Transfusion in Head and Neck Cancer Patients Undergoing Pedicled Flap Reconstruction

Abstract

Objective Blood product utilization is monitored to prevent unnecessary transfusions. Head‐and‐neck pedicled flap reconstruction transfusion‐related outcomes were assessed. Methods One hundred and thirty‐six pedicled flap patients were reviewed: 64 supraclavicular artery island flaps (SCAIF), 57 pectoralis major (PM) flaps, and 15 submental (SM) flaps. Outcome parameters included flap‐related complications, medical complications, length of stay (LOS), and flap survival. Multivariable logistic regression analyses were performed. Multivariable logistic regression analyses were performed to adjust for relevant pre‐ and perioperative factors. Results Of all head‐and‐neck pedicled flap patients included in our analyses (n = 136), 40 (29.4%) received blood transfusions. The average pretransfusion hematocrit (Hct) was 24.3% ± 0.5%, with 2.65 ± 0.33 units transfused and a posttransfusion Hct increase of 5.0% ± 0.6%. Transfusion rates differed with PM (47.4%), SCAIF (17.2%), and SM (13.3%) flaps (P < 0.005). Patients undergoing PM reconstruction trended toward higher transfusion requirements (PM 2.89 ± 0.47 units, SC 2.18 ± 0.28 units, and SM 2.00 ± 0.0 units), with transfusion occurring later in the postoperative course (4.9 ± 1.3 days vs. 2.4 ± 0.1 days for all other flaps; P = 0.08). Infection, dehiscence, fistula, or medical complications were not different. Transfusion thresholds of Hct < 21 versus Hct < 27 exhibited no difference in LOS, flap‐survival, or medical/flap‐related complications. Conclusion Transfusion is not associated with surgical or medical morbidity following head and neck pedicled flap reconstruction. There were no differences in outcomes between transfusion triggers of Hct < 21 versus Hct < 27, suggesting that a more conservative transfusion trigger may not precipitate adverse patient complications. Our data recapitulate findings in free flap patients and warrant further investigation of transfusion practices in head and neck flap reconstruction. Level of Evidence 4. Laryngoscope, 128:E409–E415, 2018

Acute normovolemic hemodilution reduced allogeneic blood transfusion without increasing perioperative complications in patients undergoing free-flap reconstruction of the head and neck

“…An animal experimentation study revealed that ANH could improve oxygenation in ischemic and hypoxic flap tissues [21]. Moreover, in a previous study, there were no differences in flap-related and medical complications between transfusion triggers of hematocrit less than 21% versus hematocrit less than 27% in free-flap reconstruction of the head and neck [22]. Thus, the present level of ANH for free-flap surgery was likely not to increase flap failure.…”

A Comprehensive Review on the Supraclavicular Flap for Head and Neck Reconstruction

“…After leaving the OR, free flaps continue to place a greater burden on the healthcare system when compared with the SCF. An intriguing retrospective study by Abt et al 67 found that free flaps require more transfusions per patient than pedicled flaps. Free flaps routinely require postoperative ICU monitoring of the flap, typically in hourly increments.…”

“…2 The complication rate in SCF reconstructions has been reported at 25.5% (21%-31%). 66,67 Patients should be positioned postoperatively in a way that reduces pedicle tension. 51 There is also a risk of iatrogenic vascular injury causing flap necrosis, which is avoidable with careful dissection by an experienced surgeon.…”

International multicentre observational study to evaluate the association between perioperative red blood cell transfusions and 1-year mortality after major cancer surgery (ARCA-1): study design, statistical analysis plan and study protocol

“…Patients will be considered for inclusion in the study if they meet all the following criteria: (1) age ≥18 years, (2) American Society of Anesthesiologists physical status I-IV, (3) scheduled oncologic surgical procedures with the intention to cure and (4) an overnight planned hospital admission. Patients who: (1) have planned ambulatory, revision or palliative surgery, (2) undergo surgeries with minimum risk of blood transfusion (≤1%) during and after (48 hours) surgery according to each centre practice, (3) emergency procedures or (4) scheduled surgery under local infiltration anaesthesia are not eligible in the study.…”

“…However, not unfrequently, PRBCs are also given perioperatively to patients without haemodynamic instability or symptomatic anaemia. 2 As a result, the rate of PRBCs transfusions during and after major cancer surgery remains variable, but it can be as high as 90% and in some cases, such as thoracic surgeries, several units (>10) of blood products are given perioperatively. [3][4][5][6][7] Perioperative strategies of PRBCs transfusions may impact short-term clinical outcomes in patients with cancer.…”