Page 2 of 2 FirstFirst 12
Results 11 to 20 of 20

Thread: Nurses - Advice on postop care for gracilis muscle flap surgery?

  1. #11
    Senior Member
    Join Date
    Jan 2003
    Location
    Madison,Wisconsin, USA
    Posts
    1,498
    Marm, I know that Matt is a sports freak, there are some pretty good hand held (or put on bookstand or pillow) sports games on little electronic game thingies-they are separate from TV use. Techie+Sports=male! Nail a laundry basket on the wall and have him lob balls in-increase or change the angle everyday-maybe the cat will play? Book tapes. Meditation tapes. Would he want a call from us? Man, quad+flat-in-bed=hardtime, so sorry.
    Hang in there, I bet you are and will do a great job. Take a few minutes and get a walk out in the leaves--bring some back for Matt--but spoil yourself shamelessly. You know the drill. God, I wish we were closer. Deb

  2. #12

    has this changed?

    Quote Originally Posted by SCI-Nurse
    Our regimen for a flap like this:

    Air-Fluidized (Clinitron type) bed for 5 weeks. No sitting or head of bed elevation during that time except for 30 degrees elevation with a foam wedge for meals ONLY after the 2nd week.

    No range of motion exercises to the involved hip or knee for 5 weeks. Keep hip and knee in neutral position at all times in bed, even during turns.

    Check incision daily for bleeding, induration (hard areas around the incision) redness, pus, or separation. Leave staples or sutures in for 4-5 weeks, then remove every other one, and remove the rest at the end of 5-6 weeks.

    Increase baclofen dosage to control spasticity/spasms, which if uncontrolled can cause hematoma formation. The pain of the incisions is what increases the spasticity.

    Drains stay in for 3 weeks, or until no drainage for at least 48 hours, whichever is longer.

    Maximize nutrition with extra protein and calories.

    No smoking.

    After the 5th week, continue another week of bedrest but the bed is then changed to a low-air-loss bed.

    During week 5, progressive slow range of motion to involved knee and hip, working up SLOWLY to 90 degrees by the 6th day.

    After week 6, start sitting with the following routine (checking skin after each episode of sitting) No sliding transfers allowed:

    Day 1: sit for 15 minutes (ideally a computerized seating interface study is done at this time).

    Day 2: sit for 15 minutes X2

    Day 3: sit for 15 minutes X2

    Day 4: sit for 30 minutes X2

    Day 5: sit for 30 minutes X2

    Day 6: sit for 30 minutes X2

    Day 7: sit for 45 minutes X2

    Day 8: sit for 45 minutes X2

    Day 9: sit for 45 minutes X2

    Day 10, 11 & 12: sit for 1 hour X2

    Day 13, 14 & 15: sit for 1.5 hours X2

    Day 16, 17, & 18: sit for 2 hours X2

    Day 19, 20 & 21: sit for 2.5 hours X2

    Day 22, 23, & 24: sit for 3 hours X 2

    Day 25, 26, & 27: sit for 3.5 hours X2

    Day 28, 29, & 30: sit for 4 hours X2

    After that, gradually increase to sitting for 1 session daily, first at 4.5, then 5, then 5.5, then 6 and building up to 8-10 hours daily. Avoid going past this for the first 3 months.

    (KLD)
    has this changed as of aug 2008
    "Yesterday's History,Tomorrow's a Mystery"

  3. #13

    gracilis flap surgery drainage

    hi, i had the flap surgery in order to close up the anal opening in october 2008. since then, i have had 10 doses of the FOLFIRI chemo therapy for metastatic rectal cancer. there is a tiny opening for drainage in the anal area--the drainage has continued since october 2008. it consists of mucous and fluid (variously yellow, green, brown) and debris that looks like little seeds or grains. is this normal? what could the debris be?

    --ralph p.

