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

Abstract

This systematic review and meta‐analysis investigates the objective evidence regarding outcomes in head and neck free flap surgeries using vasoactive agents in the perioperative period. A search was performed in PubMed, Cochrane, Web of Science, and Scopus databases. Inclusion criteria were clinical studies in which vasopressors were used in head and neck free flap surgery during the intraoperative and perioperative period. Eighteen studies (n = 5397) were included in the qualitative analysis and nine (n = 4381) in the meta‐analysis. There was no difference in flap failure outcomes with perioperative vasopressor use in head and neck free flap surgery (n = 4015, OR = 0.93, 95% CI [0.60, 1.44]). When patients received vasopressors perioperatively, there was an associated decrease in flap‐specific complications (n = 3881, OR = 0.69, 95% CI [0.55, 0.87]). Intraoperative vasopressor use does not negatively impact free tissue transfer outcomes in head and neck surgery and may reduce overall free flap complications.

Impact of goal‐directed hemodynamic therapy on perioperative outcomes in head and neck free flap surgery: A before‐and‐after pilot study

“…The two groups before (n = 346) versus monitored (GDHT) (n = 68) had no statistically significant differences in terms of age, comorbidities (Charlson score), past medical history of hypertension, and duration of anesthesia (Table 1). When comparing the two groups before versus monitored, the number of episodes of IOH and the total duration of IOH did not significantly change with the use of hemodynamic monitoring (respectively, 6 [2][3][4][5][6][7][8][9][10][11][12] vs. 8 [3][4][5][6][7][8][9][10][11][12][13][14] p = 0.15; and 93 vs. 109 [47-180] min, p = 0.21).…”

“…7 The avoidance of IOH due to vasodilation is even more challenging in free flap cases as the use of vasopressors to maintain blood pressure is still a matter of debate even if recent studies have reported that it does not increase the risk of flap complications. 8,9 In these conditions, avoiding fluid administration or vasopressors may expose FTT patients to long periods of IOH, especially during times of minimal stimulation (e.g., microvascular anastomosis) leading to flap and organ hypoperfusion and dysfunction. 4,6 Several surgical specialties (e.g., major abdominal surgery) have made extensive use of goal-directed hemodynamic therapy (GDHT) based on relatively noninvasive cardiac output (CO) monitoring to optimize fluid balance during and after surgery, which has resulted in a decrease in postoperative morbidity.…”

“…The main challenge in perioperative fluid management is the balance of avoiding significant hypovolemia, which may induce IOH with end‐organ hypoperfusion, without over‐resuscitating the patient with the risk of not only organ edema but also free flap edema due to the absence of lymphatic drainage 7 . The avoidance of IOH due to vasodilation is even more challenging in free flap cases as the use of vasopressors to maintain blood pressure is still a matter of debate even if recent studies have reported that it does not increase the risk of flap complications 8,9 …”

Impact of perioperative use of vasopressors in free flap surgery: A trial sequential analysis

“…On the contrary, the TSA on major medical complications showed a Z-line between the two conventional boundaries, with a ratio of patients recruited/needed of n = 417/4805 (Figure 4), therefore suggesting the need for further research on this outcome. The promising results regarding the use of vasopressors in free flap surgery, as demonstrated by Michelle et al, 1 appear robust and may not require further validation. However, additional studies are warranted to explore the impact of vasopressors on major clinical complications in this type of surgery.…”

“…We commend Michelle et al for their work suggesting that intraoperative vasopressor use does not negatively impact free tissue transfer outcomes in head and neck surgery. 1 Michelle et al found managing intraoperative hypotension during free flap surgery did not appear to increase the risk of complete or partial necrosis of the flap necessitating removal or replacement. Furthermore, the use of vasopressors reduced the odds ratio of total complications (OR = 0.65, 95% CI [0.52, 0.82], p < 0.001) and flap complications (OR = 0.69, 95% CI [0.55, 0.87], p = 0.002), indicating a potential beneficial role.…”