Consideration on Flap Surgery in Vegetative Patients Having Nosocomial Infection

Kim, Jeong Tae; Kim, Kee Woong; Kim, Yeon Hwan; Kim, Chang Yeon

Abstract

PURPOSE: The vegetative state is a clinical condition with complete unawareness of self and environment, but with preservation of brain-stem functions. Vegetative patients may have nosocomial infections in their wounds, such as pressure sores and infected craniums after cranioplasties. Flap surgery is usually necessary for those wounds, but decision of undergoing surgery is difficult because of various adverse conditions of vegetative patients. We share our experience of several successful flap surgeries in vegetative patients, and evaluate obstacles and requirements to obtain satisfactory results.
METHODS
From December 2005 to September 2008, a total of 4 vegetative patients underwent surgeries. In case of 2 patients with infected artificial craniums, scalp reconstructions with free flaps were performed. In case of other 2 patients with huge pressure sores with sepsis, island flap coverage of wounds was performed. Retrospective study was made of hospitalization period, vegetative period, number of surgeries performed, underlying diseases, causative bacteria, and contents of informed consent.
RESULTS
Mean hospital day was 14 months and mean vegetative period was 17.5 months. Patients underwent average of 4.5 surgeries under general anesthesia. There were several underlying diseases like hypertension, DM, CHF and chronic anemia. MRSA (Methicilinresistant Staphylococcus aureus) was cultured from every patient's wounds. Informed consent included a warning for high mortality and a need of attentive familial cooperation.
CONCLUSION
There are three requirements for doing flap surgeries in vegetative patients. First, to prevent aggravation of brain damage and underlying diseases by general anesthesia, multidisciplinary team approach is needed. Second, operation should be beneficial for prolonging patient's lifespan. Third, because postoperative care is very difficult and long hospitalization is needed, detailed informed consent and highly cooperative attitude of family should be confirmed before operation.