Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
  Table of Contents / Chapter 35:
Preoperative and Postoperative Care
  An accident victim with an amputation must first be treated as would any other trauma patient. Appropriate examination for potential life-threatening internal injuries or other conditions that might preclude replantation surgery should be performed. Preoperative evaluation and preparation of a microsurgery patient must include the same detail as required for the safe management of any patient undergoing major surgery. Detailed discussion of preoperative care is given in standard texts. 1-5

Patients are assessed preoperatively according to the American Society of Anesthesia criteria. Electrocardiograms, arterial blood gases, and other tests are ordered on a case-by-case basis based on history and physical examination (Fig. 35-1).

Adequate hydration preoperatively, intraoperatively, and postoperatively is essential for optimal flap or replant circulation. Patients who are volume-depleted preoperatively may become significantly dehydrated during the prolonged operative time. Large surgical or traumatic wounds cause further significant fluid loss. Preoperative angiography may also contribute to dehydration. We have found, however, that volume status in most microsurgical patients is adequately monitored by assessment of vital signs and urine output. Rarely, central venous pressure measurements or pulmonary artery pressure and cardiac output determinations are required (See Chapter 39).


For purposes of circulatory hemodynamics, hematocrits of 25% to 30% are acceptable and even desirable in microsurgery patients. Wounds can heal well with hematocrits as low as 25%.6 If a patient's hematocrit is already in the 25% to 30% range, preoperative transfusion may be appropriate, depending on the anticipated blood loss.

In elective cases, aspirin is given the night before surgery to provide antiplatelet activity, which is desirable to prevent clotting in microvascular anastomoses. For clean cases, a short course of perioperative antibiotics (usually a cephalosporin) is begun immediately preoperatively. When a chronic wound is present, or in the instance of an infected fracture or osteomyelitis, appropriate antibiotic coverage is chosen for the cultured organism. Figure 35-1 shows typical preoperative orders for a healthy young patient.

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