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Le JP, Truong N, Newland M, Lorenz FJ, Goyal N. The Influence of Vasopressors on Free Flap Outcomes in Head and Neck Cancer Patients. Otolaryngol Head Neck Surg 2024; 171:1008-1016. [PMID: 39101344 DOI: 10.1002/ohn.924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 06/27/2024] [Accepted: 07/20/2024] [Indexed: 08/06/2024]
Abstract
OBJECTIVE To compare free flap outcomes between those who received and did not receive vasopressors (VPs) at the time of free flap reconstruction. STUDY DESIGN This retrospective cohort study includes patients from January 2013 to January 2023. SETTING This multicenter cohort study utilized data from the TriNetX Research Network which includes 80 health care organizations. METHODS Head and neck cancer patients older than 18 years who underwent free flap reconstruction were separated into those who received or did not receive VPs on the day of surgery. The primary outcomes were flap failure defined by need for secondary free flap procedures, blood vessel repair, and other flap revision procedures. RESULTS After propensity score matching, 7446 patients were analyzed. The VP group included 3723 patients (mean age [SD], 62.9 [11.4] years; 2511 males [67.4%]). The non-VP group included 3723 patients (mean age [SD], 63.0 [11.2] years; 2479 males [66.6%]). Free flap outcomes were not statistically different between groups (secondary free flap: 166 [4.5%] VP vs 155 [4.2%] non-VP, P = .04; vessel repair: 314 [8.4%] vs 319 [8.6%], P = .06; other flap revision procedures: 416 [11.2%] vs 449 [12.1%], P = .02). Bony flaps were found to have decreased rates of vessel repair in the VP group (47 [6.1%] vs 69 [9.0%], P = .003]. For secondary outcomes, pneumonia (173 [4.6%] vs 231 [6.2%], P = .0002), urinary tract infection (34 [1.0%] vs 59 [1.6%], P = .0007), and deep vein thrombosis (93 [2.5%] vs 122 [3.3%], P = .004) were significantly different. CONCLUSION VP use is not significantly associated with free flap complications. These results imply that VP use on the same day as surgery may be safe if clinically necessary.
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Affiliation(s)
- John Philip Le
- College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania, USA
| | - Nguyen Truong
- College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania, USA
| | - Mary Newland
- College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania, USA
| | - F Jeffrey Lorenz
- College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania, USA
- Department of Otolaryngology-Head and Neck Surgery, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Neerav Goyal
- Department of Otolaryngology-Head and Neck Surgery, Penn State College of Medicine, Hershey, Pennsylvania, USA
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Bækgaard ES, Madsen BK, Crone V, El-Hallak H, Møller MH, Vester-Andersen M, Krag M. Perioperative hypotension and use of vasoactive agents in non-cardiac surgery: A scoping review. Acta Anaesthesiol Scand 2024. [PMID: 38965670 DOI: 10.1111/aas.14485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 06/03/2024] [Accepted: 06/13/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND Perioperative hypotension is common and associated with adverse patient outcomes. Vasoactive agents are often used to manage hypotension, but the ideal drug, dose and duration of treatment has not been established. With this scoping review, we aim to provide an overview of the current body of evidence regarding the vasoactive agents used to treat perioperative hypotension in non-cardiac surgery. METHODS We included all studies describing the use of vasoactive agents for the treatment of perioperative hypotension in non-cardiac surgery. We excluded literature reviews, case studies, and studies on animals and healthy subjects. We posed the following research questions: (1) in which surgical populations have vasoactive agents been studied? (2) which agents have been studied? (3) what doses have been assessed? (4) what is the duration of treatment? and (5) which desirable and undesirable outcomes have been assessed? RESULTS We included 124 studies representing 10 surgical specialties. Eighteen different agents were evaluated, predominantly phenylephrine, ephedrine, and noradrenaline. The agents were administered through six different routes, and numerous comparisons between agents, dosages and routes were included. Then, 88 distinct outcome measures were assessed, of which 54 were judged to be non-patient-centred. CONCLUSIONS We found that studies concerning vasoactive agents for the treatment of perioperative hypotension varied considerably in all aspects. Populations were heterogeneous, interventions and exposures included multiple agents compared against themselves, each other, fluids or placebo, and studies reported primarily non-patient-centred outcomes.