  4. #14
    Get those spasms taken care of. Tell whoever takes care of his baclofen pump then it needs to be increased and I'll bet someone will come out to increase it for you. I had to have mine filled after my last flap surgery and they came out to do everything at my house without problems. With the baclofen pump in, their oral dosage may be nowhere near enough to bring spasms down. Mine kind of tore a few of my stitches apart when they got really bad but my pump was maxed out so there's not much we could do about it other than keep putting them back together. Good luck getting it all taken care of. And don't forget, the new skin, especially at the incision lines, will be really delicate for a while. I've been trying to get over a sore on my incision line for a while now just because I had a bowel movement.
    C-5/6, 7-9-2000
    Scottsdale, AZ

    Make the best out of today because yesterday is gone and tomorrow may never come. Nobody knows that better than those of us that have almost died from spinal cord injury.

  5. #15
    I agree re: taking care of the spasms .... they can definitely make the surgery fail if they get bad enough.
    CKF

  6. #16

    Has post op sitting changed since 2001 and other questions re: gracilis flap

    Quote Originally Posted by SCI-Nurse View Post
    Our regimen for a flap like this:

    Air-Fluidized (Clinitron type) bed for 5 weeks. No sitting or head of bed elevation during that time except for 30 degrees elevation with a foam wedge for meals ONLY after the 2nd week.

    No range of motion exercises to the involved hip or knee for 5 weeks. Keep hip and knee in neutral position at all times in bed, even during turns.

    Check incision daily for bleeding, induration (hard areas around the incision) redness, pus, or separation. Leave staples or sutures in for 4-5 weeks, then remove every other one, and remove the rest at the end of 5-6 weeks.

    Increase baclofen dosage to control spasticity/spasms, which if uncontrolled can cause hematoma formation. The pain of the incisions is what increases the spasticity.

    Drains stay in for 3 weeks, or until no drainage for at least 48 hours, whichever is longer.

    Maximize nutrition with extra protein and calories.

    No smoking.

    After the 5th week, continue another week of bedrest but the bed is then changed to a low-air-loss bed.

    During week 5, progressive slow range of motion to involved knee and hip, working up SLOWLY to 90 degrees by the 6th day.

    After week 6, start sitting with the following routine (checking skin after each episode of sitting) No sliding transfers allowed:

    Day 1: sit for 15 minutes (ideally a computerized seating interface study is done at this time).

    Day 2: sit for 15 minutes X2

    Day 3: sit for 15 minutes X2

    Day 4: sit for 30 minutes X2

    Day 5: sit for 30 minutes X2

    Day 6: sit for 30 minutes X2

    Day 7: sit for 45 minutes X2

    Day 8: sit for 45 minutes X2

    Day 9: sit for 45 minutes X2

    Day 10, 11 & 12: sit for 1 hour X2

    Day 13, 14 & 15: sit for 1.5 hours X2

    Day 16, 17, & 18: sit for 2 hours X2

    Day 19, 20 & 21: sit for 2.5 hours X2

    Day 22, 23, & 24: sit for 3 hours X 2

    Day 25, 26, & 27: sit for 3.5 hours X2

    Day 28, 29, & 30: sit for 4 hours X2

    After that, gradually increase to sitting for 1 session daily, first at 4.5, then 5, then 5.5, then 6 and building up to 8-10 hours daily. Avoid going past this for the first 3 months.

    (KLD)
    -----
    SCI-Nurse,

    Thank you for this information. This is exactly what we were looking for as I am facing the same surgery.

    I am a t8 complete para and my butt issues did not start as a pressure ulcer but rather my entire left butt cheek developed a deep tissue infection (of unknown origin) directly below the ischial tuberosity. After the infection was discovered, I went on multiple broad spectrum antibiotics and two weeks bed rest. After two weeks my butt cheek was looking less inflamed, but a CT showed a 6x9cm mass...

    I was admitted at UPMC and stayed as an inpatient for 5 days. After the MRI the docs eventually decided to open the area expecting an abscess, but found little in there except (infection caused?) fibrous tissue and all cultures were negative... so whatever infection had been there was killed.

