Expert Consensus Statement on the Perioperative Management of Adult Patients Undergoing Head and Neck Surgery and Free Tissue Reconstruction From the Society for Head and Neck Anesthesia

Abstract

The perioperative care of adult patients undergoing free tissue transfer during head and neck surgical (microvascular) reconstruction is inconsistent across practitioners and institutions. The executive board of the Society for Head and Neck Anesthesia (SHANA) nominated specialized anesthesiologists and head and neck surgeons to an expert group, to develop expert consensus statements. The group conducted an extensive review of the literature to identify evidence and gaps and to prioritize quality improvement opportunities. This report of expert consensus statements aims to improve and standardize perioperative care in this setting. The Modified Delphi method was used to evaluate the degree of agreement with draft consensus statements. Additional discussion and collaboration was performed via video conference and electronic communication to refine expert opinions and to achieve consensus on key statements. Thirty-one statements were initially formulated, 14 statements met criteria for consensus, 9 were near consensus, and 8 did not reach criteria for consensus. The expert statements reaching consensus described considerations for preoperative assessment and optimization, airway management, perioperative monitoring, fluid management, blood management, tracheal extubation, and postoperative care. This group also examined the role for vasopressors, communication, and other quality improvement efforts. This report provides the priorities and perspectives of a group of clinical experts to help guide perioperative care and provides actionable guidance for and opportunities for improvement in the care of patients undergoing free tissue transfer for head and neck reconstruction. The lack of consensus for some areas likely reflects differing clinical experiences and a limited available evidence base.

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

“… 9 A recent consensus statement on patients undergoing head and neck surgery and free flap reconstruction stated that fluid overload may increase the risk of free flap failure in these patients and recommended judicious fluid administration. 10 This is supported by various studies showing an increased risk of free flap complications with increased fluid administration. 11 , 12 However, the delicate balance between too much versus too little fluid is different for each patient and each case.…”

“…However, there is also evidence that restrictive fluid regimens can contribute to hypovolemia and multiple organ dysfunction or failure 9 . A recent consensus statement on patients undergoing head and neck surgery and free flap reconstruction stated that fluid overload may increase the risk of free flap failure in these patients and recommended judicious fluid administration 10 . This is supported by various studies showing an increased risk of free flap complications with increased fluid administration 11,12 .…”

Whole-organ deceased donor tracheal allograft transplantation for the treatment of refractory tracheal stenosis: a case report

“…Our anesthetic approach borrowed from routinely employed management techniques in microvascular free flap reconstruction, including judicious intravenous fluid administration [12] and a focus on early extubation, which is not only important in head and neck free flap surgery [13] , but also important in lung transplantation where it decreases anastomotic injury and postoperative infections [14,15] . A total intravenous anesthetic was utilized to limit waste gases during endotracheal tube manipulation and to facilitate smooth emergence.…”

Opioid prescribing and consumption after head and neck free flap reconstruction: what is the evidence for multimodal analgesia?

“…Furthermore, engaging learners is a key step in application of quality improvement initiatives ( 23 , 24 ) and affords the opportunity of cultivating future champions for effective opioid stewardship. Best practice in perioperative management of head and neck surgery patients continues to rely heavily on consensus expertise ( 25 ). As the evidence base mature and cancer care evolves through advances surgery and chemoradiotherapy ongoing tailoring of approaches will be necessary.…”