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

  1. #1

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

    My son just had this surgery a week ago Thursday, to close a right ischial wound that just wouldn't heal.

    Plastic surgeon did the op; she did a great job, but doesn't have tons of experience in care for quads postop. She did want us to take him home day after surgery, as she felt we could care for him better at home than the nurses in the hospital. (Charleston is woefully behind the times with SCI medicine). So he was discharged on a KCI fluid-air bed; she gave us instructions for dressing changes; incision from knee to groin for muscle flap, then it kind of goes under the buttock like the top of a candy cane where the actual sore was.

    He's on IV ertapenum based on the wound/bone cultures they did, through a PICC line; nurses are coming once a week for the dressing change for that.

    There are 2 drains; one at the knee, and one at the groin, which have been draining between 5-20 cc every 2 days; her instructions for those were as long as there's drainage, leave 'em in.

    She said he could elevate to 45 degrees in the bed for meals for the first 2 weeks, then gradually more and more. She's not going to see him for 6 weeks, unless something comes up; then we'll transport via ambulance to the ER, and she'll see him there.

    We have so many questions! Mainly, after the first 2 weeks, can he sit up a little further in the air bed for longer periods of time? Will we have to worry about orthostatic hypotension when he does finally sit/get all the way up? Will he stay in that bed for 6 weeks?

    He's been having more leg spasms; has a baclofen pump that was refilled the day before surgery. I'm assuming the spasms are from lying so still, plus the stimuli from the incisions? Are these normal, par for the course?

    He had conscious sedation/LMA anesthesia, and is using an incentive spirometer, so lung compromise isn't a big issue - should it be? (no problems breathing, wheezing, etc so far)

    They decided only to use TEDS for DVT prophylaxis; she didn't want to use a blood thinner for fear of a hematoma at the wound site. Told us how to range the surgical leg gently below the knee, and normal ranging on the other leg.

    The incisions are clean; we're watching protein intake, he's taking extra C and zinc.

    If you can advise on anything else we should be doing, as well as 'schedule' for gradual sitting up, or anything else you can think of that we haven't covered, I'd sure appreciate it!
    _____________

  2. #2
    Senior Member
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    Marm, no advise, just my best to you, Matt and Chris. I know this has been a long haul for ya'll and hope the healing is quick. Sure have missed you. Deb

  3. #3
    Tx, Deb - was going to call you, but it was totally nutsy this past week. We'll talk soon!
    _____________

  4. #4
    Senior Member lynnifer's Avatar
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    Sounds like things are all taken care of - hope that wound heals. The only thing I can offer is the more time spent down right after the surgery, the better the skin will be in the long run. (I had a wound flap down when I was 15 - not a problem until I scraped the incision scar last November).
    Roses are red. Tacos are enjoyable. Don't blame immigrants, because you're unemployable.

    T-11 Flaccid Paraplegic due to TM July 1985 @ age 12

  5. #5
    Tx, Lynifer - I feel like we've done more educating of the docs than they have of us, lol!

    Anyone have any ideas on keeping from getting bored out of his mind?
    _____________

  6. #6
    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)

  7. #7
    Thank you, KLD - the sitting times schedule is exactly what we were looking for!

    Re the baclofen - Matt has a pump; since we can't get him in to get the dosage increased, would some additional oral baclofen do the trick?

    The drains are acting like they want to come out; there's been 5 ml of drainage in one, and about 10 in the other, over the last 24 hours. No sutures/staples; she just did a subcu closure.

    Tx again! In one sense, we're flattered that the doc thought enough of our care she wanted to send him home right away; on the other hand, I'm petrified we're going to make some stupid mistake.
    _____________

  8. #8
    Marm, Chris and Matt~ Sending good vibes your way. Hope all heals well and that life improves for all.

    For boredon, Netfilck, music, books on tape, mazes, word games, gameboys, playstation all with adaptions, doing detailed plans for a even when he can get up, etc. Let him work to be part of the house planning or a short trip, something to look forward to. Spend time breaking it into small sections. Volunteer to grade papers at home for a local school teacher, read on tape for an elderly or visually impaired person in the community, visit carecure, plan a funraiser, plan high protein vegitarian meals for a week with grocery lists.

    Sorry, some of the suggestions mught not be feasible or simply lame, bottom line, keep the brain busy with details other than recovery.
    Every day I wake up is a good one

  9. #9
    Since he's lying flat, you're right; most aren't feasible; he can't even feed himself right now. Thank god for the baseball playoffs, lol.
    _____________

  10. #10
    Yes, you can supplement with oral baclofen, but be sure to discuss this with his SCI physician first.

    Too soon to pull any of the drains. Leave them alone until there is no drainage for a minimum of 48 hours. We often leave them in 3 weeks or longer to be sure.

    Just be sure to never put any tension on the incision line, and of course avoid pressure to that area. Keep an eye on his lungs (keep up with the incentive spirometer) and be sure he is drinking enough. An air fluidized bed will cause up to 1000 cc. of "insensible" fluid loss daily, and can quickly cause dehydration.

    If any redness, incision separation, etc. is noted when sitting, it is back to downtime until completely resolved, and then backwards on the schedule again.

    (KLD)

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