    The external incision was small 2x3cm, but there was a large cavernous space inside the butt cheek extending all the way down to the ischium. I was instructed to pack wound with gauze or similar and water irrigate handheld shower twice a day. I do this in the evening after my normal manual digital toileting routine and don't take the external bandage off until after thoroughly cleaning / showering at the end of the shower, irrigate, transfer onto a plastic sterile field on my chair cushion, then transfer to bed to put on the new dressing.

    The general surgeon said they don't usually recommending bed rest / no sitting pressure for this type of thing, which didn't sound like a good idea to me. So I voluntarily choose to do about 2.5 months of very limited sitting bed rest hoping it would help heal the wound faster, but it didn't seem to be healing very quickly.

    We switched from using just Kurlex gauze to also using Aquacel Hydro fiber AG rope. There has never been any signs of infection, but we added the AG dressing because of the worry of how close the wound opening was to my anus and the possibility of it becoming contaminated/infected during toileting. I Eventually we discontinued the Kurlex because it tended to bunch up (creating hard pebble-like areas) inside the wound, which could have posed additional pressure issues. Followed up with the general surgeon who said to keep doing the same.

    We are currently using an Aquacel Hydrofiber AG 4"x5" sheet with the edges trimmed to the wound shape (a 4" pancake). We liked the idea of the hydrofiber because it gels up almost immediately after being placed into (and flattened out) within the wound. This provides more of a soft gel cushion (rather than a hard ball of gauze) and seems to be a softer primary wound packing material. The wound is very clean, but it is very wet and produces very large amounts of exudate that over runs all of the 'new tech' pads we've found on the market including: 6x8" Mepilex Border, Mextra Superabsorbent Pads, and Aquacel Extra Foam dressings between 12 hour dressing changes...even with all the edges taped down.

    It's been 6 months now and external opening of the wound is only 2x3 cm, but the pancake-like wound space still consists of 4" of circular undermining.

    Saw the specialist Dr. Sandeep Kathju at UPMC Wound Care / Plastic Surgery. He said he thought a wound of this size will never heal without flap surgery. That he first recommend taking the hamstring (but that would eliminate any possibility of walking on that leg again), or their second choice would be doing a gracilis muscle flap (as they would do for an able-bodied person). I know the hamstring has a better success rate, but I also like the idea of keeping the possibility of walking again in the future....who knows what great breakthroughs in the future may happen with regards to actually curing paralysis.

    I'm currently trying take in 2g of protein per kg of body weight (155 lbs) = 72kg = 140g of protein ...but this would be something like 40 egg whites a day, so I was thinking of using a muscle milk body builder protein supplement that has 50g protein per 310 calories. Also trying to boost zinc, vitamin C, water.


    How total many calories I should be talking in per day? And any other dietary recommendations?

    Any suggestions on how to better try to heal / shrink / make a better possibility of success flap while waiting surgery this fall?

    Appropriate sitting time vs. quality of life being able to leave the bed...while waiting for surgery? I have alway used a roho tall on my everyday chair and Varilite (Evolution) on my manual standing chair.

    How much standing time should I try to be getting in per day now? The CT did show some beginning signs of osteoporosis?

    What would be best regarding exercise? I have some free weights, chin-up bar, and press bars... but was worried about repeated weighting / unweighting on my chair using them.

    Do you think UPMC can adequately handle something like this (including the post-op) or should I be looking to try and get to someplace like Craig or Good Shepherd? I have Medicare and WV Medicaid as a secondary.

    Do you still use the same sitting regimen (used in 2001) today? Or are their updates?

    And THANK YOU SO MUCH FOR WHAT YOU DO. Its is really hard finding adequate SCI care from someone with actual experience/knowledge in WV (and likely most rural areas) and your contributions really improve the lives for those of us with SCIs etc... Thank you.

    ~e.t.

  7. #17
    Ask the surgeon about a soft tissue flap which does not include muscle. We rarely do full myocutaneous flaps anymore. This way you don't have to sacrifice muscle for possible return or cure someday.

