1
|
Roohani I, Moshal T, Boudiab EM, Stanton EW, Zachary P, Lo J, Carey JN, Daar DA. The Impact of Intraoperative Vasopressor Use and Fluid Status on Flap Survival in Traumatic Lower Extremity Reconstruction. J Reconstr Microsurg 2024. [PMID: 38782028 DOI: 10.1055/a-2331-8174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
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.
Collapse
Affiliation(s)
- Idean Roohani
- Keck School of Medicine of University of Southern California, Los Angeles, California
| | - Tayla Moshal
- Keck School of Medicine of University of Southern California, Los Angeles, California
| | - Elizabeth M Boudiab
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, Los Angeles, California
| | - Eloise W Stanton
- Keck School of Medicine of University of Southern California, Los Angeles, California
| | - Paige Zachary
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, Los Angeles, California
| | - Jessica Lo
- Keck School of Medicine of University of Southern California, Los Angeles, California
| | - Joseph N Carey
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, Los Angeles, California
| | - David A Daar
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, Los Angeles, California
| |
Collapse
|
2
|
Diaddigo SE, Lavalley MN, Truong AY, Otterburn DM. Catastrophic complications following microvascular free tissue transfer: A 10-year review of NSQIP data. J Plast Reconstr Aesthet Surg 2024; 93:42-50. [PMID: 38640554 DOI: 10.1016/j.bjps.2024.02.058] [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: 10/03/2023] [Revised: 02/01/2024] [Accepted: 02/22/2024] [Indexed: 04/21/2024]
Abstract
INTRODUCTION There is an absence of literature regarding the risks of catastrophic medical outcomes (CMOs) such as stroke, cardiac arrest, and pulmonary embolism in microvascular free tissue transfer. This study aims to determine the CMO and mortality rates, as well as risk factors, associated with microvascular reconstruction of the head and neck, extremity, and breast. METHODS This study uses data from the American College of Surgeons National Surgical Quality Improvement Program. Cases of microvascular free tissue transfer from 2012 to 2021 were analyzed to assess the 30-day rates of CMOs, including death, as well as associated risk factors. RESULTS Of the 22,839 included patients, 785 (3.44%) experienced 1043 CMOs, including 99 (0.43%) deaths. Pulmonary complications of prolonged respiratory failure and pulmonary embolism were the most common. Independent risk factors included age, male sex, underweight status, longer operation times, American Society of Anesthesiologists (ASA) class of III or above, wound classification other than clean, and underlying conditions such as diabetes, hypertension, chronic obstructive pulmonary disorder, dyspnea, metastatic cancer, and ventilator dependence. CMOs were associated with an average 10-day delay in hospital discharge. Multivariate regression analysis revealed that head and neck reconstructions were associated with increased risk of CMO (OR 4.96; p < 0.0001). CONCLUSION This is the largest study to examine CMOs following microvascular free tissue transfer. Compared to previous literature spanning the period between 2006 and 2011, we observed a decreased rate of CMOs but a slight increase in 30-day mortality. Our data provide updated and comprehensive criteria for risk stratification and patient counseling. The modifiable risk factors reported in our study should be considered in elective, non-urgent cases of microvascular reconstruction.
Collapse
Affiliation(s)
- Sarah E Diaddigo
- NewYork-Presbyterian Hospital, Columbia University/Weill Cornell Medicine, New York, NY, USA
| | - Myles N Lavalley
- NewYork-Presbyterian Hospital, Columbia University/Weill Cornell Medicine, New York, NY, USA
| | - Albert Y Truong
- NewYork-Presbyterian Hospital, Columbia University/Weill Cornell Medicine, New York, NY, USA
| | - David M Otterburn
- NewYork-Presbyterian Hospital, Columbia University/Weill Cornell Medicine, New York, NY, USA.
| |
Collapse
|
3
|
Pražetina M, Šribar A, Sokolović Jurinjak I, Matošević J, Peršec J. Effect of machine learning-guided haemodynamic optimization on postoperative free flap perfusion in reconstructive maxillofacial surgery: A study protocol. Br J Clin Pharmacol 2024; 90:684-690. [PMID: 37876305 DOI: 10.1111/bcp.15942] [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: 08/04/2023] [Revised: 10/14/2023] [Accepted: 10/15/2023] [Indexed: 10/26/2023] Open
Abstract
AIMS Intraoperative hypotension and liberal fluid haemodynamic therapy are associated with postoperative medical and surgical complications in maxillofacial free flap surgery. The novel haemodynamic parameter hypotension prediction index (HPI) has shown good performance in predicting hypotension by analysing arterial pressure waveform in various types of surgery. HPI-based haemodynamic protocols were able to reduce the duration and depth of hypotension. We will try to determine whether haemodynamic therapy based on HPI can improve postoperative flap perfusion and tissue oxygenation by improving intraoperative mean arterial pressure and reducing fluid infusion. METHODS We present here a study protocol for a single centre, randomized, controlled trial (n = 42) in maxillofacial patients undergoing free flap surgery. Patients will be randomized into an intervention or a control group. In the intervention, group haemodynamic optimization will be guided by machine learning algorithm and functional haemodynamic parameters presented by the HemoSphere platform (Edwards Lifesciences, Irvine, CA, USA), most importantly, HPI. Tissue oxygen saturation of the free flap will be monitored noninvasively by near-infrared spectroscopy during the first 24 h postoperatively. The primary outcome will be the average value of tissue oxygen saturation in the first 24 h postoperatively.