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Affiliation(s)
| | - Bennedikte Kollerup Madsen
- Department of Anaesthesiology and Intensive Care, Holbæk Hospital, Holbæk, Denmark
- Department of Anaesthesiology and Intensive Care, Zealand University Hospital, Køge, Denmark
| | - Vera Crone
- Department of Anaesthesiology and Intensive Care, Holbæk Hospital, Holbæk, Denmark
| | - Hayan El-Hallak
- Department of Anaesthesiology and Intensive Care, Holbæk Hospital, Holbæk, Denmark
- Department of Anaesthesiology, Copenhagen University Hospital-Gentofte, Hellerup, Denmark
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Morten Vester-Andersen
- Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Anaesthesiology and Intensive Care, Copenhagen University Hospital-Herlev-Gentofte, Herlev, Denmark
| | - Mette Krag
- Department of Anaesthesiology and Intensive Care, Holbæk Hospital, Holbæk, Denmark
- Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
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Zhu A, Perrotta A, Choi V, Haykal S, Zhong T, Hofer SOP, O'Neill AC. Intraoperative vasopressor use does not increase complications in microvascular post-mastectomy breast reconstruction: Experience in 1729 DIEP flaps at a single center. J Plast Reconstr Aesthet Surg 2023; 84:1-8. [PMID: 37315455 DOI: 10.1016/j.bjps.2023.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 02/24/2023] [Accepted: 03/15/2023] [Indexed: 04/05/2023]
Abstract
INTRODUCTION Vasopressors are traditionally avoided in microsurgery due to concerns about their effect on free flap survival. We examine the impact of intraoperative vasopressors on microsurgical outcomes in a large series of DIEP flap breast reconstructions. METHODS A retrospective chart review was performed of patients who underwent DIEP breast reconstruction between January 2010 and May 2020. Intraoperative and postoperative microsurgical outcomes were compared in patients who received vasopressors and those who did not. RESULTS The study included 1102 women who underwent 1729 DIEP. 878 patients (79.7%) received intraoperative phenylephrine, ephedrine, or a combination of both. There was no significant difference in overall complications, intraoperative microvascular events, takebacks for microvascular complications, or partial or total flap loss between groups. Outcomes were not affected by vasopressor type, dose, or timing of administration. The vasopressor group received significantly lower intraoperative fluid volumes. Multivariate logistic regression found a significant association between overall complications and excessive fluids (OR 2.03, 99% CI 0.98-5.18, p = 0.03) but not vasopressor use (OR 0.79, 99% CI 0.64-3.16, p = 0.7) CONCLUSION: This study demonstrates that vasopressors do not adversely affect clinical outcomes after DIEP breast reconstruction. Withholding vasopressors results in excessive intravenous fluid administration and increased postoperative complications.
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Affiliation(s)
- Alice Zhu
- Division of Plastic and Reconstructive Surgery and Division of Surgical Oncology, University Health Network, Department of Surgery, University of Toronto, Canada
| | - Amanda Perrotta
- Division of Plastic and Reconstructive Surgery and Division of Surgical Oncology, University Health Network, Department of Surgery, University of Toronto, Canada
| | - Vincent Choi
- Division of Plastic and Reconstructive Surgery and Division of Surgical Oncology, University Health Network, Department of Surgery, University of Toronto, Canada
| | - Siba Haykal
- Division of Plastic and Reconstructive Surgery and Division of Surgical Oncology, University Health Network, Department of Surgery, University of Toronto, Canada
| | - Toni Zhong
- Division of Plastic and Reconstructive Surgery and Division of Surgical Oncology, University Health Network, Department of Surgery, University of Toronto, Canada
| | - Stefan O P Hofer
- Division of Plastic and Reconstructive Surgery and Division of Surgical Oncology, University Health Network, Department of Surgery, University of Toronto, Canada
| | - Anne C O'Neill
- Division of Plastic and Reconstructive Surgery and Division of Surgical Oncology, University Health Network, Department of Surgery, University of Toronto, Canada.
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Lee S, Ju JW, Yoon S, Lee HJ, Ha JH, Hong KY, Jin US, Chang H, Cho YJ. Norepinephrine preserved flap blood flow compared to phenylephrine in free transverse rectus abdominis myocutaneous flap breast reconstruction surgery: A randomized pilot study. J Plast Reconstr Aesthet Surg 2023; 83:438-447. [PMID: 37311286 DOI: 10.1016/j.bjps.2023.04.080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 04/13/2023] [Accepted: 04/26/2023] [Indexed: 06/15/2023]
Abstract
BACKGROUND Vasopressors are used in up to 85% of cases during free flap surgery. However, their use is still debated with concerns of vasoconstriction-related complications, with rates up to 53% in minor cases. We investigated the effects of vasopressors on flap blood flow during free flap breast reconstruction surgery. We hypothesized that norepinephrine may preserve flap perfusion better than phenylephrine during free flap transfer. METHODS A randomized pilot study was performed in patients undergoing free transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction. Patients with peripheral artery disease, allergies to study drugs, previous abdominal operations, left ventricular dysfunction, or uncontrolled arrhythmias were excluded. Twenty patients were randomized to receive either norepinephrine (0.03-0.10 µg/kg/min) or phenylephrine (0.42-1.25 µg/kg/min) (each n = 10) to maintain a mean arterial pressure of 65-80 mmHg. The primary outcome was differences in mean blood flow (MBF) and pulsatility index (PI) of flap vessels after anastomosis measured using transit time flowmetry in the two groups. Secondary outcomes included flap loss, necrosis, thrombosis, wound infection, and reoperation within 7 days postoperatively. RESULTS After anastomosis, MBF showed no significant change in the norepinephrine group (mean difference, -9.4 ± 14.2 mL/min; p = 0.082), whereas it was reduced in the phenylephrine group (-7.9 ± 8.2 mL/min; p = 0.021). PI did not change in either group (0.4 ± 1.0 and 1.3 ± 3.1 in the norepinephrine and phenylephrine groups; p = 0.285 and 0.252, respectively). There were no differences in secondary outcomes between the groups. CONCLUSION During free TRAM flap breast reconstruction, norepinephrine seems to preserve flap perfusion compared to phenylephrine. However, further validation studies are required.
