Impact of intraoperative vasopressor use in free tissue transfer for head, neck, and extremity reconstruction. Ann Plast Surg. 2014;72:S135-S138. [PMID: 24691344 DOI: 10.1097/sap.0000000000000076]

Perioperative hypotension and use of vasoactive agents in non-cardiac surgery: A scoping review

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.

The Impact of Intraoperative Vasopressor Use and Fluid Status on Flap Survival in Traumatic Lower Extremity Reconstruction

BACKGROUND

 Historically, the use of intraoperative vasopressors during free flap lower extremity (LE) reconstruction has been proposed to adversely affect flap survival due to concerns about compromising flap perfusion. This study aims to analyze the impact of intraoperative vasopressor use and fluid administration on postoperative outcomes in patients undergoing traumatic LE reconstruction.

METHODS

 Patients who underwent LE free flap reconstruction between 2015 and 2023 at a Level I Trauma Center were retrospectively reviewed. Statistical analysis was conducted to evaluate the association between vasopressor use and intraoperative fluids with partial/complete flap necrosis, as well as the differential effect of vasopressor use on flap outcomes based on varying fluid levels.

RESULTS

 A total of 105 LE flaps were performed over 8 years. Vasopressors were administered intraoperatively to 19 (18.0%) cases. Overall flap survival and limb salvage rates were 97.1 and 93.3%, respectively. Intraoperative vasopressor use decreased the overall risk of postoperative flap necrosis (OR 0.00005, 95% CI [9.11 × 10-9-0.285], p = 0.025), while a lower net fluid balance increased the risk of this outcome (OR 0.9985, 95% CI [0.9975-0.9996], p = 0.007). Further interaction analysis revealed that vasopressor use increased the risk of flap necrosis in settings with a higher net fluid balance (OR 1.0032, 95% CI [1.0008-1.0056], p-interaction =0.010).

CONCLUSION

 This study demonstrated that intraoperative vasopressor use and adequate fluid status may be beneficial in improving flap outcomes in LE reconstruction. Vasopressor use with adequate fluid management can optimize hemodynamic stability when necessary during traumatic LE microvascular reconstruction without concern for increased risk of flap ischemia.

Evidence based recommendations for perioperative vasopressor use and fluid resuscitation in microsurgery

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.

Outcomes of perioperative vasopressor use for hemodynamic management of patients undergoing free flap surgery: A systematic review and meta-analysis

This systematic review and meta-analysis investigates the objective evidence regarding outcomes in head and neck free flap surgeries using vasoactive agents in the perioperative period. A search was performed in PubMed, Cochrane, Web of Science, and Scopus databases. Inclusion criteria were clinical studies in which vasopressors were used in head and neck free flap surgery during the intraoperative and perioperative period. Eighteen studies (n = 5397) were included in the qualitative analysis and nine (n = 4381) in the meta-analysis. There was no difference in flap failure outcomes with perioperative vasopressor use in head and neck free flap surgery (n = 4015, OR = 0.93, 95% CI [0.60, 1.44]). When patients received vasopressors perioperatively, there was an associated decrease in flap-specific complications (n = 3881, OR = 0.69, 95% CI [0.55, 0.87]). Intraoperative vasopressor use does not negatively impact free tissue transfer outcomes in head and neck surgery and may reduce overall free flap complications.

Intraoperative Invasive Blood Pressure Monitoring in Flap-Based Lower Extremity Reconstruction

BACKGROUND

Despite the lack of clear indications for the use of intra-arterial lines (IALs) for intraoperative hemodynamic monitoring, they are often used in a variety of settings. In this retrospective review of patients undergoing free tissue transfer (FTT) for lower extremity (LE) reconstruction, we sought to (1) identify patient factors associated with IAL placement, (2) compare hemodynamic measurements obtained via IAL versus noninvasive blood pressure (NIBP) monitoring, and (3) investigate whether method of hemodynamic monitoring affected intraoperative administration of blood pressure-altering medications.

METHODS

Patients undergoing LE FTT from January 2017 through June 2020 were retrospectively reviewed. Patients were pair matched based on flap donor site, sex, and body mass index to identify patient factors associated with IAL placement. Methods previously described by Bland and Altman (Lancet. 1986;327:307-310) were used to investigate agreement between IAL and NIBP measurements.

