Alexandra M Anker1, Lukas Prantl2, Catharina Strauss2, Vanessa Brébant2, Felix Schenkhoff3, Michael Pawlik3, Jody Vykoukal4, Silvan M Klein2. 1. Center for Plastic, Reconstructive, Aesthetic, and Hand Surgery, University Hospital Regensburg and Caritas Hospital St. Josef Regensburg, Regensburg, Germany. alexandra.anker@ukr.de. 2. Center for Plastic, Reconstructive, Aesthetic, and Hand Surgery, University Hospital Regensburg and Caritas Hospital St. Josef Regensburg, Regensburg, Germany. 3. Department of Anesthesiology, Caritas Hospital St. Josef Regensburg, Regensburg, Germany. 4. Department of Clinical Cancer Prevention and The McCombs Institute for the Early Detection and Treatment of Cancer, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
Abstract
BACKGROUND: Dogmatic denial of vasopressor agents for blood pressure regulation during free-flap surgery is associated with concomitant large-volume intraoperative fluid administration. Yet, the doctrinal banning of vasopressors during microvascular breast reconstruction still is a subject of controversy. Several retrospective observations have recently drawn attention to serious iatrogenic consequences of intravenous crystalloid overload in microsurgery such as thrombus formation and increased flap failure rates. METHODS: This prospective randomized controlled trial investigated the potential effects of fluid-restrictive vasopressor-dominated hemodynamic support (FRV) compared with vasopressor-restrictive liberal fluid administration (LFA) on clinically relevant perfusion of the deep inferior epigastric perforator (DIEP) flap via intraoperative indocyanine green (ICG) fluorescence imaging. The primary end point of the study was quantitative assessment of the percentage of insufficiently perfused tissue (NP) on the overall flap. Major complications were assessed as secondary end points. RESULTS: In 44 DIEP flap breast reconstructions after mastectomy, FRV circulatory support resulted in no statistically significant difference in total flap perfusion as detected via ICG fluorescence imaging in direct comparison with a traditional LFA strategy (NPFRV, 31.8% ± 12.2% vs NPLFA, 29.5% ± 13.3%; p = 0.559). One flap failure was registered with LFA, whereas no major complication occurred in the FRV cohort. CONCLUSIONS: According to the results of this study, neither a norepinephrine concentration of 0.065 ± 0.020 μg/kg/min (FRV) nor fluid administration of 5.1 ± 2.2 ml/kg/h (LFA) has a clinically significant impact on microperfusion in a standard DIEP flap procedure for breast reconstruction. Consistent with the current literature reporting a rise in complications with intraoperative fluid over-resuscitation, one flap failure occurred in the LFA cohort.
RCT Entities:
BACKGROUND: Dogmatic denial of vasopressor agents for blood pressure regulation during free-flap surgery is associated with concomitant large-volume intraoperative fluid administration. Yet, the doctrinal banning of vasopressors during microvascular breast reconstruction still is a subject of controversy. Several retrospective observations have recently drawn attention to serious iatrogenic consequences of intravenous crystalloid overload in microsurgery such as thrombus formation and increased flap failure rates. METHODS: This prospective randomized controlled trial investigated the potential effects of fluid-restrictive vasopressor-dominated hemodynamic support (FRV) compared with vasopressor-restrictive liberal fluid administration (LFA) on clinically relevant perfusion of the deep inferior epigastric perforator (DIEP) flap via intraoperative indocyanine green (ICG) fluorescence imaging. The primary end point of the study was quantitative assessment of the percentage of insufficiently perfused tissue (NP) on the overall flap. Major complications were assessed as secondary end points. RESULTS: In 44 DIEP flap breast reconstructions after mastectomy, FRV circulatory support resulted in no statistically significant difference in total flap perfusion as detected via ICG fluorescence imaging in direct comparison with a traditional LFA strategy (NPFRV, 31.8% ± 12.2% vs NPLFA, 29.5% ± 13.3%; p = 0.559). One flap failure was registered with LFA, whereas no major complication occurred in the FRV cohort. CONCLUSIONS: According to the results of this study, neither a norepinephrine concentration of 0.065 ± 0.020 μg/kg/min (FRV) nor fluid administration of 5.1 ± 2.2 ml/kg/h (LFA) has a clinically significant impact on microperfusion in a standard DIEP flap procedure for breast reconstruction. Consistent with the current literature reporting a rise in complications with intraoperative fluid over-resuscitation, one flap failure occurred in the LFA cohort.
Authors: Mahdi Al-Taher; Tim Pruimboom; Rutger M Schols; Nariaki Okamoto; Nicole D Bouvy; Laurents P S Stassen; René R W J van der Hulst; Michael Kugler; Alexandre Hostettler; Eric Noll; Jacques Marescaux; Sophie Diemunsch; Michele Diana Journal: Sci Rep Date: 2021-05-06 Impact factor: 4.379
Authors: Thais O Polanco; Meghana G Shamsunder; Madeleine E V Hicks; Kenneth P Seier; Kay See Tan; Sabine Oskar; Joseph H Dayan; Joseph J Disa; Babak J Mehrara; Robert J Allen; Jonas A Nelson; Anoushka M Afonso Journal: J Plast Reconstr Aesthet Surg Date: 2021-02-04 Impact factor: 3.022