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Affiliation(s)
- Seohee Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Jae-Woo Ju
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Susie Yoon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Ho-Jin Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Jeong Hyun Ha
- Department of Plastic and Reconstructive Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Ki Yong Hong
- Department of Plastic and Reconstructive Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Ung Sik Jin
- Department of Plastic and Reconstructive Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Hak Chang
- Department of Plastic and Reconstructive Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Youn Joung Cho
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea.
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5
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Safeek R, Bryan J, Heath F, Satteson E, Maurer A, Safa B, Sorice-Virk S. Evidence based recommendations for perioperative vasopressor use and fluid resuscitation in microsurgery. Microsurgery 2023. [PMID: 37052570 DOI: 10.1002/micr.31047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 02/10/2023] [Accepted: 03/29/2023] [Indexed: 04/14/2023]
Abstract
Blood pressure regulation is critical in patients undergoing microsurgical free tissue transfer; however, guidelines for addressing and preventing perioperative hypotension remain highly debated, with two current thought paradigms: (1) intravenous fluid administration with a balanced salt solution (e.g., lactate ringer and normal saline) and/or colloid (e.g., albumin) and (2) vasoactive pharmacological support with vasopressors (e.g., dobutamine, norepinephrine, epinephrine), with fluid administration being the preferred conventional approach. Here, we review the most up to date available literature and summarize currents perspectives and practices for fluid resuscitation and vasopressor use, while offering evidence-based guidelines to each.
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Affiliation(s)
- Rachel Safeek
- Division of Plastic Surgery, Department of Surgery, University of Florida, Gainesville, Florida, USA
| | - Jaimie Bryan
- College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Frederick Heath
- Stanford University School of Medicine, Stanford, California, USA
| | - Ellen Satteson
- Division of Plastic Surgery, Department of Surgery, University of Florida, Gainesville, Florida, USA
| | - Adrian Maurer
- Department of Anesthesiology, University of Florida, Gainesville, Florida, USA
| | - Bauback Safa
- The Buncke Clinic, San Francisco, California, USA
| | - Sarah Sorice-Virk
- Division of Plastic Surgery, Department of Surgery, University of Florida, Gainesville, Florida, USA
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Lentine B, Vaickus M, Shewmaker G, Niu R, Son SJ, Mustafa W, Reist H, Smith EL. Characterizing Intraoperative Vasopressor Use in Total Knee Arthroplasty: A Retrospective Cohort Study. J Knee Surg 2023; 36:216-221. [PMID: 34348400 DOI: 10.1055/s-0041-1731721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Preoperative optimization and protocols for joint replacement care pathways have led to decreased length of stay (LOS)and narcotic use, and are increasingly important in delivering quality, cost savings, and shifting appropriate cases to an outpatient setting. The intraoperative use of vasopressors is independently associated with increased LOS and risk of adverse postoperative events including death, and in total hip arthroplasty, there is an increased risk for intensive care unit (ICU) admission. Our aim is to characterize the patient characteristics associated with vasopressor use specifically in total knee arthroplasty (TKA). We retrospectively reviewed the electronic medical records of a cohort of patients who underwent inpatient primary TKA at a single academic hospital from January 1, 2017 to December 31, 2018. Demographics, comorbidities, perioperative factors, and intraoperative medication administration were compared with multivariate regression to identify patients who may require intraoperative vasopressors. Out of these, 748 patients underwent TKA, 439 patients required intraoperative vasopressors, while 307 did not. Significant independent predictors of vasopressor use were older age (odds ratio [OR] = 1.06, 95% confidence interval [CI]: 1.03-1.08) and history of a prior cerebrovascular accident (CVA; OR = 11.80, CI: 1.48-93.81). While not significant, male sex (OR = 0.72, CI: 0.50-1.04) and regional anesthesia (OR = 0.64, CI: 0.40-1.05) were nearing significance as negative independent predictors of vasopressor use. In a secondary analysis, we did not observe an increase in complications attributable to vasopressor administration intraoperatively. In conclusion, nearly 59% of patients undergoing TKA received intraoperative vasopressor support. History of stroke and older age were significantly associated with increased intraoperative vasopressor use. As the first study to examine vasopressor usage in a TKA patient population, we believe that understanding the association between patient characteristics and intraoperative vasopressor support will help orthopaedic surgeons select the appropriate surgical setting during preoperative optimization.
