Intraoperative vasopressors in head and neck free flap reconstruction

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.

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

“…The overall free flap survival rate was 75/79 (95%). Investigators found no significant difference in flap failure or flap‐related complications between the vasopressor group and the traditional protocol group 23 . A fourth RCT with an intention‐to‐treat analysis randomized 27 patients into one of three unblinded groups, in which patients would either be controls (given fluids if MAP <60 mm Hg), or receive dopamine (maximum dose 13.3 mcg/kg/min) or norepinephrine to maintain MAP 80–90 mm Hg.…”

“…Investigators found no significant difference in flap failure or flap-related complications between the vasopressor group and the traditional protocol group. 23 A fourth RCT with an intention-to-treat analysis randomized 27 patients into one of three unblinded groups, in which patients would either be controls (given fluids if MAP <60 mm Hg), or receive dopamine (maximum dose 13.3 mcg/kg/min) or norepinephrine to maintain MAP 80-90 mm Hg. Patients were monitored postsurgery for 72 h with continuous measurement of tissue partial pressure of oxygen and microdialysis metabolite measurements.…”

Effect of Perioperative Antithrombotics on Head and Neck Microvascular Free Flap Survival After Anastomotic Revision

“…The growing consensus of available data show that vasopressor use intraoperatively does not decrease free flap survival. [19][20][21][22][23] In fact, studies show vasopressors can improve free flap skin paddle blood flow 24 and are preferred to large-volume resuscitation. 25,26 Some of the anastomotic revisions without thrombectomy in the current study may have been performed in response to vasospasm.…”

“…Traditionally, microvascular surgeons were hesitant to use vasopressors, with the belief that the flap pedicle is hypersensitive to vasoconstrictor medications, potentially endangering the flap. The growing consensus of available data show that vasopressor use intraoperatively does not decrease free flap survival 19‐23 . In fact, studies show vasopressors can improve free flap skin paddle blood flow 24 and are preferred to large‐volume resuscitation 25,26 .…”

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

“…However, there is now a robust and growing body of literature demonstrating efficacy and safety of vasopressor use in microsurgery (Brinkman et al, 2013; Naik et al, 2020; Swanson et al, 2016; Taylor et al, 2021) (Table 1). Several studies demonstrate no differences in the flap failure incidence between flaps exposed to pressor versus not (Fang et al, 2018; Heine‐Geldern et al, 2019; Knackstedt et al, 2019; Naik et al, 2020; Swanson et al, 2016).…”