    How total many calories I should be talking in per day? And any other dietary recommendations?
    What is your height and current weight? Male/female? Any amputations? We generally recommend at least 100-120 gm. of dietary protein intake daily as well, as long as your kidneys are healthy. Ask your physician to check your blood zinc level as well, and if low, consider taking a zinc supplement (we use Zinc Sulfate) for 2-3 weeks. A multivitamin (stress-tabs type) is also a good idea.

    Any suggestions on how to better try to heal / shrink / make a better possibility of success flap while waiting surgery this fall? ?
    We often use NPWT (like a VAC) therapy to prepare the wound bed for a flap, as it creates more blood vessels in the surrounding tissues. It should only be used on non-necrotic tissue though.

    Appropriate sitting time vs. quality of life being able to leave the bed...while waiting for surgery? I have alway used a roho tall on my everyday chair and Varilite (Evolution) on my manual standing chair.?
    . Staying on bedrest completely will help your wound now prepare for surgery. Since this appears to be an ischial pressure ulcer, sitting should be avoided in your chair, commode/toilet, and even in bed if the head of the bed is up more than 30 degrees. I hope you are on some type of pressure reducing mattress such as a Dolphin or LAL mattress.

    How much standing time should I try to be getting in per day now? The CT did show some beginning signs of osteoporosis? ?
    Standing is good for ROM, spasticity reduction, better bowel function, and for emotional reasons, but there is no evidence that passive standing does anything to either prevent or improve osteoporosis.

    What would be best regarding exercise? I have some free weights, chin-up bar, and press bars... but was worried about repeated weighting / unweighting on my chair using them.?
    Free weights, and Theraband which you can use in bed.

    Do you think UPMC can adequately handle something like this (including the post-op) or should I be looking to try and get to someplace like Craig or Good Shepherd? I have Medicare and WV Medicaid as a secondary.?
    Talk to your plastic surgeon about how much experience both he and the nursing staff there have in both soft tissue and myocutaneous flaps in people with SCI. I am not familiar with that facility. Would he be putting you on an air fluidized bed, and for how long? How long would he have you in the hospital? Where would you go after that for the rest of your bedrest time (usually 6 weeks if all goes well)? Where would you do your seating program and seating evaluation/prescription of your post-operative cushion/chair?

    Do you still use the same sitting regimen (used in 2001) today? Or are their updates??
    Yes, the sitting program is pretty much unchanged from what is listed above.

    (KLD)

  8. #18
    Quote Originally Posted by SCI-Nurse View Post
    Ask the surgeon about a soft tissue flap which does not include muscle. We rarely do full myocutaneous flaps anymore. This way you don't have to sacrifice muscle for possible return or cure someday.

    What is your height and current weight? Male/female? Any amputations? We generally recommend at least 100-120 gm. of dietary protein intake daily as well, as long as your kidneys are healthy. Ask your physician to check your blood zinc level as well, and if low, consider taking a zinc supplement (we use Zinc Sulfate) for 2-3 weeks. A multivitamin (stress-tabs type) is also a good idea.

    We often use NPWT (like a VAC) therapy to prepare the wound bed for a flap, as it creates more blood vessels in the surrounding tissues. It should only be used on non-necrotic tissue though.

    . Staying on bedrest completely will help your wound now prepare for surgery. Since this appears to be an ischial pressure ulcer, sitting should be avoided in your chair, commode/toilet, and even in bed if the head of the bed is up more than 30 degrees. I hope you are on some type of pressure reducing mattress such as a Dolphin or LAL mattress.

    Standing is good for ROM, spasticity reduction, better bowel function, and for emotional reasons, but there is no evidence that passive standing does anything to either prevent or improve osteoporosis.

    Free weights, and Theraband which you can use in bed.

    Talk to your plastic surgeon about how much experience both he and the nursing staff there have in both soft tissue and myocutaneous flaps in people with SCI. I am not familiar with that facility. Would he be putting you on an air fluidized bed, and for how long? How long would he have you in the hospital? Where would you go after that for the rest of your bedrest time (usually 6 weeks if all goes well)? Where would you do your seating program and seating evaluation/prescription of your post-operative cushion/chair?