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Affiliation(s)
- Brandon Lentine
- Department of Orthopaedic Surgery, Boston Medical Center, Boston, Massachusetts
| | - Max Vaickus
- Boston University School of Medicine, Boston, Massachusetts
| | | | - Ruijia Niu
- Department of Orthopaedic Surgery, Boston Medical Center, Boston, Massachusetts
| | - Sung Jun Son
- Boston University School of Medicine, Boston, Massachusetts
| | - Wissam Mustafa
- Department of Anesthesiology, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Hailee Reist
- Department of Orthopaedic Surgery, University of Vermont Medical Center, Burlington, Vermont
| | - Eric L Smith
- Department of Orthopaedic Surgery, New England Baptist Hospital, Boston, Massachusetts
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Ruccia F, Savage JA, Sorooshian P, Lees M, Fesatidou V, Zoccali G. Hyponatremia after Autologous Breast Reconstruction: A Cohort Study Comparing Two Fluid Management Protocols. J Reconstr Microsurg 2023; 39:35-42. [PMID: 36075382 DOI: 10.1055/a-1939-5874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Perioperative fluid management is an important component of enhanced recovery pathways for microsurgical breast reconstruction. Historically, fluid management has been liberal. Little attention has been paid to the biochemical effects of different protocols. This study aims to reduce the risk of postoperative hyponatremia by introducing a new fluid management protocol. METHODS A single-institution cohort study comparing a prospective series of patients was managed using a new "modestly restrictive" fluid postoperative fluid management protocol to a control group managed with a "liberal" fluid management protocol. RESULTS One-hundred thirty patients undergoing microsurgical breast reconstruction, at a single institution during 2021, are reported. Hyponatremia is demonstrated to be a significant risk with the original liberal fluid management protocol. At the end of the first postoperative day, mean fluid balance was +2,838 mL (± 1,630 mL). Twenty-four patients of sixty-five (36%) patients had low blood sodium level, 14% classified as moderate-to-severe hyponatremia. Introducing a new, "modestly-restrictive" protocol reduced mean fluid balance on day 1 to +844 mL (±700) (p ≤ 0.0001). Incidence of hyponatremia reduced from 36 to 14% (p = 0.0005). No episodes of moderate or severe hyponatremia were detected. Fluid intake, predominantly oral water, between 8am and 8pm on the first postoperative day is identified as the main risk factor for developing hyponatremia (odds ratio [OR]: 7; p = 0.019). Modest fluid restriction, as guided by the new protocol, protects patients from low sodium level (OR: 0.25; confidence interval: 95%; 0.11-1.61; p = 0.0014). CONCLUSION The original "liberal" fluid management protocol encouraged unrestricted postoperative oral intake of water. Patients were often advised to consume in excess of 5 L in the first 24 hours. This unintentionally, but frequently, was associated with moderate-to-severe hyponatremia. We present a new protocol characterized by early cessation of intravenous fluid and an oral fluid limit of 2,100 mL/day associated with a significant reduction in the incidence of hyponatremia and fluid overload.
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Affiliation(s)
- Francesca Ruccia
- Department of Plastic Surgery, Queen Victoria Hospital NHS Foundation Trust, East Grinstead, United Kingdom
| | - Jessica Anne Savage
- Plastic and Reconstructive Surgery Department, Salisbury District Hospital, Salisbury, United Kingdom
| | - Parviz Sorooshian
- Department of Plastic Surgery, Queen Victoria Hospital NHS Foundation Trust, East Grinstead, United Kingdom
| | - Matthew Lees
- Department of Anaesthesia and Critical care, Queen Victoria Hospital NHS Foundation Trust, East Grinstead, United Kingdom
| | - Vasiliki Fesatidou
- Department of Plastic Surgery, Queen Victoria Hospital NHS Foundation Trust, East Grinstead, United Kingdom
| | - Giovanni Zoccali
- Department of Plastic Surgery, Queen Victoria Hospital NHS Foundation Trust, East Grinstead, United Kingdom
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8
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Vasopressors Improve Outcomes in Autologous Free Tissue Transfer: A Systematic Review and Meta-analysis. J Plast Reconstr Aesthet Surg 2022; 81:151-163. [DOI: 10.1016/j.bjps.2022.08.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 07/02/2022] [Accepted: 08/18/2022] [Indexed: 11/19/2022]
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9
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Rhee DH, Constantine RS, Colakoglu S, Karimpour-Fard A, Kaoutzanis C, Mathes DW, Chong TW. Clinical Outcomes of Intraoperative Dopamine Infusion for Hypotensive Patients During Breast Reconstruction with Deep Inferior Epigastric Perforator (DIEP) Flaps. J Plast Reconstr Aesthet Surg 2022; 75:2982-2990. [DOI: 10.1016/j.bjps.2022.06.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 06/01/2022] [Accepted: 06/10/2022] [Indexed: 11/27/2022]