RESULTS

Sixty-eight patients were included with 34 patients in the IAL group and 34 in the NIBP group. Older patients (P = 0.03) and those with a higher Charlson Comorbidity Index (P = 0.05) were significantly more likely to have an IAL placed. Agreement analysis demonstrated that mean arterial pressures calculated from IAL readings were as much as 31 points lower or 28 points higher than those from NIBP. Bias calculations with this extent of difference suggest poor correlation between IAL readings and NIBP (R2 = 0.3027). There was no significant difference between groups in rate of administration of blood-pressure altering medications.

CONCLUSIONS

Surgeons should consider the risks and benefits of IAL placement on a case-by-case basis, particularly for patients who are young and healthy. Our findings highlight the need for clearer guidance regarding the use of IAL in patients undergoing LE FTT.

Association of Continuous Intraoperative Vasopressor Use With Reoperation Rates in Head and Neck Free-Flap Reconstruction

Importance

Continuous vasopressor use in free-flap reconstruction is a point of contention among microvascular surgeons despite data demonstrating safety.

Objective

To investigate the association between continuous vasopressor use and the incidence of reoperation in the early postoperative period.

Design, Setting, and Participants

In this cohort study, a retrospective medical record review was conducted of patients who underwent head and neck free-flap reconstructions between May 1, 2014, and October 31, 2019, in an academic tertiary care center. All patients undergoing free-flap reconstruction for head and neck defects were included.

Exposures

Continuous intraoperative vasopressors.

Main Outcomes and Measures

Patient medical records were queried for demographic variables; intraoperative use of vasopressors; vasopressor type, duration, and infusion rate; reoperation within the first 5 postoperative days; and reason for reoperation.

Results

Four hundred forty-nine consecutive free-flap reconstructions were performed on 426 patients. The mean age was 62 years (IQR, 55.7-71.1); 293 patients were men (65.3%), 380 were White (84.6%), 55 were Black (12.2%), and 14 were of other race or ethnicity (3.1%). A total of 174 patients received a continuous vasopressor during their reconstruction. Twenty-three reoperations occurred within 5 days postoperatively, 8 of which included vasopressors during initial intervention. Vasopressor type had no association with reoperation (4.5% vs 5.5% [8/174 vs 15/275, respectively] for patients who received vasopressors vs those who did not) (dobutamine odds ratio [OR], 1.02 [95% CI, 0.21-2.91]; dopamine OR, 1.48 [95% CI, 0.33-4.26]). No difference was seen in the duration (dobutamine OR, 1.50 [95% CI, 0.78-2.90]; dopamine OR, 0.87 [95% CI, 0.59-1.28]) or infusion rate (dobutamine OR, 1.50 [95% CI, 0.99-1.02]; dopamine OR, 1.00 [95% CI, 0.99-1.01]) of vasopressors between patients who underwent reoperation and those who did not. Analysis after the exclusion of reasons for reoperation that did not represent possible microvascular anastomosis failure (eg, Doppler malfunction, donor site complications) showed no increased propensity for reoperation (OR, 1.18; 95% CI, 0.27-3.9).

Conclusions and Relevance

In this cohort study, use of vasopressors for extensive periods intraoperatively during free-tissue transfer appeared to have no association with the rate of reoperation within 5 days of intervention, regardless of agent used, simultaneous use of agents, type of free-flap operation performed, or reason for reoperation. This study adds to the body of literature supporting the judicious use of vasopressors in patients requiring intraoperative pharmacological pressure support during free-flap reconstruction.

Intraoperative Vasopressor Usage in Free Tissue Transfer: Should We Be Worried?

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.

Best New Flaps and Tips for Success in Microsurgery

LEARNING OBJECTIVES

After reviewing this article, the participant should be able to: 1. Understand the trends in reconstruction using flaps. 2. Understand the surgical anatomy and elevation of the three best flaps: superficial circumflex iliac artery perforator, profunda artery perforator, and thin anterolateral thigh perforator. 3. Understand the core principle and the modern evolution of microsurgery. 4. Be acquainted with new microsurgical tips to maximize outcomes.

