A literature review and meta‐analysis of outcomes in microsurgical reconstruction using vasopressors

Knackstedt, Rebecca; Gatherwright, James; Gürünlüoğlu, Raffi

doi:10.1002/micr.30341

Cited by 12 publications

(13 citation statements)

References 37 publications

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“…27,28 Our series differs from existing literature, where phenylephrine or ephedrine dominates. 8,23 Only one previous study includ-ed the administration of metaraminol, and this was in the minority. 15 Metaraminol was by far the most commonly administered agent in our series, so it is likely to be an indicator rather than a cause of poor outcomes.…”

Section: Discussionmentioning

confidence: 99%

“…Largely different end points, ranging from 5 days to 3 months, alongside inconsistent outcomes, defined from total flap loss to flap complications requiring surgical revision, naturally make comparison difficult. 8 Second, while many studies have investigated the impact of vasopressor use on flap outcomes, none have addressed the effect of different methods of administration (i.e., continuous IV administration or repeated boluses). These methodological difficulties indicate that further clear quantitative data are required.…”

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confidence: 99%

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

Munro

Chang

Tinker

et al. 2021

J Reconstr Microsurg

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Background The role of vasopressors has long been a subject of debate in microsurgery. Conventional wisdom dictates the avoidance of vasopressor use, due to concerns such as peripheral vasoconstriction, inducing vasospasm of the anastomoses, and leading to failure in perfusion. It has since become common practice in some centers to avoid intraoperative vasopressor use during free tissue transfer surgery. Recent studies have suggested that this traditional view may not be supported by clinical evidence. However, none of these studies have separated vasopressor use by method of administration. Methods We conducted a retrospective review of our experience of vasopressor use in free flap surgery at a single high-volume center. The outcome measures were flap failure, flap-related complications and overall postoperative complications (reported using the Clavien–Dindo classification). Groups were compared using Chi-square or Fisher's Exact test where appropriate. Results A total of 777 cases in 717 patients were identified. 59.1% of these had vasopressors administered intraoperatively. The overall failure rate was 2.2%, with 9.8% experienced flap-related complications. There was no difference in flap loss when vasopressors were administered, but an increased rate of microvascular thrombosis was noted (p = 0.003). Continuous administration of vasopressors was associated with reduced venous congestion, whereas intermittent boluses increased risk of microvascular thrombosis. Conclusion Our study confirms previous findings that intraoperative vasopressor use in free flap surgery is not associated with increased failure rate. Administering vasopressors continuously may be safer than via repeated boluses.

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Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

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

Munro

Chang

Tinker

et al. 2021

J Reconstr Microsurg

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“…The safety of vasoactive agents in reconstructive microsurgery observed in this study falls in line with the findings of several recent publications. 9 , 33 , 34 …”

Section: Discussionmentioning

confidence: 99%

Liberal versus Modified Intraoperative Fluid Management in Abdominal-flap Breast Reconstructions. A Clinical Study

Sjöberg

Numan

Weerd

2021

Plastic and Reconstructive Surgery - Global Open

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Background: The outcome of reconstructive microsurgery is influenced by the intraoperative anesthetic regimen. The aim of this study was to compare the impact on the intra- and postoperative complication rates of our modified fluid management (MFM) protocol with a previously used liberal fluid management protocol in abdominal-flap breast reconstructions. Methods: This retrospective study analyzed adverse events related to secondary unilateral abdominal-flap breast reconstructions in two patient cohorts, one with a liberal fluid management protocol and one with a MFM protocol. In the MFM protocol, intravenous fluid resuscitation was restricted and colloid use was minimized. Both noradrenaline and propofol were implemented as standard in the MFM protocol. The primary endpoints were surgical and medical complications, as observed intraoperatively or postoperatively, during or shortly after the hospital stay. Results: Of the 214 patients included in the study, 172 patients followed the MFM protocol. Prior radiotherapy was more frequent in the MFM protocol. Surgical procedures to achieve venous superdrainage were more often used in the MFM cohort. Intraoperative as well as postoperative complications occurred significantly more frequently in the liberal fluid management cohort and were specifically associated with partial and total flap failures. Prior radiotherapy, additional venous drainage, or choice of inhalation agent did not have an observable impact on outcome. Conclusions: The incidence of adverse events during and after autologous breast reconstructive procedures was reduced with the introduction of an MFM protocol. Strict intraoperative fluid control combined with norepinephrine and propofol was both beneficial and safe.

