he concept of extremity replantation and even transplantation was clearly in the minds of men in the third century AD. Cosmos and Damian, the patron saints of physicians, are shown in Figure 1 transplanting a healthy leg of a fallen Ethiopian to replace the tumorous leg of a tower bell custodian. In modern times, surgeons such as Halstead (1887), Hufner (19031, Carrel (19061,and Lapshinsky (1906)did much to set the stage of human replantation by their diligent work with experimental animals. It was not until May 1962, however, that Malt and McKhann a t the Massachusetts General Hospital in Boston successfully replanted the totally severed arm of a 12-year-old boy injured in a train accident.' In 1963, two surgeons, Buncke of the United States and Ch'en of China, worked independently to transform microsurgical techniques (originally explored by Jacobson in the early 1960s) into useful clinical techniques for human digital replantation. Herbsman and coworkers reported a successful hand replantation
T
Amputation: Injury to replantation
James W May, Jr, MD Abbie L Thurmond, RN Harold E Kleinert, MD
James W May, Jr, MD, is an instructor in
surgery at Harvard Medical School in Boston and an assistant in surgery at Massachusetts General Hospital, Boston. Dr May received his AB degree from the University of Kentucky in Lexington and his MD from Northwestern University Medical School in Chicago. Abbie L Thurmond, R N , is supervisor of the
recovery room, Jewish Hospital, Louisville. She is a diploma graduate of Sts Mary and Elizabeth Hospital in Louisville. Harold E Kleinert, MD, is clinical professor of surgery at the University of Louisville School of Medicine in Louisville and the Indiana University-Purdue University School of Medicine in Indianapolis. A graduate of the University of Michigan in Ann Arbor, Dr Kleinert received his MD from Temple University Medical School in Philadelphia.
AORN Journal, January 1978, V o l 2 7 , No 1
36
Fig 7. Early painting of the patron saints of physicians, Cosmos and Damian, transplanting the leg of a fallen Ethiopian onto a tower bell custodian whose leg was tumorous.
in November 1962,2 but the first successful digital replantation was not noted until 1966, when Komatsu and Tamai reported a successful thumb rep l a n t a t i ~ nThe . ~ first finger replantation was likely done in China in 1967, but this case was not officially reported in the literature. Since the late 19609, all anatomical levels of human extremity replantation have been reported. Recently, a successful microvascular human penis replantation has been rep ~ r t e dSuccessful .~ replantation in humans is now done commonly not only in China and the United States but in many other areas of the world as well. The successful replantation of an amputated part requires the smooth cooperation of a specialized team of professionals. The outcome of this surgical effort can significantly change the course of a patient’s life. The immediatecare of the patient and injured part is crucial. Following an amputation injury, appreciation of the fact that surgical replantation may be possible is fundamental. Occasionally, this will not be recognized until the victim is hospitalized. When this has occurred, questioning the patient and his
36
companions will frequently uncover useful information about the accident and the whereabouts of the amputated part. If the part has been or can be retrieved, the stage for replantation can be set. It is better t o err on the side of referring a patient with his amputated part to a replantation center even if replantation is not possible than to deny a patient a possible replantation option for fear of referring an “inappropriate patient,” It is important to know your local replantation referral lines. Valuable time can be saved in the process of direct referral when appropriate notification of the referral center has been made. It is very important to make it clear to the patient that referral is being arranged for replantation evaluation but not for replantation itself. This can greatly reduce the disappointment factor if replantation is not believed to be possible or to be in the patient’s best interest. The single most important step following an amputation injury is evaluation and treatment of the patient. This evaluation should consist of a complete history and physical examination.
