The Importance of Perioperative Care and Planning To Improve Outcomes in Flap Surgery

The dehiscence of reconstructive flap incisions has long been a problem following pressure ulcer repair. The wound care specialist plays a critical role in identifying and managing perioperative barriers that can impact the success of the surgery.  Therefore, a team was established with the purpose of developing a system to assist the patient in navigating through the perioperative process.   They found a well organized sequence of events must occur to allow for the best opportunity for a successful outcome.  The objectives of this systematic approach were to minimize perioperative complications, improve outcomes, and provide patients with the education necessary to prevent recurrence.  The first step to this new system included preoperative management which involved seating evaluations, nutritional assessment and optimization, education and agreement to the perioprative plan. A critical but often overlooked step was the seating evaluation which included pressure mapping to address pressure redistribution, and adjustment or replacement of wheelchair and cushion as indicated.  Completion of this prior to surgery was vital as the seating system was often the cause of the pressure ulcer and can impact the success of the surgery. An equally important component of the preoperative plan was the patients’ understanding and agreement to the course of care.  Post operative care included bed rest on air fluidized beds, routine evaluations by the wound care team, activity progression per sitting protocol, reassessment of wheelchair/cushion and reinforcement of education for long term pressure management.  Initial positive outcomes were exemplified by four patients with paraplegia and Stage IV pressure ulcers who participated in this systematic approach.  All these patients healed with minimal and manageable complications.  These early, encouraging outcomes resulted in full implementation of this perioperative planning program.