SUMMARY

Plastic surgery has a long history of innovation expanding the conditions we can treat, and microsurgical reconstruction has played a pivotal role. Freestyle free flaps now create another paradigm shift in reconstructive surgery, relying on a better understanding of anatomy and physiology, opening the door to patient-specific customized reconstruction. This article aims to provide information regarding useful and practical new advances in the field of microsurgery.

Intraoperative vasopressors in head and neck free flap reconstruction

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.

Serial Perioperative Assessment of Free Flap Perfusion With Laser Angiography

Study Design

Prospective cohort study.

Objective

Reconstruction with microvascular free flaps is quite predictable but excessive fluids intraoperatively and excessive use of vasopressors have been implicated in postoperative complications. However, vasopressors assist in limiting fluid administration and counteract vasodilatory effects of general anesthetics, while maintaining proper intravascular volume. This is of paramount importance during surgery to ensure adequate tissue and organ perfusion. The purpose of this study is to quantify perfusion changes in free flaps at specific time points during peri- and postoperative periods, incorporating SPY technology.

Methods

A prospective study of patients who underwent free flap reconstruction was conducted (n = 9), using SPY laser angiography with indocyanine green to assess effects of general anesthetics and vasopressors on flap perfusion. Free flaps were evaluated prior to pedicle division, after inset and anastomosis, and in the immediate postoperative setting. Mean perfusion, mean arterial pressure, total operative time, fluid shifts, and vasopressor use were recorded. Data were analyzed with univariate and multivariable analyses.

Results

Those with major complications in this cohort, on average received less vasopressors, had shorter operation times and less blood loss, however, they received more fluids intraoperatively.

Conclusion

Changes in mean perfusion to the free flap during the intraoperative and immediate postoperative period are nominal.

Anesthesia and Enhanced Recovery After Head and Neck Surgery

Enhanced recovery protocols have been developed from gastrointestinal, colorectal, and thoracic surgery populations. The basic tenets of head and neck enhanced recovery are: a multidisciplinary team working around the patient, preoperative carbohydrate loading, multimodal analgesia, early mobilization and oral feeding, and frequent reassessment and auditing of protocols to improve patient outcomes. The implementation of enhanced recovery protocols across surgical populations appear to decrease length of stay, reduce cost, and improve patient satisfaction without sacrificing patient quality of care or changing readmission rates. This article examines evidence-based enhanced recovery interventions and tailors them to a major head and neck surgery population.

Intraoperative Use of Vasopressors Does Not Increase the Risk of Free Flap Compromise and Failure in Cancer Patients

OBJECTIVE

To examine the effects of vasopressors on free flap outcomes.

BACKGROUND

Most micro-surgeons avoid the use of vasopressors during free flap surgery due to concerns of vasoconstriction, which could potentially lead to vascular thrombosis and flap failure. Previous studies lack the statistical power to draw meaningful conclusions.

METHODS

All free flaps between 2004 and 2014 from a single institution were reviewed retrospectively. Vasopressors were given intraoperatively as an intravenous bolus when blood pressure dropped >20% from baseline. The timing of intraoperative vasopressor administration was divided into 3 phases: from anesthesia induction to 30 minutes before the start of flap ischemia (P1); end of P1 to 30 minutes after revascularization (P2); end of P2 to end of surgery (P3). Agents included phenylephrine, ephedrine and calcium chloride.

RESULTS

A total of 5671 free flap cases in 4888 patients undergoing head and neck, breast, trunk, or extremity reconstruction were identified. Vasopressors were used intraoperatively in 85% of cases. The overall incidence of pedicle compromise was 3.6%, with a flap loss rate of 1.7%. A propensity score matching analysis showed that intraoperative use of any agents at any time of surgery was not associated with increased overall pedicle compromise [51/1584 (3.2%) vs 37/792 (4.7%); P = 0.074] or flap failure rates [26/1584 (1.6%) vs 19/792 (2.4%); P = 0.209]. Rather, there was less risk of venous congestion [33/1584 (2.1%) vs 31/792 (3.9%); P = 0.010].