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10
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Munro SP, Chang C, Tinker RJ, Anderson IB, Bedford GC, Ragbir M, Ahmed OA. Intraoperative Vasopressor Usage in Free Tissue Transfer: Should We Be Worried? J Reconstr Microsurg 2021; 38:75-83. [PMID: 34229352 DOI: 10.1055/s-0041-1731302] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND The role of vasopressors has long been a subject of debate in microsurgery. Conventional wisdom dictates the avoidance of vasopressor use, due to concerns such as peripheral vasoconstriction, inducing vasospasm of the anastomoses, and leading to failure in perfusion. It has since become common practice in some centers to avoid intraoperative vasopressor use during free tissue transfer surgery. Recent studies have suggested that this traditional view may not be supported by clinical evidence. However, none of these studies have separated vasopressor use by method of administration. METHODS We conducted a retrospective review of our experience of vasopressor use in free flap surgery at a single high-volume center. The outcome measures were flap failure, flap-related complications and overall postoperative complications (reported using the Clavien-Dindo classification). Groups were compared using Chi-square or Fisher's Exact test where appropriate. RESULTS A total of 777 cases in 717 patients were identified. 59.1% of these had vasopressors administered intraoperatively. The overall failure rate was 2.2%, with 9.8% experienced flap-related complications. There was no difference in flap loss when vasopressors were administered, but an increased rate of microvascular thrombosis was noted (p = 0.003). Continuous administration of vasopressors was associated with reduced venous congestion, whereas intermittent boluses increased risk of microvascular thrombosis. CONCLUSION Our study confirms previous findings that intraoperative vasopressor use in free flap surgery is not associated with increased failure rate. Administering vasopressors continuously may be safer than via repeated boluses.
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Affiliation(s)
- Samuel P Munro
- Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Chad Chang
- Department of Plastic Surgery, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
| | - Rory J Tinker
- Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
| | - Iain B Anderson
- Department of Plastic Surgery, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
| | - Geoff C Bedford
- Department of Anesthesia, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Maniram Ragbir
- Department of Plastic Surgery, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
| | - Omar A Ahmed
- Department of Plastic Surgery, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
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Gilmour A, Cutress R, Gandhi A, Harcourt D, Little K, Mansell J, Murphy J, Pennery E, Tillett R, Vidya R, Martin L. Oncoplastic breast surgery: A guide to good practice. Eur J Surg Oncol 2021; 47:2272-2285. [PMID: 34001384 DOI: 10.1016/j.ejso.2021.05.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 04/18/2021] [Accepted: 05/05/2021] [Indexed: 02/08/2023] Open
Abstract
Oncoplastic Breast Surgery has become standard of care in the management of Breast Cancer patients. These guidelines written by an Expert Advisory Group; convened by the Association of Breast Surgery (ABS) and the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS), are designed to provide all members of the breast cancer multidisciplinary team (MDT) with guidance on the best breast surgical oncoplastic and reconstructive practice at each stage of a patient's journey, based on current evidence. It is hoped they will also be of benefit to the wide range of professionals and service commissioners who are involved in this area of clinical practice.
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Affiliation(s)
- A Gilmour
- Canniesburn Plastic Surgery Unit, Glasgow Royal Infirmary, United Kingdom
| | - R Cutress
- University of Southampton and University Hospital Southampton, United Kingdom
| | - A Gandhi
- Manchester Academic Health Sciences Centre & Manchester University Hospitals NHS Trust, Manchester, United Kingdom
| | - D Harcourt
- Centre for Appearance Research, University of the West of England, Bristol, United Kingdom
| | - K Little
- Liverpool Breast Unit, Liverpool University Foundation Trust, United Kingdom
| | - J Mansell
- Gartnavel General Hospital, Glasgow, United Kingdom
| | - J Murphy
- Manchester University Hospitals NHS Trust, United Kingdom
| | | | - R Tillett
- Royal Devon and Exeter NHS Trust, Exeter, United Kingdom
| | - R Vidya
- The Royal Wolverhampton NHS Trust, Wolverhampton, United Kingdom
| | - L Martin
- Liverpool Breast Unit, Liverpool University Foundation Trust, United Kingdom.
