Does perioperative use of noradrenaline affect free flap outcome following reconstructive microvascular surgeries? A retrospective analysis

Abstract

Background: Over concerns of vasoconstriction leading to free flap failure, it has been a common practice to avoid vasopressors for the maintenance of blood pressure during reconstructive microvascular surgeries. Aims: The aim of this study was to assess the impact of use of noradrenaline in the perioperative period on outcome of free flaps in patients who underwent reconstructive surgeries as compared to those who did not receive noradrenaline. Settings and Design: Retrospective analysis was conducted at a tertiary care institute. Materials and Methods: A total of 120 patients who underwent free flap surgeries were included in the study, of which 102 patients who did not require noradrenaline perioperatively formed the control group (Group C), whereas those who required noradrenaline infusion constituted the study group (Group N). Data regarding flap outcome at discharge, intraoperative hemodynamics and temperature were documented. Statistical Test Used: Chi-square test, Mann–Whitney test, Independent sample t -test, and paired t -test were used for statistical analysis. Results: Out of 120 patients, 15% ( n = 18) patients required noradrenaline (Group N). In Group N, 27.78% ( n = 5) patients and in Group C, 22.55% ( n = 23) were re-explored. Four patients in Group C and none in Group N had a poor flap outcome (3.92% vs. 0%). There was no significant difference in surgical duration and the volume of crystalloids received in both groups. Preoperative hemoglobin levels were lower in Group N; intraoperatively, they were more hypothermic and needed more colloids, blood, and plasma. Conclusion: Perioperative use of noradrenaline did not adversely affect free flap survival in patients who underwent microvascular reconstructive surgeries. Although re-exploration rate was marginally increased with use of noradrenaline, the final flap outcome was unaffected.

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

“…Reference No. (Continues) from 0.02 to 2 μg/kg/min), norepinephrine did not adversely affect free flap survival (Rajan et al, 2019). A 2019 meta-analysis and sys- was not statistically significant (Chen et al, 2010).…”

“…Rajan et al investigated norepinephrine administration among 120 patients with head and neck free flaps. Irrespective of dose (range from 0.02 to 2 μg/kg/min), norepinephrine did not adversely affect free flap survival (Rajan et al, 2019). A 2019 meta‐analysis and systematic review included 14 studies representing 8653 flaps across indications.…”

“…Administering vasopressors continuously may be safer than via repeated boluses. More studies are needed to confirm appropriate concentration (Chen et al, 2010; Monroe et al, 2011; Munro et al, 2022; Rajan et al, 2019).…”