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Fig. 4.11. Revascularization in major limb injury starts with placement of an arterial shunt to limit ischemia time and myonecrosis.

Oral pain medication is given to provide comfort and reduce anxiety. Chlorpro-mazine (Thorazine) 25 mg is given three times a day to relieve anxiety and provide peripheral vasodilation. Hydration with saline solution is maintained at 125 cc to 150 cc per hour for the first 5 days. The replanted part is monitored for color, turgor, capillary refill, and warmth. Surface temperature monitoring of the digit has proven useful in indicating adequate vascularity of the digit. A surface probe is attached to the skin of the replanted part, and periodic recordings of the part are taken by the nursing staff. If the temperature falls below 30°C, the part is assumed to have poor perfusion, and the cause for the compromised circulation is located and corrected. Other techniques of monitoring the digit include transcutaneous oxygen measurement and laser Doppler flowmetry.64

At the conclusion of the case, I routinely place a catheter adjacent to the median nerve at the level of the distal forearm and infuse bupivicaine 0.5% at a rate of 2 cc per hour to provide peripheral sympatholysis for 5 days postoperatively. This provides excellent pain relief in addition to its sympatholytic effect. If the catheter malfunctions, it can easily be replaced percutaneously at the bedside.

If the replanted part appears to be in jeopardy, several actions can be taken to reestablish flow. First, the patient should be evaluated for hydration status. If dehydrated, then a 500 cc saline bolus can be administered. A bolus of heparin can be given to reverse vascular clotting. Removal of factors that may be causing anxiety may prove useful. When a sudden loss of perfusion is evident, return to the operating room for re-exploration to remove a thrombus, reanastomosis, or vein graft can save a failing replant but must be done within 4 to 6 hours of perfusion loss to be successful. When venous congestion is unrelieved by position change, leeches can be applied (Fig. 4.12). Rarely is re-exploration beneficial after 72 hours postreplantation.

Fig. 4.12. Application of leeches was successful when venous cogestion developed in this replanged thumb 48 hours postoperative.

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