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12
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Polanco TO, Shamsunder MG, Hicks MEV, Seier KP, Tan KS, Oskar S, Dayan JH, Disa JJ, Mehrara BJ, Allen RJ, Nelson JA, Afonso AM. Goal-directed fluid therapy in autologous breast reconstruction results in less fluid and more vasopressor administration without outcome compromise. J Plast Reconstr Aesthet Surg 2021; 74:2227-2236. [PMID: 33745850 DOI: 10.1016/j.bjps.2021.01.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 12/03/2020] [Accepted: 01/24/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Aggressive or restricted perioperative fluid management has been shown to increase complications in patients undergoing microsurgery. Goal-directed fluid therapy (GDFT) aims to administer fluid, vasoactive agents, and inotropes according to each patient's hemodynamic indices. This study assesses GDFT impact on perioperative outcomes of autologous breast reconstruction (ABR) patients, as there remains a gap in management understanding. We hypothesize that GDFT will have lower fluid administration and equivocal outcomes compared to patients not on GDFT. METHODS A single-center retrospective review was conducted on ABR patients from January 2010-April 2017. An enhanced recovery after surgery (ERAS) using GDFT was implemented in April 2015. With GDFT, patients were administered intraoperative fluids and vasoactive agents according to hemodynamic indices. Patients prior to April 2015 were included in the pre-ERAS cohort. Primary outcomes included the amount and rate of fluid delivery, urine output (UOP), vasopressor administration, major (i.e., flap failure) and minor (i.e., seroma) complications, and length of stay (LOS). RESULTS Overall, 777 patients underwent ABR (ERAS: 312 and pre-ERAS: 465). ERAS patients received significantly less total fluid volume (ERAS median: 3750 mL [IQR: 3000-4500 mL]; pre-ERAS median: 5000 mL [IQR 4000-6400 mL]; and p<0.001), had lower UOP, were more likely to receive vasopressor agents (47% vs 35% and p<0.001), and had lower LOS (ERAS: 4 days [4-5]; pre-ERAS: 5 [4-6]; and p<0.001) as compared to pre-ERAS patients. Complications did not differ between cohorts. CONCLUSIONS GDFT, as part of ERAS, and the prudent use of vasopressors were found to be safe and did not increase morbidity in ABR patients. GDFT provides individualized perioperative care to the ABR patient.
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Affiliation(s)
- Thais O Polanco
- Department of Surgery, Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Mailbox 24, New York, NY 10065, United States
| | - Meghana G Shamsunder
- Department of Surgery, Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Mailbox 24, New York, NY 10065, United States
| | - Madeleine E V Hicks
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Kenneth P Seier
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Kay See Tan
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Sabine Oskar
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Joseph H Dayan
- Department of Surgery, Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Mailbox 24, New York, NY 10065, United States
| | - Joseph J Disa
- Department of Surgery, Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Mailbox 24, New York, NY 10065, United States
| | - Babak J Mehrara
- Department of Surgery, Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Mailbox 24, New York, NY 10065, United States
| | - Robert J Allen
- Department of Surgery, Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Mailbox 24, New York, NY 10065, United States
| | - Jonas A Nelson
- Department of Surgery, Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Mailbox 24, New York, NY 10065, United States.
| | - Anoushka M Afonso
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY, United States.
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Taylor RJ, Patel R, Wolf BJ, Stoll WD, Hornig JD, Skoner JM, Hand WR, Day TA. Intraoperative vasopressors in head and neck free flap reconstruction. Microsurgery 2021; 41:5-13. [PMID: 33170969 PMCID: PMC8396078 DOI: 10.1002/micr.30677] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Revised: 05/25/2020] [Accepted: 10/02/2020] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Historically, there were concerns vasopressors impair free flap outcomes, but recent studies suggest vasopressors are safe. Here we investigate this controversy by (1) evaluating vasopressors' effect on head and neck free-flap survival and surgical complications, and (2) performing soft tissue and bony subset analysis. PATIENTS AND METHODS Post hoc analysis was performed of a single-blinded, prospective, randomized clinical trial at a tertiary care academic medical center involving patients ≥18 years old undergoing head and neck free flap reconstruction over a 16-month period. Patients were excluded if factors prevented accurate FloTrac™ use. Patients were randomized to traditional volume-based support, or goal-directed support including vasopressor use. Primary data was obtained by study personnel through intraoperative data recording and postoperative medical record review. RESULTS Forty-one and 38 patients were randomized to traditional and pressor-based algorithms, respectively. Flap survival was 95% (75/79). There was no significant difference between the pressor-based and traditional protocols' flap failure (1/38 [3%] vs. 3/41 [7%], RR 0.36, 95% CI of RR 0.04-3.31, p = .63) or flap-related complications (12/38 [32%] vs. 18/41 [44%], RR 0.72, 95% CI 0.40-1.29, p = .36) Soft tissue flaps had surgical complication rates of 12/30 (40%) and 9/27 (33%) for traditional and pressor-based protocols, respectively. Bony flaps had surgical complication rates of 6/11 (55%), and 3/11 (27%) for traditional and pressor-based protocols, respectively. CONCLUSIONS Intraoperative goal-directed vasopressor administration during head and neck free flap reconstruction does not appear to increase the rate of flap complications or failures.
