Goal-directed fluid therapy for microvascular free flap reconstruction following mastectomy: A pilot study

Abstract

S ince the 1940s, the prevailing wisdom regarding the amount of fluid to administer to surgical patients has undergone several paradigm shifts (1-4). The fluid management of patients undergoing microvascular free flap reconstruction is particularly challenging. This is typically a long operation with minimal surgical stimulation. The use of vasopressors in these cases is contraindicated so as not to compromise blood flow to the flap. Inadequate volume replacement in these patients can potentially lead to poor flow in the flap with resultant ischemia and flap loss. Aggressive fluid administration in these patients, to maintain adequate blood pressure, can result in flap edema, venous engorgement and, ultimately, flap loss. There have been several retrospective studies that have examined fluid administration in these patients and found that excessive perioperative fluid administration has been associated with flap loss (5,6).

Role of a fluid-restrictive strategy in flap-surgery: A single center retrospective cohort study

“…Karamanos et al [ 14 ] found that restrictive fluid resuscitation (<7 mL/kg/h) can increase blood flow to the flap and reduce wound-related complications in breast reconstruction patients. Funk et al [ 15 ] administered goal-directed fluid therapy to patients undergoing microvascular free flap reconstruction after mastectomy, aiming to maintain stroke volume variation at 13% or less; they reported that intra-arterial blood pressure monitoring was helpful for achieving this goal, and the intervention group had a baseline fluid infusion rate of 5 mL/kg/h.…”

Perioperative Tissue Oximetry-driven Fluid Resuscitation Improves Flap Perfusion in Autologous Free Tissue Breast Reconstruction

“…A prospective pilot study by Funk et al compared traditional parameters such as blood pressure and heart rate to noninvasive cardiac monitoring in patients undergoing mastectomy and microvascular reconstruction. 12 In comparison to the traditional parameters used to assess organ perfusion, goal-directed fluid therapy utilizing an elevated stroke volume variation (>13%) as a trigger for fluid boluses resulted in improved end operative hemodynamics. 12 The authors also noted that the use of a goal directed approach with Vigileo monitoring may have prompted earlier and more timely resuscitation, leading to improved end outcomes.…”

“…12 In comparison to the traditional parameters used to assess organ perfusion, goal-directed fluid therapy utilizing an elevated stroke volume variation (>13%) as a trigger for fluid boluses resulted in improved end operative hemodynamics. 12 The authors also noted that the use of a goal directed approach with Vigileo monitoring may have prompted earlier and more timely resuscitation, leading to improved end outcomes. The limitations of the traditional parameters used to assess organ perfusion are also found in the pediatric patient population, where the PRS Global Open • 2022 use of NIRS has been routinely employed to assess cerebral oxygen saturation.…”

“…10,11 The impact of perioperative fluid administration on free flap outcomes is also well established across the surgical literature. 5,8,9,12 Whereas the use of NIRS monitoring as a parameter to predict fluid responsiveness has previously been examined, no such studies have been reported in breast or microvascular reconstruction. 13 The present work is the first to examine the use of NIRS as a guide to real-time fluid administration in autologous breast flap reconstruction.…”

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

“…A common component of ERAS protocols is goal directed fluid therapy (GDFT), in which stroke volume variation (SVV) >13% is targeted as the opportune timing for delivery of fluids to increase cardiac output. This may improve hemodynamics postoperatively while avoid fluid overload (Al Saied et al, 2020;Funk et al, 2015).…”