Collapse
Affiliation(s)
- Marko Pražetina
- Clinical Department of Anesthesiology, Reanimatology and Intensive Care Medicine, University Hospital Dubrava, Zagreb, Croatia
| | - Andrej Šribar
- Clinical Department of Anesthesiology, Reanimatology and Intensive Care Medicine, University Hospital Dubrava, Zagreb, Croatia
- School of Dental Medicine, Zagreb University, Zagreb, Croatia
| | - Irena Sokolović Jurinjak
- Clinical Department of Anesthesiology, Reanimatology and Intensive Care Medicine, University Hospital Dubrava, Zagreb, Croatia
| | - Jelena Matošević
- Clinical Department of Anesthesiology, Reanimatology and Intensive Care Medicine, University Hospital Dubrava, Zagreb, Croatia
| | - Jasminka Peršec
- Clinical Department of Anesthesiology, Reanimatology and Intensive Care Medicine, University Hospital Dubrava, Zagreb, Croatia
- School of Dental Medicine, Zagreb University, Zagreb, Croatia
| |
Collapse
|
4
|
Speck NE, Dreier K, Fluetsch A, Ranacher C, Babst D, Lardi AM, Farhadi J. Flying high?-Exploring the effect of red bull on blood pressure after microsurgical breast reconstruction in a randomized controlled trial. J Plast Reconstr Aesthet Surg 2024; 90:200-208. [PMID: 38387416 DOI: 10.1016/j.bjps.2024.01.015] [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: 08/05/2023] [Revised: 11/26/2023] [Accepted: 01/29/2024] [Indexed: 02/24/2024]
Abstract
BACKGROUND A sufficiently high blood pressure (BP) is essential for flap perfusion after microsurgical breast reconstruction. However, postoperative hypotension is common after these procedures. Perioperative volume overload may increase flap-related complications, and postoperative vasopressor use may be limited depending on institutions. Red Bull has been shown to increase BP in several studies. We aimed to evaluate the effect of Red Bull on perfusion-related variables after microsurgical breast reconstruction. METHODS We conducted a multicenter, prospective, randomized controlled trial. Female patients undergoing unilateral microsurgical breast reconstruction from June 2020 to October 2022 were randomly assigned to the intervention or control groups. The intervention group received 250 ml of Red Bull 2 h after surgery and twice on postoperative day (POD) 1. The control group received 250 ml still water at the respective intervals. BP was measured using a 24-hour monitoring device. Vasopressor use, fluid balance, and flap outcomes were compared. RESULTS One hundred patients were included in the study. Both groups were comparable concerning age, body mass index, and caffeine consumption. Mean arterial and diastolic BP were significantly higher in the Red Bull group after the second drink in the morning of POD1 (p-value = 0.03 and 0.03, respectively). Vasopressor use was similar, with a tendency for less postoperative etilefrine in the Red Bull group (p-value = 0.08). No flap loss was observed. CONCLUSIONS We observed increased mean arterial and diastolic BP in the Red Bull group after the second drink. Red Bull may be a useful adjunct after microsurgical breast reconstruction. LEVEL OF EVIDENCE I, therapeutic.
Collapse
Affiliation(s)
- Nicole E Speck
- Plastic Surgery Group, Zurich, Switzerland; Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Basel, Switzerland.
| | - Kathrin Dreier
- Department of Anesthesiology, Klinik Pyramide am See, Zurich, Switzerland
| | - Andrin Fluetsch
- Novartis Institutes for Biomedical Research, Basel, Switzerland
| | | | | | | | - Jian Farhadi
- Plastic Surgery Group, Zurich, Switzerland; Faculty of Medicine, University of Basel, Basel, Switzerland
| |
Collapse
|
5
|
List MA, Knackstedt M, Liu L, Kasabali A, Mansour J, Pang J, Asarkar AA, Nathan C. Enhanced recovery after surgery, current, and future considerations in head and neck cancer. Laryngoscope Investig Otolaryngol 2023; 8:1240-1256. [PMID: 37899849 PMCID: PMC10601592 DOI: 10.1002/lio2.1126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 11/15/2022] [Indexed: 10/31/2023] Open
Abstract
Objectives Review of the current and relevant literature to develop a list of evidence-based recommendations that can be implemented in head and neck surgical practices. To provide rationale for the multiple aspects of comprehensive care for head and neck surgical patients. To improve postsurgical outcomes for head and neck surgical patients. Methods Extensive review of the medical literature was performed and relevant studies in both the head and neck surgery and other surgical specialties were considered for inclusion. Results A total of 18 aspects of perioperative care were included in this review. The literature search included 276 publications considered to be the most relevant and up to date evidence. Each topic is concluded with recommendation grade and quality of evidence for the recommendation. Conclusion Since it's conception, enhanced recovery after surgery (ERAS) protocols have continued to push for comprehensive and evidence based postsurgical care to improve patient outcomes. Head and neck oncology is one of the newest fields to develop a protocol. Due to the complexity of this patient population and their postsurgical needs, a multidisciplinary approach is needed to facilitate recovery while minimizing complications. Current and future advances in head and neck cancer research will serve to strengthen and add new principles to a comprehensive ERAS protocol. Level of Evidence 2a.
Collapse
Affiliation(s)
- Marna A. List
- Department of Otolaryngology/HNSLouisiana State University Health‐ShreveportShreveportLouisianaUSA
| | - Mark Knackstedt
- Department of Otolaryngology/HNSLouisiana State University Health‐ShreveportShreveportLouisianaUSA
| | - Lucy Liu
- Department of Otolaryngology/HNSLouisiana State University Health‐ShreveportShreveportLouisianaUSA
| | - Ahmad Kasabali
- Department of Otolaryngology/HNSLouisiana State University Health‐ShreveportShreveportLouisianaUSA
- College of MedicineLouisiana State University Health‐ShreveportShreveportLouisianaUSA
| | - Jobran Mansour
- Department of Otolaryngology/HNSLouisiana State University Health‐ShreveportShreveportLouisianaUSA
| | - John Pang
- Department of Otolaryngology/HNSLouisiana State University Health‐ShreveportShreveportLouisianaUSA
| | - Ameya A. Asarkar
- Department of Otolaryngology/HNSLouisiana State University Health‐ShreveportShreveportLouisianaUSA
| | - Cherie‐Ann Nathan
- Department of Otolaryngology/HNSLouisiana State University Health‐ShreveportShreveportLouisianaUSA
- Feist‐Weiller Cancer CenterShreveportLouisianaUSA
| |
Collapse
|
6
|
Liu Z, Cheng S, Wang C, Liu X, Huang H, Zhu Y, Zhou B, Wu H, Cao M. Preoperative flurbiprofen diminishes the rate of reoperation after free flap reconstruction: A retrospective study. J Craniomaxillofac Surg 2023; 51:560-567. [PMID: 37620245 DOI: 10.1016/j.jcms.2023.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 01/09/2023] [Accepted: 08/14/2023] [Indexed: 08/26/2023] Open
Abstract
This study aimed to evaluate the association between preoperative flurbiprofen, a non-selective COX inhibitor, and reoperation for flap crisis after free flap reconstruction. In this retrospective study, patients who underwent head and neck surgery with free flap reconstructions were collected. To identify risk factors for reoperation from demographic features and perioperative variables, univariate and multivariate logistic analyses were conducted. After propensity score matching (PSM), univariate and adjusted multivariate analyses were employed to explore the impact of preoperative flurbiprofen on reoperation after free flap reconstruction. This study comprised 437 patients, 33 of whom underwent reoperations for flap crisis. After multivariate analysis, radiotherapy history (P = 0.005; odds ratio [OR] = 0.225; 95% CI, 0.080-0.636) and preoperative flurbiprofen (P = 0.038; OR = 5.059; 95% CI, 1.094-23.386) were identified as independent factors for reoperation. PSM was achieved, and preoperative flurbiprofen was found to diminish the reoperation rate (P = 0.046; OR = 4.765; 95% CI, 1.029-22.202) without increasing bleeding complications. Within the limitations of the study, flurbiprofen should be administered preoperatively to reduce the rate of reoperations for flap crisis whenever appropriate.