AORN Journal, January 1978,Vol27, No 1
Bleeding can usually be stopped a t the amputation site after saline cleansing and irrigation by pressure application with a sterile dressing. Small muscular peripheral arteries as in the forearm and hand frequently go into spasm after total transection, thus making hemostasis with pressure reasonably simple. Clamp or tourniquet damage to the vessels, nerves, a n d tissues must be avoided. Before the patient is transported to the referral center, an intravenous infusion should be started through a large 16 or 18 intravenous catheter in a dorsal peripheral vein (opposite hand), and intravenous cephalothin plus appropriate tetanus prophylaxis should be administered. The patient should be kept NPO and made as comfortable as possible. Frequently, intramuscular diazepam and meperidine will help decrease anxiety and pain, but if blood loss has been extensive, intramuscular medications should be given with caution or not a t all. The extremity should be elevated. The amputated part should be washed with sterile saline, wrapped in a sterile gauze, and placed inside a plastic bag. The plastic bag should then be immersed in ice inside a n insulated container. This single refrigeration maneuver can extend greatly the length of time that can safely elapse before blood supply is restored to the amputated part. Under ideal circumstances, successful replantation cases have been reported after more than 30 hours of ischemia, although shorter time intervals are obviously preferable. Transportation itself has played a n important role in the changing picture of replantation surgery. One hundred years ago, the patient was transported by carriage, horseback, or boat to the hospital with the hope of having his amputation stump closed successfully as a life-saving measure. Today, a simi-
~~
Table 1
Indications and contraindications for replantation Indications Selected single digit amputation Multidigit amputation Partial or total hand amputation Contraindications Patient refusal Damaged vessels, nerves, and supporting tissues Age limitation Constitutional disease lar individual is likely transported by jet aircraft, helicopter, or modern ambulance service to a replantation center with the expectation of a successful replantation from the viewpoint of viability and function. When the patient and amputated part arrive at the referral center, coordinated teamwork is essential in delivering a viable and successful replantation. Initially, the patient is reexamined and assessed by a surgical team to see if transportation has been well tolerated. The extent of extremity injury is then evaluated to see if replantation is possible. Following this, a second surgical team takes the amputated part to the operating room for evaluation both grossly and with the operating microscope. If evaluation of both the patient and the amputated part seems to be consistent with replantation, then the patient is told that replantation will be attempted. It is important to emphasize to any replantation candidate that if the replanted part is made viable again, it will still require weeks to months before final results will be achieved. Even then, results never approach normal function. In addition, it must be emphasized that the replanted part, even if initially viable, may become nonviable during the week to ten days required for
AORN Journal, January 1978, Vol27, No 1
37
Fig 2. Microinstruments used in replantation surgery.
Fig 3. Nylon sutures (sizes 10-0at leit and 1 1-0at right) tied around a human hair for size comparison.
inhospital follow-up. If this occurs, the patient should be aware that a repeat procedure may be indicated. There are a few rigid indications and contraindications to replantation surgery (Table 1). If the surgeon feels that the procedure is anatomically possible and that the results are likely to be functionally and aesthetically better than amputation, replantation is indicated. Relative indications and contraindications are accepted by most replantation surgeons, but exceptions to any rule exist. Few patients are refused replantation on the basis of psychologic instability alone. Most patients can accept the replanted part better than a n amputation stump. Possible exceptions to this exist when the amputation has been self-inflicted. In these cases, careful psychiatric evaluation is crucial to an ultimately successful replantation, although very few suicide attempts result in total amputation. In the operating room, anesthesia is usually rendered by long-acting axillary or supraclavicular block. This avoids some of the problems of lengthy general anesthesia. Intravenous fluids
38
as well as antibiotics are continued, and 1oo/o dextran 40 solution is started at 25 cc per hour. The patient is given support stockings, footboard, and water- or air-mattress support to avoid pressure ulcer formation. A Foley catheter is often used or should be readily available. The surgical replantation team consists of surgeons and nurses who have expertise in clinical microvascular surgery as it applies to replantation. In the past, the laboratory time required to achieve this expertise has probably been exaggerated, but the clinical experience required to deliver a successful replantation has been underestimated. Nonetheless, the support and backup of multiple available surgeons in a replantation team cannot be overemphasized. This is particularly true when a patient has multiple amputations or when a replantation has to be repeated shortly after the initial procedure. Recent instrumentation advances have greatly facilitated replantation surgery. The operating diploscope allows the surgeon and his assistant to view and repair structures with a facil-
AORN Journal, January 1978, Vol27, No 1
Fig 4. Repaired ariery only 0.3 mm across. (Photograph courtesy of Robert Acland, MD) ity not possible in the past. Small forceps, needle holders, and microvascular clamps (Fig 2) are complemented by 10-0 and 11-0 nylon suture material (Fig 3). These instruments and materials allow micronerve, artery, and vein repair to be done in structures that have a n external diameter of 1 mm or less (Fig 4). No two replantation operations are the same, but the basic operative sequence of events, listed in Table 2, is Table 2
Extremity replantation steps 1. Amputated part to operating room with
cooling 2. General surgical evaluation of patient 3. Tetanus toxoid and intravenous antibi-
otics 4. Debridement
5. Bony shortening, fixation, and periosteal
closure 6. Extensor tendon repair
Dorsal venous anastomoses Volar arterial repair Flexor and tendon repair Nerve repair 11. Skin closure 7. 8. 9. 10.