    Yes, the sitting program is pretty much unchanged from what is listed above.

    (KLD)

    I am a Male, 36 yo, Height: 6'0, weight: 155 lbs = 72 kg,
    no amputations, no ostomy, toileting Q.D. via digital stimulation / manual removal, use closed system and straight cath, no UTIs, zero spasticity, no history of previous serious pressure ulcers, use a roho tall seat cushion w/ ADI hardback in everyday chair, no smoking, muscles were non-responsive to FES bike

    I live alone, but have official (personal assistant/chore worker 120 hr/mo) and some unofficial supports.

    Currently in home with standard Sleep Number Type Air Bed (adding memory foam topper tomorrow). I always rotate from side to side to stomach every 2-4 hr and haven't had any bed pressure problems so far, but I do worry about my knees if in prone too long (ie forget to set alarm for changing positions during the night) ...they will display light stage 1 redness that quickly resolves.

    Had one re-assessment done with University of Pittsburgh Medical Center
    Dr. Sandeep Kathju - Wound Care Director & Chief of Plastic Surgery
    ...not sure how much SCI specific experience they and post op staff have (but I will inquire). He said he feels it must be a Clinitron Bed post op.

    Since this wound was at least this big or bigger after the first General Surgery Op, it seems like maybe this should have done before general surgery discharged me 5 Months ago?

    So bed bath/toileting now...ugh.

    Insurance:Medicare Primary / WV Medicare secondary
    ... I'm not opposed to travel anywhere to get excellent SCI specific care, but not sure where I'll be able to get WV Medicaid to cover the 20%. I know Good Shepherd and Craig have excellent reputations. I don't think either in-state hospitals (Charleston Area Medical Center or WVU Ruby Memorial) would be options.


    Where else IS recommended for providing excellent SCI/Ischial Wound care?

    How does toileting work during post op if pts are supposed to be motionless (in prone position?) at first?
    I am NOT at all thrilled about the idea of a 'temporary' ostomy and all those additional possible complications.

    Recommended Calorie intake?


    Thank you,
    Eric
    (W-EMT...or was prior to injury)
    Last edited by ericonthego; 06-14-2016 at 02:03 AM.

  9. #19
    Quote Originally Posted by SCI-Nurse View Post
    Ask the surgeon about a soft tissue flap which does not include muscle. We rarely do full myocutaneous flaps anymore. This way you don't have to sacrifice muscle for possible return or cure someday.

    What is your height and current weight? Male/female? Any amputations? We generally recommend at least 100-120 gm. of dietary protein intake daily as well, as long as your kidneys are healthy. Ask your physician to check your blood zinc level as well, and if low, consider taking a zinc supplement (we use Zinc Sulfate) for 2-3 weeks. A multivitamin (stress-tabs type) is also a good idea.

    We often use NPWT (like a VAC) therapy to prepare the wound bed for a flap, as it creates more blood vessels in the surrounding tissues. It should only be used on non-necrotic tissue though.

    . Staying on bedrest completely will help your wound now prepare for surgery. Since this appears to be an ischial pressure ulcer, sitting should be avoided in your chair, commode/toilet, and even in bed if the head of the bed is up more than 30 degrees. I hope you are on some type of pressure reducing mattress such as a Dolphin or LAL mattress.

    Standing is good for ROM, spasticity reduction, better bowel function, and for emotional reasons, but there is no evidence that passive standing does anything to either prevent or improve osteoporosis.

    Free weights, and Theraband which you can use in bed.

    Talk to your plastic surgeon about how much experience both he and the nursing staff there have in both soft tissue and myocutaneous flaps in people with SCI. I am not familiar with that facility. Would he be putting you on an air fluidized bed, and for how long? How long would he have you in the hospital? Where would you go after that for the rest of your bedrest time (usually 6 weeks if all goes well)? Where would you do your seating program and seating evaluation/prescription of your post-operative cushion/chair?

