Impact of Intraoperative Vasopressor Use in Free Tissue Transfer for Head, Neck, and Extremity Reconstruction

Abstract

General anesthesia induces hypotension and this is commonly treated intraoperatively with administering vasopressors. Microsurgeons are hesitant to use vasopressors due to the potential risk of inducing vasoconstriction and flap necrosis. The aim of this study was to determine the frequency of intraoperative vasopressor utilization in patients undergoing free tissue transfer reconstruction and to determine its impact on patient outcomes. An IRB-approved retrospective review was performed for 47 consecutive patients undergoing free tissue transfer for head, neck, and extremity reconstruction at Wake Forest Baptist Health over a 3-year period. Free flap survival was 97%, with 3% of patients having total flap necrosis and 17% with partial flap necrosis. The frequency of intraoperative vasopressor use was 53.2%. There was no significant difference in the frequency of total or partial flap necrosis between patients who received intraoperative vasopressors and those who did not. Similarly, there was no statistical significance in the rate of arterial or venous thrombosis between the 2 groups (P = 0.095 and P = 0.095, respectively). The use of vasopressors did not significantly increase postoperative complications. The timing of vasopressor administration did not affect outcomes. Intraoperative vasopressors are used more frequently than previously realized during free tissue transfer for reconstructive surgery. The use of intraoperative vasopressors does not appear to adversely affect outcomes of free tissue transfer. Further investigation and larger study size are needed to analyze the timing of drug administration, dose, and type of vasopressor to better understand the impact of intraoperative vasopressor use in free tissue transfer outcomes.

Emerging Paradigms in Perioperative Management for Microsurgical Free Tissue Transfer

“…93 Interestingly, in several clinical studies, intraoperative vasopressor administration affected neither the incidence of flap loss nor the rate of reoperation. [29][30][31][32][33] Cumulative dosage and timing of vasopressor administration showed no correlation with adverse outcomes. 29,33 Dobutamine has been shown to significantly improve flap flow.…”

Paravertebral Blocks Reduce Narcotic Use Without Affecting Perfusion in Patients Undergoing Autologous Breast Reconstruction

“…Our PVB groups and ERAS subgroup had similar blood pressure measurements and fluid administration throughout the intraoperative period, and similar doses of vasopressor medications. The use of vasopressors for management of intraoperative hypotension, while previously avoided in microsurgery, has not been found to have a significant adverse effect on flap outcomes, 33 although caution is still recommended based on known effects of vasoconstriction in animal models. 31 , 34 In our study, neither the use of a PVB or our ERAS protocol had an effect on use of vasopressor medications.…”

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“…These two techniques are easily used in the operating room and their reported sensitivity was up to 60% [48]. Murawa and colleagues [48] published the first use of the SPY system to assess the gastric graft and several other studies [47,49,50] suggested the utility of using this technique. The SPY system may be particularly useful with considerable contribution when a complex esophageal reconstruction is considered to assess the adequacy of supercharged graft blood supply.…”

“…Therefore information given by intraoperative assessments can be used to guide intraoperative decision making. As recommended by authors [47,48,49,50], these tools are used in conjunction with clinical acumen to decide whether the conduit blood supply is suitable or whether another conduit must be sought.…”