CONCLUSIONS

Intraoperative use of phenylephrine, ephedrine, or calcium chloride as an intravenous bolus does not increase flap compromise and failure rates in cancer patients.

Assessment of DIEP Flap Perfusion with Intraoperative Indocyanine Green Fluorescence Imaging in Vasopressor-Dominated Hemodynamic Support Versus Liberal Fluid Administration: A Randomized Controlled Trial With Breast Cancer Patients

BACKGROUND

Dogmatic denial of vasopressor agents for blood pressure regulation during free-flap surgery is associated with concomitant large-volume intraoperative fluid administration. Yet, the doctrinal banning of vasopressors during microvascular breast reconstruction still is a subject of controversy. Several retrospective observations have recently drawn attention to serious iatrogenic consequences of intravenous crystalloid overload in microsurgery such as thrombus formation and increased flap failure rates.

METHODS

This prospective randomized controlled trial investigated the potential effects of fluid-restrictive vasopressor-dominated hemodynamic support (FRV) compared with vasopressor-restrictive liberal fluid administration (LFA) on clinically relevant perfusion of the deep inferior epigastric perforator (DIEP) flap via intraoperative indocyanine green (ICG) fluorescence imaging. The primary end point of the study was quantitative assessment of the percentage of insufficiently perfused tissue (NP) on the overall flap. Major complications were assessed as secondary end points.

RESULTS

In 44 DIEP flap breast reconstructions after mastectomy, FRV circulatory support resulted in no statistically significant difference in total flap perfusion as detected via ICG fluorescence imaging in direct comparison with a traditional LFA strategy (NP_FRV, 31.8% ± 12.2% vs NP_LFA, 29.5% ± 13.3%; p = 0.559). One flap failure was registered with LFA, whereas no major complication occurred in the FRV cohort.

CONCLUSIONS

According to the results of this study, neither a norepinephrine concentration of 0.065 ± 0.020 μg/kg/min (FRV) nor fluid administration of 5.1 ± 2.2 ml/kg/h (LFA) has a clinically significant impact on microperfusion in a standard DIEP flap procedure for breast reconstruction. Consistent with the current literature reporting a rise in complications with intraoperative fluid over-resuscitation, one flap failure occurred in the LFA cohort.

Does Perioperative Use of Noradrenaline Affect Free Flap Outcome Following Reconstructive Microvascular Surgeries? A Retrospective Analysis

Background:

Over concerns of vasoconstriction leading to free flap failure, it has been a common practice to avoid vasopressors for the maintenance of blood pressure during reconstructive microvascular surgeries.

Aims:

The aim of this study was to assess the impact of use of noradrenaline in the perioperative period on outcome of free flaps in patients who underwent reconstructive surgeries as compared to those who did not receive noradrenaline.

Settings and Design:

Retrospective analysis was conducted at a tertiary care institute.

Materials and Methods:

A total of 120 patients who underwent free flap surgeries were included in the study, of which 102 patients who did not require noradrenaline perioperatively formed the control group (Group C), whereas those who required noradrenaline infusion constituted the study group (Group N). Data regarding flap outcome at discharge, intraoperative hemodynamics and temperature were documented.

Statistical Test Used:

Chi-square test, Mann–Whitney test, Independent sample t-test, and paired t-test were used for statistical analysis.

Results:

Out of 120 patients, 15% (n = 18) patients required noradrenaline (Group N). In Group N, 27.78% (n = 5) patients and in Group C, 22.55% (n = 23) were re-explored. Four patients in Group C and none in Group N had a poor flap outcome (3.92% vs. 0%). There was no significant difference in surgical duration and the volume of crystalloids received in both groups. Preoperative hemoglobin levels were lower in Group N; intraoperatively, they were more hypothermic and needed more colloids, blood, and plasma.

Conclusion:

Perioperative use of noradrenaline did not adversely affect free flap survival in patients who underwent microvascular reconstructive surgeries. Although re-exploration rate was marginally increased with use of noradrenaline, the final flap outcome was unaffected.

Intraoperative hypotension and flap loss in free tissue transfer surgery of the head and neck

BACKGROUND

In free flap head and neck reconstructions, hemodynamic management is complicated by the deleterious effects of excessive crystalloid administration. Patients may undergo periods of hypotension or excess fluid administration. The purpose of this study was to present our examination of the hypotheses that intraoperative hypotension and blood pressure lability are associated with increased fluid administration and flap failure.

