surgery, may help to avoid problems. During the postoperative period, analgesics are given to relieve pain. (See Chapter 36. For postoperative monitoring and rehabilitation, see Chapters 35 and 37.)
Treatment of a Failing Digital Replant
A replant that shows signs of failure must be diagnosed promptly, and corrective action must be taken immediately.
If a digit turns pale after a dressing change, this may indicate vasospasm. Maintaining a warm environment with a heating pad or other heating device, administering analgesics, and- performing a regional block may effectively reduce vasospasm.
When a digit becomes blue and tense, venous insufficiency exists. The treatment may be by leeches, 83-86 removal of the nail plate,41 a fishmouth incision over the tip of the finger, held open with a Penrose drain,22 or redoing the venous anastomosis, usually with vein grafting. Time is critical because prolonged venous obstruction leads to arterial obstruction and loss of the replanted part.
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