Collapse
Affiliation(s)
- Zhongqi Liu
- Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Shi Cheng
- Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Chengli Wang
- Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiaoqing Liu
- Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Haoquan Huang
- Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yingying Zhu
- Clinical Research Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Bin Zhou
- Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Haixuan Wu
- Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Minghui Cao
- Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China.
| |
Collapse
|
7
|
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.
Collapse
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.
| |
Collapse
|
8
|
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.
Collapse
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.
| |
Collapse
|
9
|
Hanba C, Lewis C. Enhanced Recovery After Surgery for Head and Neck Oncologic Surgery Requiring Microvascular Reconstruction. Otolaryngol Clin North Am 2023; 56:801-812. [PMID: 37380326 DOI: 10.1016/j.otc.2023.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
It has been demonstrated since the 1990's that surgical outcomes can be improved through protocolized perioperative interventions. Since then, multiple surgical societies have engaged in adopting Enhanced Recovery After Surgery (ERAS) Societal recommendations to improve patient satisfaction, decrease the cost of interventions, and improve outcomes. In 2017, ERAS released consensus recommendations detailing the perioperative optimization of patients undergoing head and neck free flap reconstruction. This population was identified as a high resource demand, oftentimes burdened with challenging comorbidity, and poorly described cohort for which a perioperative management protocol could help to optimize outcomes. The following pages aim to further detail perioperative strategies to streamline patient recovery after head and neck reconstructive surgery.
Collapse
Affiliation(s)
- Curtis Hanba
- Department of Otolaryngology-Head and Neck Surgery, MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA.
| | - Carol Lewis
- Department of Otolaryngology-Head and Neck Surgery, MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| |
Collapse
|
10
|
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.
Collapse
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
| |
Collapse
|
11
|
Michelle L, Bitner BF, Pang JC, Berger MH, Haidar YM, Rajan GR, Tjoa T. Outcomes of perioperative vasopressor use for hemodynamic management of patients undergoing free flap surgery: A systematic review and meta-analysis. Head Neck 2023; 45:721-732. [PMID: 36618003 DOI: 10.1002/hed.27289] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 10/25/2022] [Accepted: 12/15/2022] [Indexed: 01/10/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Lauren Michelle
- Department of Otolaryngology - Head and Neck Surgery, University of California Irvine Medical Center, Orange, California, USA
| | - Benjamin F Bitner
- Department of Otolaryngology - Head and Neck Surgery, University of California Irvine Medical Center, Orange, California, USA
| | - Jonathan C Pang
- Department of Otolaryngology - Head and Neck Surgery, University of California Irvine Medical Center, Orange, California, USA
| | - Michael H Berger
- Department of Otolaryngology - Head and Neck Surgery, University of California Irvine Medical Center, Orange, California, USA
| | - Yarah M Haidar
- Department of Otolaryngology - Head and Neck Surgery, University of California Irvine Medical Center, Orange, California, USA
| | - Govind R Rajan
- Department of Anesthesiology and Perioperative Care, University of California Irvine Medical Center, Orange, California, USA
| | - Tjoson Tjoa
- Department of Otolaryngology - Head and Neck Surgery, University of California Irvine Medical Center, Orange, California, USA
| |
Collapse
|
12
|
Bishop JL, Vasudev M, Garcia N, Heslop G, Pham TT, Hicks MD, Chowdhury F, Grayson JW, Goddard JA, Tjoa T, Haidar Y, Thomas CM. Effect of Perioperative Antithrombotics on Head and Neck Microvascular Free Flap Survival After Anastomotic Revision. Otolaryngol Head Neck Surg 2023; 168:1353-1361. [PMID: 36939436 DOI: 10.1002/ohn.295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 01/10/2023] [Accepted: 01/21/2023] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To determine if antithrombotic therapy improves head and neck microvascular free flap survival following anastomotic revision. STUDY DESIGN A retrospective review of all patients with microvascular free tissue transfer to the head and neck between August 2013 and July 2021. SETTING Otolaryngology-Head and Neck Surgery Departments at University of Alabama at Birmingham, University of Colorado, and University of California Irvine. METHODS Perioperative use of anticoagulation, antiplatelets, intraoperative heparin bolus, tissue plasminogen activator (tPA) and vasopressor use, and leech therapy were collected plus microvascular free flap outcomes. The primary endpoint was free flap failure. Analyses of free flaps that underwent anastomotic revision with or without thrombectomy were performed. RESULTS A total of 843 microvascular free flaps were included. The overall rate of flap failure was 4.0% (n = 34). The overall rate of pedicle anastomosis revision (artery, vein, or both) was 5.0% (n = 42) with a failure rate of 47.6% (n = 20) after revision. Anastomotic revision significantly increased the risk of flap failure (odds ratio [OR] 52.68, 95% confidence interval [CI] [23.90, 121.1], p < .0001) especially when both the artery and vein were revised (OR 9.425, 95% CI [2.117, 52.33], p = .005). Free flap failure after the anastomotic revision was not affected by postoperative antiplatelet therapy, postoperative prophylactic anticoagulation, intraoperative heparin bolus, tPA, and therapeutic anticoagulation regardless of which vessels were revised and if a thrombus was identified. CONCLUSION In cases of microvascular free tissue transfer pedicle anastomotic revision, the use of antithrombotic therapy does not appear to significantly change free flap survival outcomes.