usually followed. Bony shortening, as in t h e case shown in Figure 5 , allows tension-free soft tissue, nerve, and vascular repairs. Appropriate tendon shortening can lessen the junctional scar process that inhibits postoperative motion and can help avoid extensor mechanism imbalance, particularly in the replanted finger. Venous and arterial repairs are done using some type of microvascular approximating clamp (Fig 6). Usually, fewer sutures a r e needed in repair of the lower pressure venous system than in the higher pressure arterial system. Toward the end of a long operation, the patient will frequently need sedation, analgesia, or even general anesthesia if the operating time required is greater than 12 to 16 hours. After replantation, a protective, immobilizing, pressure-free dressing is applied that allows for observation of the amputated part and appropriate elevation of the extremity. Postoperative care is summarized in Table 3. Patient monitoring is directed by the nursing staff in the recovery room and then on the unit. A flow sheet can be helpful in recording important circulatory changes. Each time the pa-
AORN Journal, January 1978, V o l 2 7 , No 1
39
Replantation sequence
First three photographs in series are reprinted from “Digital replantation-selection, technique, and results” by H E Kleinert et a1 (in Orthopedic Clinics of North America, April 1977, 309-318, courtesy of W B Saunders Co).
40
AORN Journal, January 1978, Vol27, No I
tient is checked, the following should be noted on a flow chart: time color temperature 0 drainage hematocrit parameters. There is no good substitute for close follow-up evaluation by both nursing and surgical staffs. If capillary refill, color, temperature, or swelling suggests a problem worsening over several hours, the patient should be considered for return to the operating room for at least a dressing change and possibly vascular reexploration. Temperature probe recording and evaluation by a Doppler flow meter hold promise for circulation evaluation in the future. On the unit, extremity evaluation, intravenous fluids, dextran, and antibiotics are continued. Aspirin is begun to lessen platelet adhesiveness, and intravenous heparin may be used in selected circumstances. The original dressing is usually not changed for ten days unless otherwise indicated. Postoperative pain is usually minimal and should be controlled initially by intramuscular medications and later by oral analgesics. Although a detailed approach to rehabilitation following replantation is not within the scope of this article, it is Table 3
Postoperative management
Fig 5. Upper left: Thumb of 18-year-oldmale amputated in meat-cutting accident. Lower left: Bony shortening andinternal wire fixation. Upper right: Eighteen months postreplantation. Lower right: Opposition with no disability.