METHODS

We reviewed the records of 445 patients undergoing head and neck surgery involving free tissue transfer. We used multivariate logistic regression to examine the relationship between hemodynamic variables and flap loss (primary outcome) and other complications.

RESULTS

On multivariate analysis, intraoperative hypotension and large-volume fluid administration were associated with flap loss. Neither blood pressure lability nor vasopressor administration was significantly associated to our primary outcome.

CONCLUSIONS

Intraoperative hypotension is associated to flap failure in head and neck free tissue transfer surgeries, as is large-volume fluid administration.

Epidural Anesthesia to Facilitate Organ Blood Flow During the First Penile Transplantation in the United States: A Case Report

Regional anesthesia has been used to help create local sympathectomy and improve blood flow in plastic surgery procedures involving tissue grafts and flaps. However, anesthetic techniques that reduce systemic vascular resistance must be used with caution in patients with aortic stenosis (AS). Combined neuraxial and general anesthesia with careful titration of the local anesthetic dose can be a safe approach for patients with AS undergoing microvascular procedures. We present the anesthetic management of the first North American penile transplant, on an obese patient with moderate AS.

Consensus Review of Optimal Perioperative Care in Breast Reconstruction: Enhanced Recovery after Surgery (ERAS) Society Recommendations

BACKGROUND

Enhanced recovery following surgery can be achieved through the introduction of evidence-based perioperative maneuvers. This review aims to present a consensus for optimal perioperative management of patients undergoing breast reconstructive surgery and to provide evidence-based recommendations for an enhanced perioperative protocol.

METHODS

A systematic review of meta-analyses, randomized controlled trials, and large prospective cohorts was conducted for each protocol element. Smaller prospective cohorts and retrospective cohorts were considered only when higher level evidence was unavailable. The available literature was graded by an international panel of experts in breast reconstructive surgery and used to form consensus recommendations for each topic. Each recommendation was graded following a consensus discussion among the expert panel. Development of these recommendations was endorsed by the Enhanced Recovery after Surgery Society.

RESULTS

High-quality randomized controlled trial data in patients undergoing breast reconstruction informed some of the recommendations; however, for most items, data from lower level studies in the population of interest were considered along with extrapolated data from high-quality studies in non-breast reconstruction populations. Recommendations were developed for a total of 18 unique enhanced recovery after surgery items and are discussed in the article. Key recommendations support use of opioid-sparing perioperative medications, minimal preoperative fasting and early feeding, use of anesthetic techniques that decrease postoperative nausea and vomiting and pain, use of measures to prevent intraoperative hypothermia, and support of early mobilization after surgery.

CONCLUSION

Based on the best available evidence for each topic, a consensus review of optimal perioperative care for patients undergoing breast reconstruction is presented.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, V.

Paravertebral Blocks Reduce Narcotic Use Without Affecting Perfusion in Patients Undergoing Autologous Breast Reconstruction

BACKGROUND

Autologous breast reconstruction offers excellent long term outcomes after mastectomy. However, maintaining adequate postoperative analgesia remains challenging. Use of paravertebral blocks (PVBs) reduces postoperative narcotic use and length of stay, and enhanced recovery protocols with mixed analgesia methods are gaining popularity, but few studies have explored the intraoperative effects of these interventions.

METHODS

Patients who underwent abdominally based autologous breast reconstruction between 2010 and 2016 were compiled into a retrospective database. We used electronic medical records to determine demographics, as well as perioperative and intraoperative vital signs and narcotic, anxiolytic, crystalloid, colloid, blood product, and vasopressor requirements, and postoperative complications. Results were compared between patients who had a PVB and those who did not and those who had a PVB alone and those who followed our enhanced recovery protocol using standard statistical methods and adjusting for preoperative values.