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“…The variability of the types of free flaps utilized in this study enhances its generalizability to the field of head and neck free flap reconstruction as a whole. Overall these results are consistent with multiple other clinical studies examining pressors in head and neck reconstruction (Chao, Taylor, Rahmati, & Rohde, 2014; Harris et al, 2012; Kelly et al, 2014; Monroe et al, 2010; Monroe et al, 2011), as well as larger studies evaluating the effect of vasopressors in free flap reconstruction of the breast, head and neck, extremities, and trunk (Table 4; Chan, Chow, & Liu, 2013; Chen et al, 2010; Fang et al, 2018; Knackstedt, Gatherwright, & Gurunluoglu, 2019; Nelson et al, 2017). The study by Nelson et al (2017) observed retrospectively that within 682 patients undergoing 1,039 flaps for breast reconstruction there was no increase in intraoperative thrombotic events (arterial or venous) or flap loss associated with vasopressor administration, but they did have a higher rate of minor complications (wound healing issues, seroma, infection, partial flap loss, and fat necrosis): 53% in the vasopressor group and 43% in those who did not receive vasopressors.…”

Section: Discussionmentioning

confidence: 99%

“…Of particular note, phenylephrine was the pressor used during the microvascular anastomosis of the case of the flap failure that occurred in the pressor group. As the meta‐analysis by Knackstedt et al (2019) describes, many surgeons recommend against phenylephrine use during microsurgical reconstruction if a vasopressor is required. Similarly, Retrouvey et al (2020) observed a trend toward increased odds of digit failure in patients who had received phenylephrine intraoperatively during their digit reimplantation/revascularization.…”

Section: Discussionmentioning

confidence: 99%

Intraoperative vasopressors in head and neck free flap reconstruction

et al. 2020

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Introduction Historically, there were concerns vasopressors impair free flap outcomes, but recent studies suggest vasopressors are safe. Here we investigate this controversy by (1) evaluating vasopressors' effect on head and neck free‐flap survival and surgical complications, and (2) performing soft tissue and bony subset analysis. Patients and methods Post hoc analysis was performed of a single‐blinded, prospective, randomized clinical trial at a tertiary care academic medical center involving patients ≥18 years old undergoing head and neck free flap reconstruction over a 16‐month period. Patients were excluded if factors prevented accurate FloTrac™ use. Patients were randomized to traditional volume‐based support, or goal‐directed support including vasopressor use. Primary data was obtained by study personnel through intraoperative data recording and postoperative medical record review. Results Forty‐one and 38 patients were randomized to traditional and pressor‐based algorithms, respectively. Flap survival was 95% (75/79). There was no significant difference between the pressor‐based and traditional protocols' flap failure (1/38 [3%] vs. 3/41 [7%], RR 0.36, 95% CI of RR 0.04–3.31, p = .63) or flap‐related complications (12/38 [32%] vs. 18/41 [44%], RR 0.72, 95% CI 0.40–1.29, p = .36) Soft tissue flaps had surgical complication rates of 12/30 (40%) and 9/27 (33%) for traditional and pressor‐based protocols, respectively. Bony flaps had surgical complication rates of 6/11 (55%), and 3/11 (27%) for traditional and pressor‐based protocols, respectively. Conclusions Intraoperative goal‐directed vasopressor administration during head and neck free flap reconstruction does not appear to increase the rate of flap complications or failures.

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A literature review and meta‐analysis of outcomes in microsurgical reconstruction using vasopressors

Cited by 12 publications

References 37 publications

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

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

Liberal versus Modified Intraoperative Fluid Management in Abdominal-flap Breast Reconstructions. A Clinical Study

Intraoperative vasopressors in head and neck free flap reconstruction

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