Bed rest, 48 hours; decubitus care Transfuse hematocrit ) 25% Anticoagulants: ASA 300 mg PO TID Dextran 500 cc IV QD Hand elevation No dressing change for seven days Q1 hour monitoring for 48 hours using flow sheet Q3 hour monitoring for five days using flow sheet
AORN Journal, January 1978, Vol27, No 1
41
Nursing care during replantation Several additional points regarding nursing care of patients undergoing replantation were made at the 1977 AORN Congress presentationby James W May,Jr, MD; Abbie L Thurmond, RN; and Harold E Kleinert, MD. The speakers continuously stressed care of the whole patient-not to let other, perhaps more vital, needs be obscured by the more dramatic possibility of replantation. Many accidents that result in amputation may have caused additional, life-threateninginjuries that need to be treated before transportation to a replantation referral center for replantation is considered. Once transport has been decided on, careful attention must be given to accurate record keeping and transmittal of information regarding medications, personal history, and allergies. In addition to proper care of the patient,each of the speakers cautioned of the need for proper care of the severed part. The part must be transported with the patient, placed in a sterile dressing in a plastic bag, and stored in a container of ice. If dry ice is used, the part could become frozen and hence useless. Nurses must not forget the concomitant care of the patient's family members, who often have been hastily uprooted in being taken to the referralhospital. Often the family members do not understand quite what has happened and what is being attempted. They should be told to expect a procedure that will last at least 10 or 12 hours. It is important for the operating room nurses to check in periodically with the family for reassurance and to let them know how the operation is progressing, especially since it lasts so long. Hospital social service departments, if available, can be helpful. In preparing for the operation, nurses need to make sure that padding is adequate, especially around the head, heels, scapula, and sacrum. During breaks in the procedure, the nurses may be asked to massage these areas or repositionthe patient if he has moved. Sometimes headphones with music are used to help the patient remain calm. For nurses in the recovery room, Thurmond stressed the importance of the intravenous
42
fluid sheet, checking for breath sounds and blood pressure every 15 minutes, and encouraging coughing and deep breathing. Positioning is also important, especially since the patient may have just come from 14 hours on his back on the operating table. Replanted fingers in the dressing need to be checked carefully because "small manipulations can cause great damage," Thurmond cautioned. One must be careful not to damage anything by probing in the dressing with forceps. If any problems do occur, the surgeons should be contacted immediately, for a return to the operating room may be necessary. Replantation patients generally have relatively minor pain, Thurmond reported. They are often more likely to require mild sedation (such as with diazepam) than pain medications. Thurmond also stressed that patients must be told they cannot smoke because the vasoconstrictive action of the nicotine and the resulting decreased blood flow could easily meanthat the replantedpart would not survive. In cleaning microinstruments, which are so fine-tippedthe ends are difficult to see with the naked eye, Dr May suggested that it is a good practice to cap them with rubber tubing so that they never come into sharp contact with another piece of metal. The tubing can be left on during steam or gas sterilization and until the surgeons are ready to use them.
AORN Journal, January 1978, Vol27, No I
Fig 6. Microclamp designed by Robert Acland, MD, holding vein for suturing.
important to consider the subject briefly because this period converts a viable replanted part into a successful replantation effort. Immediately after the amputation, many things happen to the patient that are totally new to him. He is rapidly transported in a unique fashion to an alien hospital setting and receives an operation that he likely has never heard of before. Postoperatively, if all goes well, he may be the recipient of much admiration and congratulations by the hospital staff and lay public alike. It is only after he is home and the original dressing is off that he truly appreciates the realistic loss that has been suffered. It is during this time that the patient desperately needs support from the nursing and surgical personnel with whom he h a s become familiar a n d trusts. With physical and occupational therapy, the patient can work toward making his replanted part more functional. Through this, he can gain a feeling of accomplishment. In the long-term postoperative period, most patients are able to return to a functional position in society within six months’ time.5 Many will benefit from secondary surgical procedures. U1timately, as with any surgery, the patient’s perception of his result will reflect a combination of factors, including replantation surgical care, replantation
nursing care, and patient cooperation. Replantation surgery is a reality. It is the responsibility of all professionals involved in this surgical frontier to be aware of replantation as a possibility and to reflect this awareness by positive action, not only in the emergency ward and operating room but in the postoperative period as well. 0 Notes 1. R A Malt, C F McKhann, “Replantation of severed arms,” Journal of the American Medical Association 189 (1 964) 1 14-120. 2. H Herbsrnan, D J Lafer, G W Shaftan, “Successful replantation of an amputated hand: Case report,” Annals of Surgery 163 (1 966) 137-143. 3. S Kornatsu, S Tamai, “Successful replantation of a completely cut-off thumb,” Plastic and Reconstructive Surgery 42 ( 1 968) 374-377. 4. B Cohen, J W May, Jr, J S Daley, H H Young, “Successfulpenis replantation with microneurovascular repair,”Plasticand ReconstructiveSurgery 59 (1976) 276-280. 5. A J Weiland, et al, “Replantation of digits and hands: Analysis of surgical techniques and functional results in 71 patients with 86 replantations,” Journal of Hand Surgery 2 (! 977) 1- 12.
