Excessive intravenous fluid therapy in head and neck cancer surgery

Impact of intraoperative fluid administration and complications in head and neck cancer free flap surgery at a tertiary care hospital of a low and middle-income country

Perioperative fluid administration plays an essential role in head and neck cancer free flap surgery. The impact of intraoperative fluid administration on postoperative complications in head and neck cancer free flap surgery remains ill-defined. All adult patients who underwent a free flap surgery for head and neck cancer between January 2014 and December 2018 were included in the study. A total of 224 patients met the inclusion criteria. The mean age of patients was 45.0 years, and the majority were male (85.7%). Buccal mucosa squamous cell carcinoma (83%) was the most common diagnosis, and anterolateral thigh flap (46.4%) was the most routinely performed procedure. Perioperatively, ringer's lactate was used most abundantly (68.3%). A total of 101 complications were reported in the postoperative period, consisting of 67 medical complications and 34 surgical complications. In conclusion, there is no statistically significant association between the quantity of fluid administration and postoperative complications.

The total amount of fluid administered is associated with postoperative complications in head and neck cancer surgery

Objective

Patients with head and neck cancer often undergo extensive ablative and reconstructive surgery. Many risk factors are unalterable, but some operative variables are possible to adjust. The goal of this study was to estimate the association between operative variables and the incidence of perioperative complications in a contemporary tertiary care university-based head and neck patient population and a Veteran Administration hospital head and neck patient population from an earlier time period.

Methods

We retrospectively reviewed all patients who underwent major head and neck surgery.

Results

Two-hundred-two university patients and 122 veteran patients were reviewed. On multivariable analysis, the total amount of intravenous (IV) fluid received during the procedure was associated with postoperative complications as were patients' weight, American Society of Anesthesiologists (ASA) score, and adult comorbidity evaluation-27 (ACE-27) score. These associations did not depend on whether the patient was treated at the university or veteran hospital.

Conclusion

Our study suggests that the odds of a postoperative complication increase as the total amount of IV fluid increases.

Risk of fluid accumulation after cardiac surgery

Objective

Patients undergoing heart surgery are at high risk of postoperative fluid accumulation due to long procedures and cardiopulmonary bypass. In the present study, we sought to investigate the prevalence of postoperative fluid accumulation and its relation to adverse events in patients undergoing cardiac surgery.

Methods

CAREBANK is prospective, single-center cohort study focusing on the adverse events after cardiac surgery. The study population was divided into 2 groups based on 5% postoperative weight gain. All the in-hospital adverse events are registered on the database. The end points of the present study were length of hospital stay, length of intensive care unit stay, occurrence of new-onset atrial fibrillation after hospital major bleeding episodes major cardiac events, cerebrovascular events, and death. Three-month and 1-year follow-up data also include all major adverse events.

Results

Altogether 1001 adult cardiac surgery patients were enrolled. The most frequent operations were coronary artery bypass grafting (56.3%). Five hundred fifty-four out of 939 (59.0%) patients had ≥5% weight gain during index hospitalization. Patients with a weight gain ≥5% were more likely to be women, have lower body mass index, had heart failure, and more often had preoperative atrial fibrillation. In-hospital period fluid accumulation was associated with reoperation due bleeding and longer total hospital stay. At 3 months' follow-up, weight gain 5% or more was associated with increased occurrence of new-onset atrial fibrillation, this was not reflected in the occurrence of strokes, transient ischemic attacks, or myocardial infarctions.

Conclusions

Postoperative fluid excess is associated with adverse outcomes in cardiac surgery. Women, low-weight patients, and patients with cardiac failure or atrial fibrillation are prone to perioperative fluid accumulation.

Identifying perioperative volume-related risk factors in head and neck surgeries with free flap reconstructions - An investigation with focus on the influence of red blood cell concentrates and noradrenaline use

INTRODUCTION

The amount of fluids administered intraoperatively seems to influence the postoperative outcome, and especially the transfusion of red blood cell concentrates (RBC) are known to have an increased risk of postoperative complications. This prospective study focuses on patients planned with microvascular free flap reconstruction and investigates the effect of various types and amounts of volumes given intraoperatively and on the intensive care unit with regard to overall postoperative complications.

MATERIAL AND METHODS

In this prospective study, 52 consecutive patients planned for reconstruction with microvascular free flaps were included. Intraoperatively administered volumes including blood products were documented by the anesthesiologists as well as volumes given during the intensive care unit stay. Postoperative complications were registered for the entire hospital stay. Statistical analysis was carried out correlating the amount and type of volumes with the incidence of postoperative complications.

RESULTS

The intraoperative use of RBC showed a close to statistically significant increased risk of postoperative complications (mean/SD concentrates: 0.5/1.1 [no complications] vs. 1.0/1.4 [complications], p = 0.058). In a multivariate analysis with stepwise selection the use of human albumin, gelatin, or Ringer's acetate showed no correlation with complications. The overall blood loss, however, had no significant influence on the incidence of complications (mean/SD ml: 1187/761 [no complications] vs. 1004/600 [complications], p = 0.37). The use of noradrenalin during reconstructive surgeries with microvascular flaps bears statistically no increased risk of failure (mean/SD μg/kg/min: 36/23 [no flap loss] vs. 22/15 [flap loss], p = 0.289) or complications (mean/SD μg/kg/min: 34/22 [no complications] vs. 35/23 [complications], p = 0.807).

CONCLUSION

In our investigation, the use of crystalloids and colloids seems to have no influence on the postoperative outcome, but the use of RBC may have an increased overall incidence of postoperative complications. A careful hemostasis to limit the use of RBC remains essential despite available options of substitutions. The use of infusion-pump-administered noradrenaline seems valuable to sustain a stable circulation during surgeries with microvascular free flaps and may have no negative impact on postoperative complications.

Determinants of re-operation for bleeding in head and neck cancer surgery

OBJECTIVE

Post-operative bleeding in the head and neck area is potentially fatal. This 'real world' study sought to assess factors that increase the risk of re-operation for post-operative bleeding in head and neck cancer surgery.

METHODS

A total of 456 patients underwent surgery for head and neck cancer (591 operations). The primary endpoint was re-operation for bleeding.

RESULTS

The rate of re-operation for bleeding was 5 per cent of all operations. Re-operation for bleeding was an independent risk factor for 30-day mortality (odds ratio = 5.27, p = 0.014). Risk factors for re-operation because of bleeding included excessive (more than 4000 ml) fluid administration (over 24 hours) (p < 0.001), heavy alcohol consumption (p = 0.014), pre-operative oncological treatment (p = 0.017), advanced disease stage (p = 0.020) and higher tumour (T) classification (p = 0.034). Operations with more excessive bleeding (700 ml or more) were associated with an increased risk (p = 0.001) of re-operation for post-operative bleeding. Moreover, the risk of re-operation was significantly higher in patients undergoing microvascular surgery compared to those who had no oncological treatment pre-operatively (18 vs 6 per cent, p = 0.001).

CONCLUSION

The 30-day mortality risk increased over 5-fold in patients undergoing re-operation for bleeding.