RESULTS

A total of 170 patients were included in the study. Sixty-six had a PVB, and 104 did not. Of the 66 who had a PVB, 19 followed our enhanced recovery protocol. Patients who did not have a PVB required 171.6 mg of total narcotic medication in the perioperative period, those with a PVB alone required 146.9 mg, and those who followed the ERAS protocol 95.2 mg (p = 0.01). There was no difference in intraoperative mean arterial pressure, time with mean arterial pressure <80% of baseline, vasopressor use, or fluid requirement. There was no difference in complication rate.

CONCLUSIONS

PVBs and an enhanced recovery protocol reduce the use of narcotic medications in autologous breast reconstruction without impacting intraoperative hemodynamics. Breast reconstruction after mastectomy restores body image and improves health-related quality of life, satisfaction with appearance and physical, psychosocial, and sexual well-being (Donovan et al. in J Clin Oncol 7(7):959-968, 1989; Eltahir et al. in Plast Reconstr Surg 132(2):201e-209e, 2013; Jagsi et al. in Ann Surg 261(6):1198-1206, 2015). For patients pursuing breast reconstruction, there are two major options: prosthetic (tissue expander/implant) or autologous reconstruction. However, while providing exceptional long-term outcomes, postoperative pain and length of hospital stay remains a major challenge preventing more widespread adoption of autologous breast reconstruction (Albornoz et al. in Plast Reconstr Surg 131(1):15-23, 2013; Gurunluoglu et al. in Ann Plast Surg 70(1):103-110, 2013; Kulkarni et al. in Plast Reconstr Surg 132(3):534-541, 2013; Sbitany et al. in Plast Reconstr Surg 124(6):1781-1789, 2009). Acute postoperative pain contributes to prolonged hospital stays, increased narcotic use, and associated risks of the aforementioned.

Microvascular surgery in the congenital cardiac patient: A case series exploring feasibility and practical applications

BACKGROUND

Pediatric congenital heart disease patients are at risk for vascular injuries during surgical procedures or when the arterial system is accessed for monitoring or diagnostic studies. Our treatment of emergent situations in this patient population using microvascular techniques shows the feasibility of such techniques.

METHODS

A retrospective chart review of patients aged 0-18 years with congenital heart disease identified six patients who underwent microvascular surgery by the senior surgeon from June 2007 to May 2015. We studied this series, highlighting technical aspects of surgery and perioperative care to determine their effect on outcome.

RESULTS

Six patients with congenital cardiac defects requiring cardiothoracic surgery were studied, body weight ranging from 3.2 to 19.1 kg at the time of surgery. Five suffered iatrogenic arterial injury to the heart or vessels used for access or diagnostic studies, including coronary artery laceration, brachial artery thrombosis, and external iliac artery avulsion. Interventions included direct end-to-end repair and vein grafting. Vessel diameter averaged 1 mm. Patients received vasopressors intraoperatively and were on vasopressors and antihypertensives postoperatively. One patient died because of disseminated intravascular coagulation on postoperative day 17, but bypass graft was patent prior to death. The rest survived with clinical evidence of patency of the repaired vessel for a long-term.

CONCLUSIONS

Microsurgical intervention may be life-saving as a revascularization procedure to the heart by direct coronary repair or bypass grafting. Iatrogenic injuries to the limb may cause critical ischemia; limbs can be salvaged by microsurgical repair. Despite technical and physiological challenges, microsurgery is feasible and sometimes crucial in this patient population.

Face transplantation: Anesthetic challenges

Face transplantation is a complex vascular composite allotransplantation (VCA) surgery. It involves multiple types of tissue, such as bone, muscles, blood vessels, nerves to be transferred from the donor to the recipient as one unit. VCAs were added to the definition of organs covered by the Organ Procurement and Transplantation Network Final Rule and National Organ Transplant Act. Prior to harvest of the face from the donor, a tracheostomy is usually performed. The osteotomies and dissection of the midface bony skeleton may involve severe hemorrhagic blood loss often requiring transfusion of blood products. A silicon face mask created from the facial impression is used to reconstruct the face and preserve the donor’s dignity. The recipient airway management most commonly used is primary intubation of an existing tracheostoma with a flexometallic endotracheal tube. The recipient surgery usually averages to 19-20 h. Since the face is a very vascular organ, there is usually massive bleeding, both in the dissection phase as well as in the reperfusion phase. Prior to reperfusion, often, after one sided anastomosis of the graft, the contralateral side is allowed to bleed to get rid of the preservation solution and other additives. Intraoperative product replacement should be guided by laboratory values and point of care testing for coagulation and hemostasis. In face transplantation, bolus doses of pressors or pressor infusions have been used intraoperatively in several patients to manage hypotension. This article reviews the anesthetic considerations for management for face transplantation, and some of the perioperative challenges faced.

