Vasopressors and Reconstructive Flap Perfusion

Ibrahim, Ahmed M.S.; Kim, Peter; Rabie, Ahmed; Lee, Bernard T.; Lin, Samuel J.

doi:10.1097/sap.0b013e31828d70b3

Cited by 29 publications

(15 citation statements)

References 20 publications

(14 reference statements)

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“…The regulation of regional blood flow and overall hemodynamics including intraoperative MAP is a critical factor to maintain microvascular flap perfusion and decrease postoperative complications and morbidity ( Sigurdsson, 1995 ; Haughey et al, 2001 ; Ibrahim et al, 2014 ; Goh et al, 2019 ). Many patients undergoing head and neck reconstruction are at risk for intraoperative hypotension due to anesthetic agents, opioid analgesics, prolonged operative times, blood loss, insensible fluid loss, hypothermia, and other associated medical co-morbidities ( Sigurdsson, 1995 ; Chan et al, 2013 ; Raittinen et al, 2016 ; Goh et al, 2019 ).…”

Section: Discussionmentioning

confidence: 99%

“…Microvascular free tissue transfer (MFTT) has become an essential component of head and neck reconstruction ( Monroe et al, 2010 ). While advancements have led to excellent surgical outcomes with MFTT success rates routinely exceeding 95% ( Densky et al, 2019 ), there remains controversy regarding the use of intraoperative intravenous vasopressor agents among both surgeons and anesthesiologists during these procedures ( Harris et al, 2012 ; Chan et al, 2013 ; Ibrahim et al, 2014 ; Swanson et al, 2016 ; Wax and Azzi, 2018 ). Due to intraoperative hypotension, it is commonplace for teams to have ongoing discussions during these cases to select intraoperative fluid administration or vasopressor therapy medication and dosing.…”

Section: Introductionmentioning

confidence: 99%

“…Due to intraoperative hypotension, it is commonplace for teams to have ongoing discussions during these cases to select intraoperative fluid administration or vasopressor therapy medication and dosing. Theoretically, vasoactive agents have been feared to cause vasoconstriction, thereby potentially increasing the risk of thrombosis and flap failure ( Cordeiro et al, 1997 ; Harris et al, 2012 ; Ibrahim et al, 2014 ). This was supported, early on, by animal models suggesting that phenylephrine decreased flow through the flap pedicle in musculocutaneous island flaps ( Cordeiro et al, 1997 ).…”

Section: Introductionmentioning

confidence: 99%

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The Use of Vasopressor Agents in Free Tissue Transfer for Head and Neck Reconstruction: Current Trends and Review of the Literature

Naik

Freeman

et al. 2020

Front. Pharmacol.

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Background/Objectives Microvascular free tissue transfer has become essential to head and neck reconstruction and recent advancements in microvascular surgery have led to excellent surgical outcomes. However, there continues to be controversy and a stigma associated with the use of perioperative intravenous vasopressor agents among both surgeons and anesthesiologists. Due to concern for vasoconstriction of peripheral vasculature flowing to the denervated tissue flap, there remains concerns about potential thrombosis, decreased tissue perfusion and ultimately flap failure. This topic becomes even more important as vasopressors play an essential role in new Extended Recovery After Surgery (ERAS) protocols being put in place to optimize postoperative recovery for patients. The purpose of this study was to comprehensively review the role and safety as well as discuss current trends with intraoperative vasopressor agents in free tissue transfer for head and neck reconstruction. Methods A scoping literature review was conducted of all studies that examined the use of vasopressor agents during head and neck free flap tissue transfer. Primary and secondary outcomes included free flap survival, arterial thrombosis, venous congestion, need for revision surgery, and other postoperative complications. Results One prospective and nine retrospective studies were identified. Phenylephrine and ephedrine were the most common vasopressors reported; the rate of vasopressor use ranged from 53% to 85% and administration methods included both bolus and infusion. The included studies did not show any significant association between the use of vasopressors and free flap failure, pedicle thrombosis, or other flap complications. Conclusion The administration of vasopressors during microvascular free tissue transfer for head and neck reconstruction does not seem to be associated with increased flap failure rates or other postoperative morbidities. Moreover, vasopressors may provide overall improved hemodynamic stability and help to limit overall fluid administration and subsequent postoperative complications. Additional prospective investigation is warranted to further elucidate and establish evidence-based recommendations regarding the type, timing, and dose of vasopressors to further enhance free flap survival and patient outcomes.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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The Use of Vasopressor Agents in Free Tissue Transfer for Head and Neck Reconstruction: Current Trends and Review of the Literature

Naik

Freeman

et al. 2020

Front. Pharmacol.