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Affiliation(s)
- Robert J. Taylor
- Department of Otolaryngology—Head & Neck Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Rusha Patel
- Department of Otolaryngology—Head & Neck Surgery, West Virginia University, Morgantown, West Virginia
| | - Bethany J. Wolf
- Division of Biostatistics, Medical University of South Carolina, Charleston, South Carolina
| | - William D. Stoll
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Joshua D. Hornig
- Department of Otolaryngology—Head & Neck Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Judith M. Skoner
- Department of Otolaryngology—Head & Neck Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - William R. Hand
- Department of Anesthesiology, Greenville Health System, Greenville, South Carolina
| | - Terry A. Day
- Department of Otolaryngology—Head & Neck Surgery, Medical University of South Carolina, Charleston, South Carolina
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14
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Grill FD, Wasmaier M, Mücke T, Ritschl LM, Wolff KD, Schneider G, Loeffelbein DJ, Kadera V. 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. J Craniomaxillofac Surg 2019; 48:67-74. [PMID: 31874805 DOI: 10.1016/j.jcms.2019.12.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 08/29/2019] [Accepted: 12/02/2019] [Indexed: 12/16/2022] Open
Abstract
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.
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Affiliation(s)
- Florian D Grill
- Department of Oral and Maxillofacial Surgery, School of Medicine, Technische Universität München, Germany.
| | - Maria Wasmaier
- Department of Anesthesiology, Technische Universität München, Germany
| | - Thomas Mücke
- Department of Oral and Maxillofacial Surgery, School of Medicine, Technische Universität München, Germany; Department of Oral and Maxillofacial Surgery Krefeld, Malteser Kliniken Rhein-Ruhr, Germany
| | - Lucas M Ritschl
- Department of Oral and Maxillofacial Surgery, School of Medicine, Technische Universität München, Germany
| | - Klaus-Dietrich Wolff
- Department of Oral and Maxillofacial Surgery, School of Medicine, Technische Universität München, Germany
| | - Gerhard Schneider
- Department of Anesthesiology, Technische Universität München, Germany
| | - Denys J Loeffelbein
- Department of Oral and Maxillofacial Surgery, School of Medicine, Technische Universität München, Germany; Department of Oral and Maxillofacial Plastic Surgery, Helios Klinikum München West, Academic Teaching Hospital of Ludwig-Maximilians-Universität München, Germany
| | - Vojta Kadera
- Department of Anesthesiology, Technische Universität München, Germany
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Chung JH, Cheon JH, Kim MS, Min DJ, Yoon ES, Lee BI, Park SH, Kim DW. Effects of vasopressors on circulation in the porcine abdominal island flap model. J Plast Reconstr Aesthet Surg 2019; 72:1653-1660. [PMID: 31395456 DOI: 10.1016/j.bjps.2019.06.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 05/14/2019] [Accepted: 06/09/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND During reconstructive surgical procedures, systemic vasopressors are frequently used to maintain normal blood pressure. However, questions have arisen regarding the pharmacologic effects of vasopressors on flap circulation. Many plastic surgeons have expressed concern about the possibility of impaired flap circulation caused by the vasoconstrictive effect of the drugs. However, the opposing argument exists that the increase in mean arterial pressure from vasoactive agents may improve flap perfusion. The purpose of this study was to evaluate the effect of commonly used vasopressors on flap circulation. METHODS The vertical rectus abdominis myocutaneous (VRAM) island flap was raised in five female pigs (38.2∼40.7 kg). Hemodynamic parameters were measured continuously by a carotid arterial catheter. A bi-directional transonic vascular doppler flow probe and Laser Doppler perfusion monitor (LDPM) unit were applied to record the continuous change in pedicle artery flow and microvascular perfusion following intravenous administration of dopamine (3, 5, 10µg/kg/minute), dobutamine (1.25, 2.5, 5µg/kg/minute), and norepinephrine (0.05, 0.1, 0.2µg/kg/minute). RESULTS Both microvascular perfusion and pedicle flow were generally proportional to the mean arterial pressure, and all three vasopressors improved flap perfusion and pedicle flow without deleterious effects. Norepinephrine showed the highest microvascular perfusion and dobutamine showed the highest pedicle flow rate. The mean blood pressure was the only statistically significant factor to affect both microvascular perfusion and pedicle flow (p < 0.0001). CONCLUSION Our results strongly suggest that the foremost three vasopressors can be used for flap surgery without deterioration, and that the maintenance of adequate systemic blood pressure is crucial for good flap circulation.