Collapse
Affiliation(s)
- Jessica L Bishop
- Department of Otolaryngology-Head & Neck Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Milind Vasudev
- University of California Irvine School of Medicine, University of California Irvine, Irvine, California, USA
| | - Natalie Garcia
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Gabriela Heslop
- Department of Otolaryngology-Head & Neck Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Tiffany T Pham
- Department of Otolaryngology-Head & Neck Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Melanie D Hicks
- Department of Otolaryngology-Head & Neck Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Farshad Chowdhury
- Department of Otolaryngology-Head & Neck Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Jessica W Grayson
- Department of Otolaryngology-Head & Neck Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Julie A Goddard
- Department of Otolaryngology-Head & Neck Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Tjoson Tjoa
- Department of Otolaryngology-Head & Neck Surgery, University of California Irvine, Irvine, California, USA
| | - Yarah Haidar
- Department of Otolaryngology-Head & Neck Surgery, University of California Irvine, Irvine, California, USA
| | - Carissa M Thomas
- Department of Otolaryngology-Head & Neck Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA.,O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, Alabama, USA
| |
Collapse
|
13
|
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]
|
14
|
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]
|
15
|
McCauley P, Moore M, Duggan E. Anaesthesia for reconstructive free flap surgery for head and neck cancer. Br J Hosp Med (Lond) 2022; 83:1-9. [DOI: 10.12968/hmed.2021.0668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Head and neck cancer surgery presents significant challenges for the anaesthetist. A thorough multidisciplinary preoperative assessment and optimisation of the patient is essential, including nutritional and psychological evaluation. The incidence of a difficult airway is high, and the anaesthetist must be skilled in advanced airway techniques. Surgery is extensive, often requiring reconstructive surgery with either a pedicled or free flap. Detailed knowledge of flap physiology and anatomy is needed, and anaesthesia comprises careful management of mean arterial pressure, fluid administration, temperature control and oxygenation. The Enhanced Recovery after Surgery Society and the Society for Head and Neck Anaesthesia consensus recommendations provide guidance on current best practice. Despite continued debate, it now appears that this constitutes goal-directed fluid therapy, coupled with judicious vasopressor therapy sufficient to achieve an adequate mean arterial pressure. Emerging techniques such as prehabilitation and postoperative near-infrared spectroscopy flap monitoring provide hope of improved outcomes going forward.
Collapse
Affiliation(s)
- Peter McCauley
- Department of Anaesthesia, Beaumont Hospital, Dublin, Ireland
| | - Michael Moore
- Department of Anaesthesia, Beaumont Hospital, Dublin, Ireland
| | - Edel Duggan
- Department of Anaesthesia, Beaumont Hospital, Dublin, Ireland
| |
Collapse
|
16
|
Bao B, Gao T, Li X, Wei H, Lin J, Sun Y, Shen J, Zhu H, Zheng X. Breaking the technical barrier of microvascular anastomosis with high-speed videography: A prospective cohort study. Int J Surg 2022; 98:106214. [PMID: 34995808 DOI: 10.1016/j.ijsu.2021.106214] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 12/11/2021] [Accepted: 12/18/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Microsurgical anastomosis is technically difficult especially for less-experienced surgeons. Traditionally, surgeons in training could only accomplish these surgeries under intensive guiding and supervision from senior surgeons. This study presents and characterises a new method for microsurgical trainees to objectively evaluating the quality of vascular anastomosis intraoperatively. MATERIALS AND METHODS We conducted a prospective study to determine the utility of patency test of vascular anastomosis with assistance of high-speed video recording (PTHVR) to evaluate the quality of vascular anastomosis during microsurgery. To determine whether the use of PTHVR outperformed traditional supervision from senior surgeons (historical control), we compared the outcomes of microsurgeries including free flap transfer and replantation between the two groups. RESULTS A total of 211 patients were enrolled, of which 98 underwent surgery under traditional supervision and 113 underwent surgery with PTHVR. Of the 211 patients, 102 underwent digit replantation (48%), 22 underwent limb replantation (10%), and 87 underwent free flap transfer (42%). There was no statistical difference between the two groups in age, gender, BMI, pre-existing comorbidities, smoking status, alcohol consumption, and duration of surgery. Use of PTHVR as an intraoperative guide significantly decreased the rate of re-exploration surgeries (PTHVR, 8.0% [9/113]; control, 23.5% [23/98]; P = 0.002) and replantation/free flap failures (PTHVR, 8.8% [10/113]; control, 19.4% [19/98]; P = 0.029) compared with historical control under traditional supervision. CONCLUSIONS PTHVR is a useful tool for improving the success rate of microsurgery for less-experienced surgeons when compared with traditional supervision mode.
Collapse
Affiliation(s)
- Bingbo Bao
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, 200233, China
| | | | | | | | | | | | | | | | | |
Collapse
|
17
|
Fahy EJ, Griffin M, Lavin C, Abbas D, Longaker MT, Wan D. The Adrenergic System in Plastic and Reconstructive Surgery: Physiology and Clinical Considerations. Ann Plast Surg 2021; 87:e62-e70. [PMID: 33833152 DOI: 10.1097/sap.0000000000002706] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT The primary organ systems and tissues concerning plastic and reconstructive surgery include the integument, vasculature, subcutis, and peripheral nerves, because these may individually or collectively be injured requiring reconstruction, or indeed be used in reconstruction themselves through grafts, flaps, or anastomoses. Adrenergic receptors are present throughout these anatomic components on the vasculature, adipose, platelets, immune cells, keratinocytes, melanocytes, fibroblasts, peripheral nerves, and tendons. Herein, the influence of adrenergic signaling on the physiology of anatomic components related to plastic surgery is discussed, along with clinical considerations of this systems involvement in procedures, such as free flap reconstruction, skin grafting, fat grafting, and other areas relevant to plastic and reconstructive surgery. Current evidence as well as potential for further investigation is discussed.
