Purpose:

At present, it is standard practice to admit all patients who undergo free flap reconstruction to the ICU or an equivalent flap recovery unit for monitoring on an hourly basis. The ICU remains a large user of hospital resources, accounting for 25% to 30% of total hospital costs, despite the fact that these beds represent only 5 to 10% of total hospital beds. To date, there have been no studies documenting an improvement in free flap outcomes or cost-savings based solely on ICU level flap monitoring. The purpose of this study is to perform a cost comparison of free flap monitoring in the ICU versus surgical floor using standard clinical criterion, external Doppler probe, and Near Infrared Spectroscopy (NIRS) in patients who have undergone free flap breast reconstruction.

Methods:

Since August 2006, 14 patients underwent free flap breast reconstruction using MS-TRAM, DIEP, or SIEA free flaps. 8 patients (10 flaps) were randomized to the ICU and 6 patients (7 flaps) to the standard surgical floor for post-operative monitoring using standard clinical criteria, external Doppler probe, and continuous NIRS monitoring. Patient demographics, procedure type, diagnosis, adjuvant treatment, and complications were recorded.

Results:

6 MS-TRAM, 6 DIEP, and 5 SIEA free flaps breast reconstructions were performed. There was no difference in flap loss, fat necrosis, or venous congestion. Average total length of stay (LoS) and cost of stay (CoS) in patients randomized to recover in the ICU was 4.25 days and $18,122. Average LoS and CoS in patients recovering on the surgical floor was 4 days and $7,564.

Conclusion:

This randomized, prospective study compares the cost and early (30-day) results of post-operative recovery and free-flap breast reconstruction monitoring in an ICU versus surgical floor setting at a single institution using external doppler probe and near-infrared spectroscopy (NIRS) as adjunctive monitoring devices. Current monitoring devices fall short of the ideal and none have gained widespread acceptance. A monitoring tool that could detect disturbances in vascular flow early, reliably, and independent of level of care and experience of nursing staff could potentially generate tremendous cost savings to both the institution and to the patient. Easy to use and accurate, NIRS technology has the potential to lower hospital costs by allowing patients to recover on a standard surgical floor while receiving continuous free flap monitoring. Long term outcomes data are needed to corroborate our early findings.