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“…A 2014 systematic review of retrospective studies showed no consistent effects on flap perfusion or flap complications. 130 Subsequent to that publication, a retrospective cohort study of 682 patients and 1039 flaps also failed to demonstrate an increased risk of thrombotic events or flap loss in patients receiving vasopressors. 131 …”

Section: Evidence-based Recommendations For Components Of Eras Protocmentioning

confidence: 99%

Paravertebral blocks and enhanced recovery after surgery protocols in breast reconstructive surgery: patient selection and perspectives

Parikh¹,

Myckatyn²

2018

JPR

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The management of postoperative pain is of critical importance for women undergoing breast reconstruction after surgical treatment for breast cancer. Mitigating postoperative pain can improve health-related quality of life, reduce health care resource utilization and costs, and minimize perioperative opiate use. Multimodal analgesia pain management strategies with nonopioid analgesics have improved the value of surgical care in patients undergoing various operations but have only recently been reported in reconstructive breast surgery. Regional anesthesia techniques, with paravertebral blocks (PVBs) and transversus abdominis plane (TAP) blocks, and enhanced recovery after surgery (ERAS) pathways have been increasingly utilized in opioid-sparing multimodal analgesia protocols for women undergoing breast reconstruction. The objectives of this review are to 1) comprehensively review regional anesthesia techniques in breast reconstruction, 2) outline important components of ERAS protocols in breast reconstruction, and 3) provide evidence-based recommendations regarding each intervention included in these protocols. The authors searched across six databases to identify relevant articles. For each perioperative intervention included in the ERAS protocols, the literature was exhaustively reviewed and evidence-based recommendations were generated using the Grading of Recommendations, Assessment, Development, and Evaluation system methodology. This study provides a comprehensive evidence-based review of interventions to optimize perioperative care and postoperative pain control in breast reconstruction. Incorporating evidence-based interventions into future ERAS protocols is essential to ensure high value care in breast reconstruction.

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“…It has been observed that there has been no difference in the outcomes when pressors were used or not used, and there is no reliable evidence to support contraindication of pressor use[23]. Frequency of flap necrosis and postoperative complications and adverse events were similar with or without use of intraoperative pressors[24].…”

Section: Anesthetic Considerationsmentioning

confidence: 99%

Face transplantation: Anesthetic challenges

Dalal

2016

WJT

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Face transplantation is a complex vascular composite allotransplantation (VCA) surgery. It involves multiple types of tissue, such as bone, muscles, blood vessels, nerves to be transferred from the donor to the recipient as one unit. VCAs were added to the definition of organs covered by the Organ Procurement and Transplantation Network Final Rule and National Organ Transplant Act. Prior to harvest of the face from the donor, a tracheostomy is usually performed. The osteotomies and dissection of the midface bony skeleton may involve severe hemorrhagic blood loss often requiring transfusion of blood products. A silicon face mask created from the facial impression is used to reconstruct the face and preserve the donor’s dignity. The recipient airway management most commonly used is primary intubation of an existing tracheostoma with a flexometallic endotracheal tube. The recipient surgery usually averages to 19-20 h. Since the face is a very vascular organ, there is usually massive bleeding, both in the dissection phase as well as in the reperfusion phase. Prior to reperfusion, often, after one sided anastomosis of the graft, the contralateral side is allowed to bleed to get rid of the preservation solution and other additives. Intraoperative product replacement should be guided by laboratory values and point of care testing for coagulation and hemostasis. In face transplantation, bolus doses of pressors or pressor infusions have been used intraoperatively in several patients to manage hypotension. This article reviews the anesthetic considerations for management for face transplantation, and some of the perioperative challenges faced.

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Vasopressors and Reconstructive Flap Perfusion

Cited by 29 publications

References 20 publications

The Use of Vasopressor Agents in Free Tissue Transfer for Head and Neck Reconstruction: Current Trends and Review of the Literature

The Use of Vasopressor Agents in Free Tissue Transfer for Head and Neck Reconstruction: Current Trends and Review of the Literature

Paravertebral blocks and enhanced recovery after surgery protocols in breast reconstructive surgery: patient selection and perspectives

Face transplantation: Anesthetic challenges

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