AORN Journal, January 1978, Val 27, No 1
43
T
Amputation: Injury to replantation
James W May, Jr, MD Abbie L Thurmond, RN Harold E Kleinert, MD
James W May, Jr, MD, is an instructor in
surgery at Harvard Medical School in Boston and an assistant in surgery at Massachusetts General Hospital, Boston. Dr May received his AB degree from the University of Kentucky in Lexington and his MD from Northwestern University Medical School in Chicago. Abbie L Thurmond, R N , is supervisor of the
recovery room, Jewish Hospital, Louisville. She is a diploma graduate of Sts Mary and Elizabeth Hospital in Louisville. Harold E Kleinert, MD, is clinical professor of surgery at the University of Louisville School of Medicine in Louisville and the Indiana University-Purdue University School of Medicine in Indianapolis. A graduate of the University of Michigan in Ann Arbor, Dr Kleinert received his MD from Temple University Medical School in Philadelphia.
AORN Journal, January 1978, V o l 2 7 , No 1
36
Fig 7. Early painting of the patron saints of physicians, Cosmos and Damian, transplanting the leg of a fallen Ethiopian onto a tower bell custodian whose leg was tumorous.
in November 1962,2 but the first successful digital replantation was not noted until 1966, when Komatsu and Tamai reported a successful thumb rep l a n t a t i ~ nThe . ~ first finger replantation was likely done in China in 1967, but this case was not officially reported in the literature. Since the late 19609, all anatomical levels of human extremity replantation have been reported. Recently, a successful microvascular human penis replantation has been rep ~ r t e dSuccessful .~ replantation in humans is now done commonly not only in China and the United States but in many other areas of the world as well. The successful replantation of an amputated part requires the smooth cooperation of a specialized team of professionals. The outcome of this surgical effort can significantly change the course of a patient’s life. The immediatecare of the patient and injured part is crucial. Following an amputation injury, appreciation of the fact that surgical replantation may be possible is fundamental. Occasionally, this will not be recognized until the victim is hospitalized. When this has occurred, questioning the patient and his
36
companions will frequently uncover useful information about the accident and the whereabouts of the amputated part. If the part has been or can be retrieved, the stage for replantation can be set. It is better t o err on the side of referring a patient with his amputated part to a replantation center even if replantation is not possible than to deny a patient a possible replantation option for fear of referring an “inappropriate patient,” It is important to know your local replantation referral lines. Valuable time can be saved in the process of direct referral when appropriate notification of the referral center has been made. It is very important to make it clear to the patient that referral is being arranged for replantation evaluation but not for replantation itself. This can greatly reduce the disappointment factor if replantation is not believed to be possible or to be in the patient’s best interest. The single most important step following an amputation injury is evaluation and treatment of the patient. This evaluation should consist of a complete history and physical examination.