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Affiliation(s)
- Jae-Ho Chung
- Department of Plastic and Reconstructive Surgery, Korea University Medical Center, 123, Jeokgeum-ro, Danwon-gu, Ansan-si, Gyeonggi-do, 15355, Korea
| | - Jeong-Hyun Cheon
- Department of Plastic and Reconstructive Surgery, Korea University Medical Center, 123, Jeokgeum-ro, Danwon-gu, Ansan-si, Gyeonggi-do, 15355, Korea
| | - Min-Sook Kim
- Department of Plastic and Reconstructive Surgery, Korea University Medical Center, 123, Jeokgeum-ro, Danwon-gu, Ansan-si, Gyeonggi-do, 15355, Korea
| | - Doo-Jae Min
- Department of Anesthesiology and Pain Medicine, Korean University Medical Center, Korea
| | - Eul-Sik Yoon
- Department of Plastic and Reconstructive Surgery, Korea University Medical Center, 123, Jeokgeum-ro, Danwon-gu, Ansan-si, Gyeonggi-do, 15355, Korea
| | - Byung-Il Lee
- Department of Plastic and Reconstructive Surgery, Korea University Medical Center, 123, Jeokgeum-ro, Danwon-gu, Ansan-si, Gyeonggi-do, 15355, Korea
| | - Seung-Ha Park
- Department of Plastic and Reconstructive Surgery, Korea University Medical Center, 123, Jeokgeum-ro, Danwon-gu, Ansan-si, Gyeonggi-do, 15355, Korea
| | - Deok-Woo Kim
- Department of Plastic and Reconstructive Surgery, Korea University Medical Center, 123, Jeokgeum-ro, Danwon-gu, Ansan-si, Gyeonggi-do, 15355, Korea.
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16
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Is opioid-free general anesthesia for breast and gynecological surgery a viable option? Curr Opin Anaesthesiol 2019; 32:257-262. [DOI: 10.1097/aco.0000000000000716] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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17
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Abstract
PURPOSE OF REVIEW Enhanced recovery pathways are a well-described perioperative healthcare program involving evidence-based interventions. Enhanced recovery is designed to standardize techniques such as drug selection and nerve blocks in order to speed recovery and reduce overall hospital costs. RECENT FINDINGS A PubMed literature search was performed for articles that included the terms enhanced recovery and breast reconstruction surgery. The present investigation summarizes enhanced recovery literature related to breast surgery with a focus on breast reconstruction. Enhanced recovery considerations discussed in this review include patient education, preadmission optimization, perforator flap planning, anesthetic techniques, optimized fasting, venous thrombosis prophylaxis, early mobilization, and antimicrobial prophylaxis.
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18
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Parikh RP, Myckatyn TM. Paravertebral blocks and enhanced recovery after surgery protocols in breast reconstructive surgery: patient selection and perspectives. J Pain Res 2018; 11:1567-1581. [PMID: 30197532 PMCID: PMC6112815 DOI: 10.2147/jpr.s148544] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The management of postoperative pain is of critical importance for women undergoing breast reconstruction after surgical treatment for breast cancer. Mitigating postoperative pain can improve health-related quality of life, reduce health care resource utilization and costs, and minimize perioperative opiate use. Multimodal analgesia pain management strategies with nonopioid analgesics have improved the value of surgical care in patients undergoing various operations but have only recently been reported in reconstructive breast surgery. Regional anesthesia techniques, with paravertebral blocks (PVBs) and transversus abdominis plane (TAP) blocks, and enhanced recovery after surgery (ERAS) pathways have been increasingly utilized in opioid-sparing multimodal analgesia protocols for women undergoing breast reconstruction. The objectives of this review are to 1) comprehensively review regional anesthesia techniques in breast reconstruction, 2) outline important components of ERAS protocols in breast reconstruction, and 3) provide evidence-based recommendations regarding each intervention included in these protocols. The authors searched across six databases to identify relevant articles. For each perioperative intervention included in the ERAS protocols, the literature was exhaustively reviewed and evidence-based recommendations were generated using the Grading of Recommendations, Assessment, Development, and Evaluation system methodology. This study provides a comprehensive evidence-based review of interventions to optimize perioperative care and postoperative pain control in breast reconstruction. Incorporating evidence-based interventions into future ERAS protocols is essential to ensure high value care in breast reconstruction.
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Affiliation(s)
- Rajiv P Parikh
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St Louis, MO, USA,
| | - Terence M Myckatyn
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St Louis, MO, USA,
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19
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Knackstedt R, Gatherwright J, Gurunluoglu R. A literature review and meta‐analysis of outcomes in microsurgical reconstruction using vasopressors. Microsurgery 2018; 39:267-275. [DOI: 10.1002/micr.30341] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 03/08/2018] [Accepted: 05/08/2018] [Indexed: 11/06/2022]
Affiliation(s)
- Rebecca Knackstedt
- Department of Plastic & Reconstructive SurgeryCleveland Clinic Cleveland Ohio
| | | | - Raffi Gurunluoglu
- Department of Plastic & Reconstructive SurgeryCleveland Clinic Cleveland Ohio
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