Collapse
Affiliation(s)
- Evan J Fahy
- From the Division of Plastic Surgery, Department of Surgery, Hagey Laboratory for Pediatric Regenerative Medicine
| | - Michelle Griffin
- From the Division of Plastic Surgery, Department of Surgery, Hagey Laboratory for Pediatric Regenerative Medicine
| | - Christopher Lavin
- From the Division of Plastic Surgery, Department of Surgery, Hagey Laboratory for Pediatric Regenerative Medicine
| | - Darren Abbas
- From the Division of Plastic Surgery, Department of Surgery, Hagey Laboratory for Pediatric Regenerative Medicine
| | | | - Derrick Wan
- From the Division of Plastic Surgery, Department of Surgery, Hagey Laboratory for Pediatric Regenerative Medicine
| |
Collapse
|
18
|
Gardner JR, Gau V, Page P, Dunlap Q, King D, Crabtree D, Sunde J, Vural E, Moreno MA. Association of Continuous Intraoperative Vasopressor Use With Reoperation Rates in Head and Neck Free-Flap Reconstruction. JAMA Otolaryngol Head Neck Surg 2021; 147:1059-1064. [PMID: 34591083 DOI: 10.1001/jamaoto.2021.1841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
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.
Collapse
Affiliation(s)
- James Reed Gardner
- Division of Head and Neck Oncology and Surgery, Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock
| | - Victoria Gau
- Division of Head and Neck Oncology and Surgery, Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock
| | - Patrick Page
- Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock
| | - Quinn Dunlap
- Division of Head and Neck Oncology and Surgery, Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock
| | - Deanne King
- Division of Head and Neck Oncology and Surgery, Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock
| | - Donald Crabtree
- Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock
| | - Jumin Sunde
- Division of Head and Neck Oncology and Surgery, Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock
| | - Emre Vural
- Division of Head and Neck Oncology and Surgery, Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock
| | - Mauricio Alejandro Moreno
- Division of Head and Neck Oncology and Surgery, Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock
| |
Collapse
|
19
|
Gupta P, Chaudhari SH, Nagar V, Jain D, Bansal A, Dutt A. Prospective analysis of goal-directed fluid therapy vs conventional fluid therapy in perioperative outcome of composite resections of head and neck malignancy with free tissue transfer. Indian J Anaesth 2021; 65:606-611. [PMID: 34584284 PMCID: PMC8445214 DOI: 10.4103/ija.ija_178_21] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 04/04/2021] [Accepted: 08/02/2021] [Indexed: 11/23/2022] Open
Abstract
Background and Aim: Head and neck cancer surgeries with free tissue transfer are complex procedures, and fluid management can grossly affect the microvascular anastomosis. We hypothesise that intra-operative goal-directed fluid therapy (GDFT) is the key to administer fluid individualised to a patient's requirement. The aim of this study was to observe the role of GDFT in perioperative flap outcome and length of hospital stay. Methods: A randomised prospective controlled study was performed in 106 patients undergoing composite resection of head and neck cancer with free tissue transfer. Patients in Group A received GDFT based on stroke volume variation whereas Group B received conventional fluid therapy intra-operatively. The endpoints of this study were total perioperative fluid, fluid boluses, vasopressor requirement, flap outcome and length of intensive care unit and hospital stay. Statistical analysis was done using Chi-square test. Results: The total intra-operative fluid given to both the groups was comparable but patients in Group A received more boluses and vasopressors compared to Group B during intra-operative period. The amount of fluid given in the first 24 hours post-operatively was significantly less in Group A (1807 + 476 ml) compared to Group B (2205 + 382 ml). Incidence of hypotension with tachycardia was observed in three patients in Group B and none in Group A. Poor flap outcome was observed in one patient in Group A versus four in Group B due to thrombosis. Conclusion: GDFT helps in early detection of fluid deficit and may avoid complications arising due to inadequate microvascular perfusion during the peri-operative period.
Collapse
Affiliation(s)
- Pushplata Gupta
- Department of Anaesthesia, Bhagwan Mahaveer Cancer Hospital and Research Centre, Jaipur, Rajasthan, India
| | - Soumi H Chaudhari
- Department of Anaesthesia, Bhagwan Mahaveer Cancer Hospital and Research Centre, Jaipur, Rajasthan, India
| | - Vaibhav Nagar
- Department of Anaesthesia, Bhagwan Mahaveer Cancer Hospital and Research Centre, Jaipur, Rajasthan, India
| | - Deepshikha Jain
- Department of Anaesthesia, Bhagwan Mahaveer Cancer Hospital and Research Centre, Jaipur, Rajasthan, India
| | - Anita Bansal
- Department of Anaesthesia, Bhagwan Mahaveer Cancer Hospital and Research Centre, Jaipur, Rajasthan, India
| | - Akanksha Dutt
- Department of Anaesthesia, Bhagwan Mahaveer Cancer Hospital and Research Centre, Jaipur, Rajasthan, India
| |
Collapse
|
20
|
Intraoperative Fluid Management Implies Insignificant Influence to Surgical Outcomes in Head and Neck Microvascular Reconstruction Cases. Plast Reconstr Surg 2021; 147:627e-633e. [PMID: 33776038 DOI: 10.1097/prs.0000000000007777] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Deliberate fluid administration has been used to maintain a hyperdynamic systemic circulation in free tissue transfer operations. The effects of intraoperative volume loading on postoperative complications have been controversial. The authors hypothesized that increasing intraoperative fluid administration was associated with increased postoperative surgical complications. METHODS Free flap operations for head and neck reconstruction between 2004 and 2014 were reviewed. A generalized estimating equation model was used to estimate the effect of intraoperative fluid administration on surgical outcomes. The optimized thresholds of anesthetic time were tested by the Youden index for flap compromise and major complications. RESULTS A total of 2983 consecutive cases were included in the study. The incidences of flap compromise and total loss were 1.5 and 3.3 percent, respectively. Intraoperative fluid administration was not associated with surgical complications (p = 0.195). However, a 1-hour increase in anesthesia time was associated with a 19 percent increased risk of flap compromise (adjusted OR, 1.19; 95 percent CI, 1.10 to 1.29; p < 0.001). CONCLUSION Prolonged anesthetic time, but not fluid administration, was associated with adverse surgical outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
Collapse
|
21
|
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.