AORN Journal, January 1978,Vol27, No 1
Bleeding can usually be stopped a t the amputation site after saline cleansing and irrigation by pressure application with a sterile dressing. Small muscular peripheral arteries as in the forearm and hand frequently go into spasm after total transection, thus making hemostasis with pressure reasonably simple. Clamp or tourniquet damage to the vessels, nerves, a n d tissues must be avoided. Before the patient is transported to the referral center, an intravenous infusion should be started through a large 16 or 18 intravenous catheter in a dorsal peripheral vein (opposite hand), and intravenous cephalothin plus appropriate tetanus prophylaxis should be administered. The patient should be kept NPO and made as comfortable as possible. Frequently, intramuscular diazepam and meperidine will help decrease anxiety and pain, but if blood loss has been extensive, intramuscular medications should be given with caution or not a t all. The extremity should be elevated. The amputated part should be washed with sterile saline, wrapped in a sterile gauze, and placed inside a plastic bag. The plastic bag should then be immersed in ice inside a n insulated container. This single refrigeration maneuver can extend greatly the length of time that can safely elapse before blood supply is restored to the amputated part. Under ideal circumstances, successful replantation cases have been reported after more than 30 hours of ischemia, although shorter time intervals are obviously preferable. Transportation itself has played a n important role in the changing picture of replantation surgery. One hundred years ago, the patient was transported by carriage, horseback, or boat to the hospital with the hope of having his amputation stump closed successfully as a life-saving measure. Today, a simi-
~~
Table 1
Indications and contraindications for replantation Indications Selected single digit amputation Multidigit amputation Partial or total hand amputation Contraindications Patient refusal Damaged vessels, nerves, and supporting tissues Age limitation Constitutional disease lar individual is likely transported by jet aircraft, helicopter, or modern ambulance service to a replantation center with the expectation of a successful replantation from the viewpoint of viability and function. When the patient and amputated part arrive at the referral center, coordinated teamwork is essential in delivering a viable and successful replantation. Initially, the patient is reexamined and assessed by a surgical team to see if transportation has been well tolerated. The extent of extremity injury is then evaluated to see if replantation is possible. Following this, a second surgical team takes the amputated part to the operating room for evaluation both grossly and with the operating microscope. If evaluation of both the patient and the amputated part seems to be consistent with replantation, then the patient is told that replantation will be attempted. It is important to emphasize to any replantation candidate that if the replanted part is made viable again, it will still require weeks to months before final results will be achieved. Even then, results never approach normal function. In addition, it must be emphasized that the replanted part, even if initially viable, may become nonviable during the week to ten days required for
AORN Journal, January 1978, Vol27, No 1
37
Fig 2. Microinstruments used in replantation surgery.
Fig 3. Nylon sutures (sizes 10-0at leit and 1 1-0at right) tied around a human hair for size comparison.
inhospital follow-up. If this occurs, the patient should be aware that a repeat procedure may be indicated. There are a few rigid indications and contraindications to replantation surgery (Table 1). If the surgeon feels that the procedure is anatomically possible and that the results are likely to be functionally and aesthetically better than amputation, replantation is indicated. Relative indications and contraindications are accepted by most replantation surgeons, but exceptions to any rule exist. Few patients are refused replantation on the basis of psychologic instability alone. Most patients can accept the replanted part better than a n amputation stump. Possible exceptions to this exist when the amputation has been self-inflicted. In these cases, careful psychiatric evaluation is crucial to an ultimately successful replantation, although very few suicide attempts result in total amputation. In the operating room, anesthesia is usually rendered by long-acting axillary or supraclavicular block. This avoids some of the problems of lengthy general anesthesia. Intravenous fluids
38
as well as antibiotics are continued, and 1oo/o dextran 40 solution is started at 25 cc per hour. The patient is given support stockings, footboard, and water- or air-mattress support to avoid pressure ulcer formation. A Foley catheter is often used or should be readily available. The surgical replantation team consists of surgeons and nurses who have expertise in clinical microvascular surgery as it applies to replantation. In the past, the laboratory time required to achieve this expertise has probably been exaggerated, but the clinical experience required to deliver a successful replantation has been underestimated. Nonetheless, the support and backup of multiple available surgeons in a replantation team cannot be overemphasized. This is particularly true when a patient has multiple amputations or when a replantation has to be repeated shortly after the initial procedure. Recent instrumentation advances have greatly facilitated replantation surgery. The operating diploscope allows the surgeon and his assistant to view and repair structures with a facil-
AORN Journal, January 1978, Vol27, No 1
Fig 4. Repaired ariery only 0.3 mm across. (Photograph courtesy of Robert Acland, MD) ity not possible in the past. Small forceps, needle holders, and microvascular clamps (Fig 2) are complemented by 10-0 and 11-0 nylon suture material (Fig 3). These instruments and materials allow micronerve, artery, and vein repair to be done in structures that have a n external diameter of 1 mm or less (Fig 4). No two replantation operations are the same, but the basic operative sequence of events, listed in Table 2, is Table 2
Extremity replantation steps 1. Amputated part to operating room with
cooling 2. General surgical evaluation of patient 3. Tetanus toxoid and intravenous antibi-
otics 4. Debridement
5. Bony shortening, fixation, and periosteal
closure 6. Extensor tendon repair
Dorsal venous anastomoses Volar arterial repair Flexor and tendon repair Nerve repair 11. Skin closure 7. 8. 9. 10.
usually followed. Bony shortening, as in t h e case shown in Figure 5 , allows tension-free soft tissue, nerve, and vascular repairs. Appropriate tendon shortening can lessen the junctional scar process that inhibits postoperative motion and can help avoid extensor mechanism imbalance, particularly in the replanted finger. Venous and arterial repairs are done using some type of microvascular approximating clamp (Fig 6). Usually, fewer sutures a r e needed in repair of the lower pressure venous system than in the higher pressure arterial system. Toward the end of a long operation, the patient will frequently need sedation, analgesia, or even general anesthesia if the operating time required is greater than 12 to 16 hours. After replantation, a protective, immobilizing, pressure-free dressing is applied that allows for observation of the amputated part and appropriate elevation of the extremity. Postoperative care is summarized in Table 3. Patient monitoring is directed by the nursing staff in the recovery room and then on the unit. A flow sheet can be helpful in recording important circulatory changes. Each time the pa-
AORN Journal, January 1978, V o l 2 7 , No 1
39
Replantation sequence
First three photographs in series are reprinted from “Digital replantation-selection, technique, and results” by H E Kleinert et a1 (in Orthopedic Clinics of North America, April 1977, 309-318, courtesy of W B Saunders Co).
40
AORN Journal, January 1978, Vol27, No I
tient is checked, the following should be noted on a flow chart: time color temperature 0 drainage hematocrit parameters. There is no good substitute for close follow-up evaluation by both nursing and surgical staffs. If capillary refill, color, temperature, or swelling suggests a problem worsening over several hours, the patient should be considered for return to the operating room for at least a dressing change and possibly vascular reexploration. Temperature probe recording and evaluation by a Doppler flow meter hold promise for circulation evaluation in the future. On the unit, extremity evaluation, intravenous fluids, dextran, and antibiotics are continued. Aspirin is begun to lessen platelet adhesiveness, and intravenous heparin may be used in selected circumstances. The original dressing is usually not changed for ten days unless otherwise indicated. Postoperative pain is usually minimal and should be controlled initially by intramuscular medications and later by oral analgesics. Although a detailed approach to rehabilitation following replantation is not within the scope of this article, it is Table 3
Postoperative management
Fig 5. Upper left: Thumb of 18-year-oldmale amputated in meat-cutting accident. Lower left: Bony shortening andinternal wire fixation. Upper right: Eighteen months postreplantation. Lower right: Opposition with no disability.
