Comparison Between the Impact of Vasopressors and Goal-Directed Fluid Therapy on the Management of Free Flap Reconstruction of Head and Neck and Monitoring in ICU.

Abdulrahman Almutairi,Ghiath Al Saied,Muhannad Almohanna,Homood M Almutairi,Yousef Alharbi

doi:10.7759/cureus.12108

Abdulrahman Almutairi, Ghiath Al Saied + Show 3 more

Open Access

https://doi.org/10.7759/cureus.12108

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Journal: Cureus	Publication Date: Dec 16, 2020
Citations: 2	License type: cc-by

Affiliation: Qassim University, King Fahd Medical City

Abstract

Head and neck reconstructions are often accompanied with complex long surgical procedures. Free flap tissue transfer is a standard reconstruction method that reestablishes severe tissue defects after resection due to trauma or cancer. Imbalanced fluid resuscitation can extremely harm the outcome of the flap either due to hypoperfusion or edema. Flap-related postoperative complications mainly flap failure necessitates the administration of a large amount of intravenous fluids perioperatively especially with lengthy operative time. Therefore, vasopressors may be used to preserve hemodynamic stability without excessive fluids use. Nevertheless, these vasopressors have long been disfavored as they may provoke anastomosis vasoconstriction leading to graft hypoperfusion and finally flap failure. However, according to recent guidelines, they are now well-thought to be safe. Of note, inotropes have been confirmed to increase blood flow in the anastomosis hence they can replace vasoconstrictors. Recently, goal-directed fluid therapy (GDFT) has been proven to be excellent in high-risk head and neck free tissue transfer surgery as it decreases prolonged intensive care unit (ICU) admission hospitalization and complication rate. Today, GDFT is highly suggested as one of the enhanced recoveries after surgery protocols for major head and neck free flap reconstruction surgery.

Highlights

BackgroundFree flap reconstruction of head and neck involves the microvascular heterotopic free tissue transfer including re-implantation of its blood supply [1]
Flap-related postoperative complications mainly flap failure necessitates the administration of a large amount of intravenous fluids perioperatively especially with lengthy operative time
Vasopressors may be used to preserve hemodynamic stability without excessive fluids use. These vasopressors have long been disfavored as they may provoke anastomosis vasoconstriction leading to graft hypoperfusion and flap failure

Summary

Introduction

Free flap reconstruction of head and neck involves the microvascular heterotopic free tissue transfer including re-implantation of its blood supply [1]. Increased risk of complications and higher cardiovascular morbidity and mortality frequently associate head and neck free flap reconstruction Patients undergoing such procedures usually have low cardiovascular reserves that limit satisfactory organ perfusion with loss of function and even failure [3]. Controlling cardiac index remains the basis of goal-directed fluid replacement which can be achieved by functional hemodynamic monitoring [22] Conferring to these data, surgical wound healing is associated with increased tissue oxygen consumption which necessitates an increase of the cardiac output and modulation of systemic vascular resistance in order to pass the perioperative period without organ failure [21]. Another promising additional parameter is the new Hypotension Probability Indicator that could be advantageous to discover any drop in the MAP, before hypotension occurs [35]

Conclusions

Findings

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