    Yes, the sitting program is pretty much unchanged from what is listed above.

    (KLD)

    I am a Male, 36 yo, Height: 6'0, weight: 155 lbs = 72 kg,
    no amputations, no ostomy, toileting Q.D. via digital stimulation / manual removal, use closed system and straight cath, no UTIs, zero spasticity, no history of previous serious pressure ulcers, use a roho tall seat cushion w/ ADI hardback in everyday chair, no smoking, muscles were non-responsive to FES bike

    I live alone, but have official (personal assistant/chore worker 120 hr/mo) and some unofficial supports.

    Currently in home with standard Sleep Number Type Air Bed (adding memory foam topper tomorrow). I always rotate from side to side to stomach every 2-4 hr and haven't had any bed pressure problems so far, but I do worry about my knees if in prone too long (ie forget to set alarm for changing positions during the night) ...they will display light stage 1 redness that quickly resolves.

    Had one re-assessment done with University of Pittsburgh Medical Center
    Dr. Sandeep Kathju - Wound Care Director & Chief of Plastic Surgery
    ...not sure how much SCI specific experience they and post op staff have (but I will inquire). He said he feels it must be a Clinitron Bed post op.

    Since this wound was at least this big or bigger after the first General Surgery Op, it seems like maybe this should have done before general surgery discharged me 5 Months ago?

    Medicare Primary / WV Medicare secondary
    ... I'm not opposed to travel anywhere to get excellent SCI specific care, but not sure where I'll be able to get WV Medicaid to cover the 20%.
    I know Good Shepherd and Craig have excellent reputations. I don't think either in-state hospitals (Charleston Area Medical Center or WVU Ruby Memorial) would be options.

    Where else IS recommended for providing excellent SCI/Ischial Wound care?

    So bed bath/toileting now...ugh.

    How does toileting work during post op if pts are supposed to be motionless (in prone position?) at first?
    I am NOT at all thrilled about the idea of a 'temporary' ostomy and all those additional possible complications.

    Do most people get a different post-operative cushion/chair?

    Thank you,
    Eric
    (W-EMT...or was prior to injury)

  10. #20
    It would be much better if you could get onto a LAL mattress now (which would mean also getting a hospital bed frame). We also require these for 6 months after the surgery when you return home. Medicare will cover rental of both if you have a documented stage III or IV pressure ulcer.

    Post op if you will be on an air fluidized bed, for how long? How long will you be able to stay in the acute care hospital before they have to move you to a nursing home? Most often it is a maximum of 10 days in the acute care hospital, esp. with Medicare as your primary insurance.

    While on an air fluidized bed you would need to do bowel care on your side, and have someone else do it...I have had too many clients contaminate their wound or even stick a finger through the incision of the flap doing bowel care, so we do not allow that on my unit, and the nurses must do your bowel care for you with you on your side, on Chux (never a bed pan).

    On an air fluidized bed you would not be prone (it doesn't work...can't breathe), but supine (on your back) and side to side, with no head of bed elevation, which can make eating and taking pills a challenge for some. Once you get moved to a LAL mattress (for us, this is no sooner than the 5th week) then you can start to prone. Bowel care is still best done on your side. We don't allow the use of a well-padded commode for bowel care until you are into the sitting program, have at least 2 hours of sitting time, and the commode time is counted as part of your sitting program time allowed.

    (KLD)

Similar Threads

  1. VA Announces Record Budget, Health Care Changes
    By antiquity in forum Health & Science News
    Replies: 0
    Last Post: 01-17-2003, 02:47 PM
  2. Replies: 0
    Last Post: 11-15-2002, 02:19 PM
  3. Muscular Dystrophy Study May Lead to Muscle Regeneration Therapies
    By antiquity in forum Health & Science News
    Replies: 1
    Last Post: 10-11-2002, 12:46 PM
  4. Sun Newspapers 2002 Hospital Directory
    By Max in forum Health & Science News
    Replies: 0
    Last Post: 09-04-2002, 12:39 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •