Postoperative care in ICU versus non-ICU after head and neck free-flap surgery: a systematic review and meta-analysis

Abstract

Objective: Admission to the intensive care unit (ICU) has long been considered as routine by most head and neck surgeons after microvascular free-flap transfer. This study aimed to answer the question 'Is there a difference in the flap survival and postoperative complications rates between admission to intensive care unit (ICU) versus Non-ICU following microvascular head and neck reconstructive surgery?'.

Design: Systematic review, and meta-analysis.

Methods: The PubMed, Embase, Scopus and Cochrane Library electronic databases were systematically searched (till April 2021) to identify the relevant studies. Studies that compared postoperative nursing of patients who underwent microvascular head and neck reconstructive surgery in ICU and non-ICU were included. The outcome variables were flap failure and length of hospital stay (LOS) and other complications. Weighted OR or mean differences with 95% CIs were calculated.

Results: Eight studies involving a total of 2349 patients were included. No statistically significant differences were observed between ICU and non-ICU admitted patients regarding flap survival reported (fixed, risk ratio, 1.46; 95% CI 0.80 to 2.69, p=0.231, I²=0%), reoperation, readmission, respiratory failure, delirium and mortality (p>0.05). A significant increase in the postoperative pneumonia (p=0.018) and sepsis (p=0.033) was observed in patients admitted to ICU compared with non-ICU setting.

Conclusion: This meta-analysis showed that an immediate postoperative nursing in the ICU after head and neck microvascular reconstructive surgery did not reduce the incidence of flap failure or complications rate. Limiting the routine ICU admission to the carefully selected patients may result in a reduction in the incidence of postoperative pneumonia, sepsis, LOS and total hospital charge.

Keywords: facial plastic & reconstructive surgery; head & neck surgery; surgery.

Figure 1

Study flow diagram.

Figure 2

Forest plot of flap survival rate. There was no difference in flap failure between intensive care unit (ICU) and non-ICU admission (fixed, risk ratio, 1.49; 95% CI 0.80 to 2.69, p=0.182, I²=0%). The horizontal lines indicate the 95% CI for the eight included studies. The squares in the middle of the lines indicate the mean effect of the study. The diamond shape at the bottom indicates the 95% CI for the pooled effect.

Figure 3

Forest plot of the incidence of pneumonia. There was statistically significant higher incidence of pneumonia in intensive care unit (ICU) compared with non-ICU nursing (fixed, risk ratio, 2.769; 95% CI 1.193 to 6.424, p=0.018, I²=0%). The horizontal lines indicate the 95% CI for the four included studies. The squares in the middle of the lines indicate the mean effect of the study. The diamond shape at the bottom indicates the 95% CI for the pooled effect.

Figure 4

Forest plot of the incidence of sepsis. There was statistically significant higher incidence of sepsis in intensive care unit (ICU) compared with non-ICU nursing (fixed, RR, 4.23; CI 1.12 to 15.91, p=0.033, I²=0%). The horizontal lines indicate the 95% CI for the five included studies. The squares in the middle of the lines indicate the mean effect of the study. The diamond shape at the bottom indicates the 95% CI for the pooled effect.

Figure 5

Forest plot of length of hospital stay (LOS). There was a statistically insignificant increase in LOS of about 1.5 day in the intensive care unit (ICU) group compared with non-ICU protocol. The horizontal lines indicate the 95% CI for the four included studies. The squares in the middle of the lines indicate the mean effect of the study. The diamond shape at the bottom indicates the 95% CI for the pooled effect.