Collapse
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
| |
Collapse
|
22
|
Burkhard JP, Pfister J, Giger R, Huber M, Lädrach C, Waser M, Olariu R, Engel D, Löffel LM, Schaller B, Wuethrich PY. Perioperative predictors of early surgical revision and flap-related complications after microvascular free tissue transfer in head and neck reconstructions: a retrospective observational series. Clin Oral Investig 2021; 25:5541-5550. [PMID: 33686470 PMCID: PMC8370926 DOI: 10.1007/s00784-021-03864-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 02/25/2021] [Indexed: 11/15/2022]
Abstract
Objectives The aim of this study was to determine the influence of perioperative fluid management and administration of vasopressors on early surgical revision and flap-related complications in free tissue transfer. Materials and methods Intraoperative amount of fluid and of vasopressors, relevant perioperative parameters, and comorbidities were recorded in 131 patients undergoing head and neck microvascular reconstruction and compared with early surgical complications, defined as interventions requiring surgery after a flap-related complication, and/or other surgical problems in the operating room within 30 days after initial surgery. The relationship between perioperative variables for each revision category was determined using an optimized multiple logistic regression. Results The administration of diuretics (p=0.001) as a treatment for perioperative fluid overload and the type of flap (p=0.019) was associated with a higher risk of early surgical revisions. Perioperative fluid overload (p=0.039) is significantly related to flap-related complications. We found no effect of intraoperative administration of vasopressors on early surgical revisions (p=0.8) or on flap-related complications (norepinephrine p=0.6, dobutamine p=0.5). Conclusion Perioperative fluid overload is associated with higher risks of early surgical revision and flap-related complications. In contrast, the administration of vasopressors seemed to have no effect on either surgical revision rate or flap-related complications. Clinical relevance In patients receiving microvascular reconstructions, a balanced fluid administration perioperatively and a targeted use of vasopressors should be the necessary strategy to reduce the complication rates in head and neck surgery.
Collapse
Affiliation(s)
- John-Patrik Burkhard
- Department of Cranio-Maxillofacial Surgery, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland.
| | - Jelena Pfister
- Department of Cranio-Maxillofacial Surgery, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland
| | - Roland Giger
- Department of Oto-Rhino-Laryngology, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland
| | - Markus Huber
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland
| | - Claudia Lädrach
- Department of Oto-Rhino-Laryngology, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland
| | - Manuel Waser
- Department of Oto-Rhino-Laryngology, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland
| | - Radu Olariu
- Department of Plastic, Reconstructive and Aesthetic Surgery, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland
| | - Dominique Engel
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland
| | - Lukas M Löffel
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland
| | - Benoît Schaller
- Department of Cranio-Maxillofacial Surgery, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland
| | - Patrick Y Wuethrich
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland
| |
Collapse
|
23
|
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.
Collapse
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.
| |
Collapse
|
24
|
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.
Collapse
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
| |
Collapse
|
25
|
Al Saied G, Almutairi HM, Alharbi Y, Almohanna M, Almutairi A. Comparison Between the Impact of Vasopressors and Goal-Directed Fluid Therapy on the Management of Free Flap Reconstruction of Head and Neck and Monitoring in ICU. Cureus 2020; 12:e12108. [PMID: 33489525 PMCID: PMC7805489 DOI: 10.7759/cureus.12108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Head and neck reconstructions are often accompanied with complex long surgical procedures. Free flap tissue transfer is a standard reconstruction method that reestablishes severe tissue defects after resection due to trauma or cancer. Imbalanced fluid resuscitation can extremely harm the outcome of the flap either due to hypoperfusion or edema. Flap-related postoperative complications mainly flap failure necessitates the administration of a large amount of intravenous fluids perioperatively especially with lengthy operative time. Therefore, vasopressors may be used to preserve hemodynamic stability without excessive fluids use. Nevertheless, these vasopressors have long been disfavored as they may provoke anastomosis vasoconstriction leading to graft hypoperfusion and finally flap failure. However, according to recent guidelines, they are now well-thought to be safe. Of note, inotropes have been confirmed to increase blood flow in the anastomosis hence they can replace vasoconstrictors. Recently, goal-directed fluid therapy (GDFT) has been proven to be excellent in high-risk head and neck free tissue transfer surgery as it decreases prolonged intensive care unit (ICU) admission hospitalization and complication rate. Today, GDFT is highly suggested as one of the enhanced recoveries after surgery protocols for major head and neck free flap reconstruction surgery.
Collapse
Affiliation(s)
- Ghiath Al Saied
- Internal Medicine - Critical Care, King Fahad Medical City, Riyadh, SAU
| | - Homood M Almutairi
- Otolaryngology, Unaizah College of Medicine, Qassim University, Buraydah, SAU
| | - Yousef Alharbi
- Medicine, Unaizah College of Medicine, Qassim University, Buraydah, SAU
| | | | | |
Collapse
|
26
|
Feasibility of an Enhanced Recovery After Surgery (ERAS) pathway for major head and neck oncologic surgery. Am J Otolaryngol 2020; 41:102679. [PMID: 32836043 DOI: 10.1016/j.amjoto.2020.102679] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 08/10/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Enhanced Recovery After Surgery (ERAS) protocols are gaining traction in the field of head and neck surgery following success in other specialties. Various institutions have reported on the feasibility of implementation and early outcomes in their centers. We report our experience of setting up an ERAS program in a high-volume tertiary cancer care center, including the challenges faced and overcome. METHODS With multidisciplinary input, an ERAS protocol was developed consisting of pre-, intra-, and post-operative interventions based on current evidence. We then assessed an initial series of 104 patients on the ERAS protocol and tracked the compliance rates for various interventions. RESULTS Compliance rates to interventions including pre-operative medication (84.6%), multimodal analgesia (84.6%95.1%), early removal of urinary catheters (76.0%) and early mobilization (56.7%) show a wide variation. However, response rates in the assessment of patient-reported outcomes are low. We discuss factors surrounding the feasibility of implementing an ERAS protocol and tracking outcomes in a diverse, high volume center. DISCUSSION While there are challenges in implementation, results indicate that a successful ERAS pathway in major head and neck oncologic surgery is feasible. Engaging shareholders and making full use of technology in the form of electronic medical systems are essential to this success. IMPLICATIONS FOR PRACTICE ERAS pathways should be encouraged in head and neck surgery, given their proven feasibility in a range of institutions. Further study is needed to confirm this program's impact on outcomes.