Bed rest, 48 hours; decubitus care Transfuse hematocrit ) 25% Anticoagulants: ASA 300 mg PO TID Dextran 500 cc IV QD Hand elevation No dressing change for seven days Q1 hour monitoring for 48 hours using flow sheet Q3 hour monitoring for five days using flow sheet
AORN Journal, January 1978, Vol27, No 1
41
Nursing care during replantation Several additional points regarding nursing care of patients undergoing replantation were made at the 1977 AORN Congress presentationby James W May,Jr, MD; Abbie L Thurmond, RN; and Harold E Kleinert, MD. The speakers continuously stressed care of the whole patient-not to let other, perhaps more vital, needs be obscured by the more dramatic possibility of replantation. Many accidents that result in amputation may have caused additional, life-threateninginjuries that need to be treated before transportation to a replantation referral center for replantation is considered. Once transport has been decided on, careful attention must be given to accurate record keeping and transmittal of information regarding medications, personal history, and allergies. In addition to proper care of the patient,each of the speakers cautioned of the need for proper care of the severed part. The part must be transported with the patient, placed in a sterile dressing in a plastic bag, and stored in a container of ice. If dry ice is used, the part could become frozen and hence useless. Nurses must not forget the concomitant care of the patient's family members, who often have been hastily uprooted in being taken to the referralhospital. Often the family members do not understand quite what has happened and what is being attempted. They should be told to expect a procedure that will last at least 10 or 12 hours. It is important for the operating room nurses to check in periodically with the family for reassurance and to let them know how the operation is progressing, especially since it lasts so long. Hospital social service departments, if available, can be helpful. In preparing for the operation, nurses need to make sure that padding is adequate, especially around the head, heels, scapula, and sacrum. During breaks in the procedure, the nurses may be asked to massage these areas or repositionthe patient if he has moved. Sometimes headphones with music are used to help the patient remain calm. For nurses in the recovery room, Thurmond stressed the importance of the intravenous
42
fluid sheet, checking for breath sounds and blood pressure every 15 minutes, and encouraging coughing and deep breathing. Positioning is also important, especially since the patient may have just come from 14 hours on his back on the operating table. Replanted fingers in the dressing need to be checked carefully because "small manipulations can cause great damage," Thurmond cautioned. One must be careful not to damage anything by probing in the dressing with forceps. If any problems do occur, the surgeons should be contacted immediately, for a return to the operating room may be necessary. Replantation patients generally have relatively minor pain, Thurmond reported. They are often more likely to require mild sedation (such as with diazepam) than pain medications. Thurmond also stressed that patients must be told they cannot smoke because the vasoconstrictive action of the nicotine and the resulting decreased blood flow could easily meanthat the replantedpart would not survive. In cleaning microinstruments, which are so fine-tippedthe ends are difficult to see with the naked eye, Dr May suggested that it is a good practice to cap them with rubber tubing so that they never come into sharp contact with another piece of metal. The tubing can be left on during steam or gas sterilization and until the surgeons are ready to use them.
AORN Journal, January 1978, Vol27, No I
Fig 6. Microclamp designed by Robert Acland, MD, holding vein for suturing.
important to consider the subject briefly because this period converts a viable replanted part into a successful replantation effort. Immediately after the amputation, many things happen to the patient that are totally new to him. He is rapidly transported in a unique fashion to an alien hospital setting and receives an operation that he likely has never heard of before. Postoperatively, if all goes well, he may be the recipient of much admiration and congratulations by the hospital staff and lay public alike. It is only after he is home and the original dressing is off that he truly appreciates the realistic loss that has been suffered. It is during this time that the patient desperately needs support from the nursing and surgical personnel with whom he h a s become familiar a n d trusts. With physical and occupational therapy, the patient can work toward making his replanted part more functional. Through this, he can gain a feeling of accomplishment. In the long-term postoperative period, most patients are able to return to a functional position in society within six months’ time.5 Many will benefit from secondary surgical procedures. U1timately, as with any surgery, the patient’s perception of his result will reflect a combination of factors, including replantation surgical care, replantation
nursing care, and patient cooperation. Replantation surgery is a reality. It is the responsibility of all professionals involved in this surgical frontier to be aware of replantation as a possibility and to reflect this awareness by positive action, not only in the emergency ward and operating room but in the postoperative period as well. 0 Notes 1. R A Malt, C F McKhann, “Replantation of severed arms,” Journal of the American Medical Association 189 (1 964) 1 14-120. 2. H Herbsrnan, D J Lafer, G W Shaftan, “Successful replantation of an amputated hand: Case report,” Annals of Surgery 163 (1 966) 137-143. 3. S Kornatsu, S Tamai, “Successful replantation of a completely cut-off thumb,” Plastic and Reconstructive Surgery 42 ( 1 968) 374-377. 4. B Cohen, J W May, Jr, J S Daley, H H Young, “Successfulpenis replantation with microneurovascular repair,”Plasticand ReconstructiveSurgery 59 (1976) 276-280. 5. A J Weiland, et al, “Replantation of digits and hands: Analysis of surgical techniques and functional results in 71 patients with 86 replantations,” Journal of Hand Surgery 2 (! 977) 1- 12.
AORN Journal, January 1978, Val 27, No 1
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