Elsevier

Injury

Volume 39, Issue 2, February 2008, Pages 203-208
Injury

Post-operative critical care and outcomes of limb replantation: Experience in a developing country

https://doi.org/10.1016/j.injury.2007.09.009Get rights and content

Summary

Replantation is the treatment of choice for traumatic amputation. Its success rates vary, reaching 80% in world's best centres. This study analyses management practices of replantation in a regional centre in a developing country. Out of six replantations, four were successful. The median warm ischaemia time of the severed limb was 4.5 h (range 1–13.5) and the median duration of general anaesthesia required for initial surgery was 6.25 h (range 4.7–8.0). All patients needed intensive care following replantation for a median of 7 days (range 5–15). Pulse oximetry values were observed to be the same in the graft and the patient in successful cases. Two grafts failed.

The median haemoglobin values on the 1st, 3rd and 5th post-operative day were 9.8, 7.0 and 8.4 g/dl, respectively. The median platelet counts in the same time periods were 118 × 109, 68 × 109 and 205 × 109 L−1. The median total fluid intake was 2.2, 3.1 and 3.4 ml/kg/h on the 1st, 3rd and 5th post-operative day and the median urine output was 2.4, 2.6 and 2.7 ml/kg/h, respectively.

The observed post-surgical reduction in platelet count normalised by the 5th post-operative day. Higher fluid intake and lower haemoglobin levels appear to minimise the systemic effects of reperfusion injury, preventing the onset of renal failure and promoting graft perfusion. Pulse oximetry was a useful tool to assess graft perfusion and appear to offer a prognostic value.

Three of the above 4 patients were traced for review 5 years later and had functioning grafts.

Introduction

Traumatic amputation of a limb carries a significant morbidity and disability. These severed extremities may be saved by replantation. Since William Balfour's first successful fingertip reattachment in 1814, much progress has been made in replantation procedures especially following the development of the operating microscope in the early 1960s.9

Several microsurgical centres around the world now achieve success rates greater than 80% in replanting severed digits, hands and limbs. Replantation at the wrist and proximal upper extremity is particularly challenging.6 Mounting clinical experience, improved micro-vascular anastomosis techniques, ultra-fine needles, micro-vascular suture material and instruments, better microscopes, improved anaesthesia and post-operative management have made replantation the procedure of choice in the management of many traumatic amputations.

This paper constitutes an assessment of our experience in limb replantation, their post-operative critical care and outcomes in a regional centre of a developing country.

Section snippets

Patients and methods

All patients who underwent replantation surgery between September 2000 and May 2003 were identified via the operating theatre register and their hospital records were traced. The data were collected from hospital medical and intensive care records of those patients using a structured form in 2003. Subsequently, in 2007, patients who had viable grafts at discharge from hospital were reviewed for a functional assessment using Ch’en criteria (see Table 1).

The demographic data, injury pattern, the

Results

Eleven replantations had been performed during the 2 years and 8 months study period and complete medical and nursing records were available in 6 cases (3 male, median age 32 years, range 3–59) and they were included in the study (see Table 3). The median warm ischaemia time of the severed limb in these cases was 4.5 h (range 1–13.5 h).

Of the 6 studied, 1 graft was lost due to severe wound infection and another due to vascular compromise, 10 and 7 days following surgery, respectively. Failed

Discussion

Replantation aims to restore the amputated part to its anatomical site, preserving function and appearance. Outcome depends on factors intrinsic to the patient and to the nature of the injury as observed in our series also. Crush and avulsion injuries are relative contraindications for replantation4 and this was reiterated in our failures. Meticulous microsurgical technique, dedicated operative and post-operative care, comprehensive occupational therapy and perseverance are needed for success.

Conclusion

Aggressive hydration pre-operatively and post-operatively contributes to graft survival and minimises reperfusion injury to the host. A reduction in platelet count and its recovery post-operatively seems to provide a useful guide to assess the ongoing reperfusion injury. Pulse oximetry is a useful tool to assess graft perfusion. Amputations resulting from guillotine type of injuries have a better chance of survival after replantation. Public education on methods of transporting severed body

Conflicts of interest

None.

Acknowledgements

The authors appreciate the help and support provided by all medical and nursing staff of Peradeniya Teaching Hospital in the clinical management of these cases and Mr. Mahes Salgado for assistance with manuscript preparation.

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