Collapse
|
27
|
Naik AN, Freeman T, Li MM, Marshall S, Tamaki A, Ozer E, Agrawal A, Kang SY, Old MO, Seim NB. The Use of Vasopressor Agents in Free Tissue Transfer for Head and Neck Reconstruction: Current Trends and Review of the Literature. Front Pharmacol 2020; 11:1248. [PMID: 32982724 PMCID: PMC7485519 DOI: 10.3389/fphar.2020.01248] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 07/29/2020] [Indexed: 11/13/2022] Open
Abstract
Background/Objectives Microvascular free tissue transfer has become essential to head and neck reconstruction and recent advancements in microvascular surgery have led to excellent surgical outcomes. However, there continues to be controversy and a stigma associated with the use of perioperative intravenous vasopressor agents among both surgeons and anesthesiologists. Due to concern for vasoconstriction of peripheral vasculature flowing to the denervated tissue flap, there remains concerns about potential thrombosis, decreased tissue perfusion and ultimately flap failure. This topic becomes even more important as vasopressors play an essential role in new Extended Recovery After Surgery (ERAS) protocols being put in place to optimize postoperative recovery for patients. The purpose of this study was to comprehensively review the role and safety as well as discuss current trends with intraoperative vasopressor agents in free tissue transfer for head and neck reconstruction. Methods A scoping literature review was conducted of all studies that examined the use of vasopressor agents during head and neck free flap tissue transfer. Primary and secondary outcomes included free flap survival, arterial thrombosis, venous congestion, need for revision surgery, and other postoperative complications. Results One prospective and nine retrospective studies were identified. Phenylephrine and ephedrine were the most common vasopressors reported; the rate of vasopressor use ranged from 53% to 85% and administration methods included both bolus and infusion. The included studies did not show any significant association between the use of vasopressors and free flap failure, pedicle thrombosis, or other flap complications. Conclusion The administration of vasopressors during microvascular free tissue transfer for head and neck reconstruction does not seem to be associated with increased flap failure rates or other postoperative morbidities. Moreover, vasopressors may provide overall improved hemodynamic stability and help to limit overall fluid administration and subsequent postoperative complications. Additional prospective investigation is warranted to further elucidate and establish evidence-based recommendations regarding the type, timing, and dose of vasopressors to further enhance free flap survival and patient outcomes.
Collapse
Affiliation(s)
- Akash N Naik
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Taylor Freeman
- College of Medicine, The Ohio State University, Columbus, OH, United States
| | - Michael M Li
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Scarlett Marshall
- Department of Anesthesia, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Akina Tamaki
- Department of Otolaryngology-Head and Neck Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Enver Ozer
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Amit Agrawal
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Stephen Y Kang
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Matthew O Old
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Nolan B Seim
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| |
Collapse
|
28
|
Massaro A, Gomez J, Weyh AM, Bunnell A, Warrick M, Pirgousis P, Fernandes R. Serial Perioperative Assessment of Free Flap Perfusion With Laser Angiography. Craniomaxillofac Trauma Reconstr 2020; 14:16-22. [PMID: 33613831 DOI: 10.1177/1943387520930608] [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] [Indexed: 12/12/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Anthony Massaro
- Department of Oral and Maxillofacial Surgery, University of Florida Jacksonville, Jacksonville, FL, USA
| | - Juliana Gomez
- Department of Oral and Maxillofacial Surgery, University of Florida Jacksonville, Jacksonville, FL, USA
| | - Ashleigh Michelle Weyh
- Department of Oral and Maxillofacial Surgery, University of Florida Jacksonville, Jacksonville, FL, USA
| | - Anthony Bunnell
- Department of Oral and Maxillofacial Surgery, University of Florida Jacksonville, Jacksonville, FL, USA
| | - Matthew Warrick
- Department of Anesthesia, University of Florida Jacksonville, Jacksonville, FL, USA
| | - Philip Pirgousis
- Department of Oral and Maxillofacial Surgery, University of Florida Jacksonville, Jacksonville, FL, USA.,Department of Otorhinolaryngology and Head and Neck Surgery, Mayo Clinic Jacksonville, Jacksonville, FL, USA
| | - Rui Fernandes
- Department of Oral and Maxillofacial Surgery, University of Florida Jacksonville, Jacksonville, FL, USA
| |
Collapse
|
29
|
Dooley BJ, Karassawa Zanoni D, Mcgill MR, Awad MI, Shah JP, Wong RJ, Broad C, Mehrara BJ, Ganly I, Patel SG. Intraoperative and postanesthesia care unit fluid administration as risk factors for postoperative complications in patients with head and neck cancer undergoing free tissue transfer. Head Neck 2019; 42:14-24. [PMID: 31593349 DOI: 10.1002/hed.25970] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 08/04/2019] [Accepted: 09/06/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This study aims to evaluate the impact of perioperative fluid administration, defined as fluid delivered intraoperatively and in the postanesthesia care unit, on postoperative outcomes. METHODS Medical records of 102 patients with oral cavity squamous cell carcinoma undergoing free flap reconstruction between January 2011 and December 2015 were reviewed. The primary endpoint was development of a postoperative complication according to the Clavien-Dindo classification. Perioperative factors recorded were Washington University Head and Neck Comorbidity Index, operating time, vasopressor use, blood loss, intraoperative fluid, and perioperative fluid. RESULTS Greater perioperative fluid administration was independently associated with surgical complications, flap complications, overall incidence of any complication, and increased length of stay. Greater intraoperative fluid administration was independently associated with higher rates of surgical complications. Intraoperative delivery of vasopressors was not associated with flap or surgical complications. CONCLUSION Receiving less perioperative fluid was associated with fewer complications and decreased length of stay.
Collapse
Affiliation(s)
- Bryan J Dooley
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Daniella Karassawa Zanoni
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Marlena R Mcgill
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Mahmoud I Awad
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jatin P Shah
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Richard J Wong
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Clara Broad
- Department of Anesthesiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Babak J Mehrara
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ian Ganly
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Snehal G Patel
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| |
Collapse
|
30
|
Anker AM, Prantl L, Strauss C, Brébant V, Schenkhoff F, Pawlik M, Vykoukal J, Klein SM. 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. Ann Surg Oncol 2019; 27:399-406. [PMID: 31468214 DOI: 10.1245/s10434-019-07758-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Indexed: 01/14/2023]
Abstract
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 (NPFRV, 31.8% ± 12.2% vs NPLFA, 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.