Vascularized Composite Allotransplantation: Medical Complications

The objective of this review is to summarize the collective knowledge regarding the risks and complications in vascularized composite tissue allotransplantation (VCA), focusing on upper extremity and facial transplantation. The field of VCA has entered its second decade with an increasing experience in both the impressive good outcomes, as well as defining challenges, risks, and experienced poor results. The limited and selective publishing of negative outcomes in this relatively new field makes it difficult to conclusively evaluate outcomes of graft and patient survival and morbidities. Therefore, published data, conference proceedings, and communications were summarized in an attempt to provide a current outline of complications. These data on the medical complications of VCA should allow for precautions to avoid poor outcomes, data to better provide informed consent to potential recipients, and result in improvements in graft and patient outcomes as VCA finds a place as a therapeutic option for selected patients.

Toward noninvasive assessment of flap viability with time-resolved diffuse optical tomography: a preclinical test on rats

The noninvasive assessment of flap viability in autologous reconstruction surgery is still an unmet clinical need. To cope with this problem, we developed a proof-of-principle fully automatized setup for fast time-gated diffuse optical tomography exploiting Mellin-Laplace transform to obtain three-dimensional tomographic reconstructions of oxy- and deoxy-hemoglobin concentrations. We applied this method to perform preclinical tests on rats inducing total venous occlusion in the cutaneous abdominal flaps. Notwithstanding the use of just four source-detector couples, we could detect a spatially localized increase of deoxyhemoglobin following the occlusion (up to 550 μM in 54 min). Such capability to image spatio-temporal evolution of blood perfusion is a key issue for the noninvasive monitoring of flap viability.

Management of Conduit Necrosis Following Esophagectomy

The management of conduit necrosis during or after esophagectomy requires the assembly of a multidisciplinary team to manage nutrition, sepsis, intravenous access, reconstruction, and recovery. Reconstruction is most often performed as a staged procedure. The initial surgery is likely to involve esophageal diversion onto the chest where possible, making an effort to preserve esophageal length. Optimization of patients before reconstruction enhances outcomes following reconstruction with either jejunum or colon after gastric conduit failure. Maintaining enteral access for feeding at all times is imperative. Management of patients should be performed at high-volume esophageal centers performing regular reconstructions.

Emerging paradigms in perioperative management for microsurgical free tissue transfer: review of the literature and evidence-based guidelines

BACKGROUND

Microsurgical free tissue transfer has become an increasingly valuable technique in reconstructive surgery. However, there is a paucity of evidence-based guidelines to direct management. A systematic review was performed to define strategies to optimize perioperative management.

METHODS

A systematic review of the literature was performed using key search terms. Strategies to guide patient management were identified, classified according to level of evidence, and used to devise recommendations in seven categories: patient temperature, anesthesia, fluid administration/blood transfusion, vasodilators, vasopressors, and anticoagulation.

RESULTS

A total of 106 articles were selected and reviewed. High-level evidence was identified to guide practices in several key areas, including patient temperature, fluid management, vasopressor use, anticoagulation, and analgesic use.

CONCLUSIONS

Current practices remain exceedingly diverse. Key strategies to improve patient outcomes can be defined from the available literature. Key evidence-based guidelines included that normothermia should be maintained perioperatively to improve outcomes (level of evidence 2b), and volume replacement should be maintained between 3.5 and 6.0 ml/kg per hour (level of evidence 2b). Vasopressors do not harm outcomes and may improve flap flow (level of evidence 1b), with most evidence supporting the use of norepinephrine over other vasopressors (level of evidence 1b). Dextran should be avoided (level of evidence 1b), and pump systems for local anesthetic infusion are beneficial following free flap breast reconstruction (level of evidence 1b). Further prospective studies will improve the quality of available evidence.