Collapse
Affiliation(s)
- Alexandra M Anker
- Center for Plastic, Reconstructive, Aesthetic, and Hand Surgery, University Hospital Regensburg and Caritas Hospital St. Josef Regensburg, Regensburg, Germany.
| | - Lukas Prantl
- Center for Plastic, Reconstructive, Aesthetic, and Hand Surgery, University Hospital Regensburg and Caritas Hospital St. Josef Regensburg, Regensburg, Germany
| | - Catharina Strauss
- Center for Plastic, Reconstructive, Aesthetic, and Hand Surgery, University Hospital Regensburg and Caritas Hospital St. Josef Regensburg, Regensburg, Germany
| | - Vanessa Brébant
- Center for Plastic, Reconstructive, Aesthetic, and Hand Surgery, University Hospital Regensburg and Caritas Hospital St. Josef Regensburg, Regensburg, Germany
| | - Felix Schenkhoff
- Department of Anesthesiology, Caritas Hospital St. Josef Regensburg, Regensburg, Germany
| | - Michael Pawlik
- Department of Anesthesiology, Caritas Hospital St. Josef Regensburg, Regensburg, Germany
| | - Jody Vykoukal
- Department of Clinical Cancer Prevention and The McCombs Institute for the Early Detection and Treatment of Cancer, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Silvan M Klein
- Center for Plastic, Reconstructive, Aesthetic, and Hand Surgery, University Hospital Regensburg and Caritas Hospital St. Josef Regensburg, Regensburg, Germany
| |
Collapse
|
31
|
Thromboprophylaxis in breast microvascular reconstruction: a review of the literature. EUROPEAN JOURNAL OF PLASTIC SURGERY 2019. [DOI: 10.1007/s00238-019-01510-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
32
|
Rajan S, Sudevan M, Kadapamannil D, Mohan A, Paul J, Kumar L. Does Perioperative Use of Noradrenaline Affect Free Flap Outcome Following Reconstructive Microvascular Surgeries? A Retrospective Analysis. Anesth Essays Res 2019; 13:79-83. [PMID: 31031485 PMCID: PMC6444947 DOI: 10.4103/aer.aer_193_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Sunil Rajan
- Department of Anaesthesiology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Manu Sudevan
- Department of Anaesthesiology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Dilesh Kadapamannil
- Department of Anaesthesiology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Anish Mohan
- Department of Anaesthesiology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Jerry Paul
- Department of Anaesthesiology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Lakshmi Kumar
- Department of Anaesthesiology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| |
Collapse
|
33
|
Heine-Geldern A, Broer P, Prantl L, Brebant V, Anker A, Kehrer A, Thiha A, Lonic D, Ehrl D, Ninkovic M, Heidekrueger P. Impact of intraoperative use of vasopressors in lower extremity reconstruction: Single centre analysis of 437 free gracilis muscle and fasciocutaneous anterolateral thigh flaps. Clin Hemorheol Microcirc 2019; 71:193-201. [DOI: 10.3233/ch-189411] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- A. Heine-Geldern
- Department of Plastic, Hand, and Reconstructive Surgery, BG Unfallklinik, Frankfurt, Germany
| | - P.N. Broer
- Department of Plastic, Reconstructive, Hand and Burn Surgery, StKM - Klinikum Bogenhausen, Academic Teaching Hospital Technical University, Munich, Germany
| | - L. Prantl
- Centre of Plastic, Aesthetic, Hand and Reconstructive Surgery, University of Regensburg, Regensburg, Germany
| | - V. Brebant
- Centre of Plastic, Aesthetic, Hand and Reconstructive Surgery, University of Regensburg, Regensburg, Germany
| | - A.M. Anker
- Centre of Plastic, Aesthetic, Hand and Reconstructive Surgery, University of Regensburg, Regensburg, Germany
| | - A. Kehrer
- Centre of Plastic, Aesthetic, Hand and Reconstructive Surgery, University of Regensburg, Regensburg, Germany
| | - A. Thiha
- Centre of Plastic, Aesthetic, Hand and Reconstructive Surgery, University of Regensburg, Regensburg, Germany
| | - D. Lonic
- Centre of Plastic, Aesthetic, Hand and Reconstructive Surgery, University of Regensburg, Regensburg, Germany
| | - D. Ehrl
- Department of Hand, Plastic, and Aesthetic Surgery, Ludwig-Maximilians University Munich, Campus Großhadern, Munich, Germany
| | - M. Ninkovic
- Department of Plastic, Reconstructive, Hand and Burn Surgery, StKM - Klinikum Bogenhausen, Academic Teaching Hospital Technical University, Munich, Germany
| | - P.I. Heidekrueger
- Centre of Plastic, Aesthetic, Hand and Reconstructive Surgery, University of Regensburg, Regensburg, Germany
| |
Collapse
|
34
|
High-Pressure Injection of Heparinized Saline for Reversing Refractory Intraoperative Phenylephrine-Induced Venous Vasospasm. Plast Reconstr Surg 2018; 143:448e-449e. [PMID: 30516747 DOI: 10.1097/prs.0000000000005246] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
35
|
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
| |
Collapse
|
36
|
Anker A, Prantl L, Strauss C, Brébant V, Heine N, Lamby P, Geis S, Schenkhoff F, Pawlik M, Klein S. Vasopressor support vs. liberal fluid administration in deep inferior epigastric perforator (DIEP) free flap breast reconstruction – a randomized controlled trial. Clin Hemorheol Microcirc 2018; 69:37-44. [DOI: 10.3233/ch-189129] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- A.M. Anker
- Center for Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - L. Prantl
- Center for Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - C. Strauss
- Center for Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - V. Brébant
- Center for Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - N. Heine
- Center for Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - P. Lamby
- Center for Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - S. Geis
- Center for Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - F. Schenkhoff
- Department of Anaesthesiology, Caritas Hospital St. Josef, Regensburg, Germany
| | - M. Pawlik
- Department of Anaesthesiology, Caritas Hospital St. Josef, Regensburg, Germany
| | - S.M. Klein
- Center for Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| |
Collapse
|