Crossing the rubicon: Exploring different peri – Operative fluid resuscitation strategies in traumatic extremity free tissue transfer- a retrospective case control study

Abstract

Free tissue transfer has added to the plastic surgeon's armamentarium and has afforded patients more chances towards limb salvage in recent decades following severe trauma. Venous congestion is a common occurrence, can be the result of several reasons and has devastating results in patients' outcomes. Recent studies have highlighted the importance of restrictive fluid administration. We hypothesized that a restrictive fluid administration in the intra – operative period would be associated with a lower incidence of venous congestion in patients undergoing free flap reconstruction of traumatic defects of the extremities. All patients undergoing a perforator free flap soft tissue reconstruction of traumatic defects of the extremities, from 2005 to 2019 were retrospectively identified. Patient's demographics, comorbidities and technical aspects of the operation were extracted. The study population was divided in two groups based on the amount of fluids administered (restrictive: < 6 ml/kg/hr; liberal: ≥ 6 ml/kg/hr). Multivariate analyses were performed to identify the impact of fluid strategy on the development of clinically significant venous congestion. A total of 75 patients were identified. Out of these, 24 patients had clinically significant venous congestion. Fluid administration strategy [AOR (95% CI): 1.53 (1.22, 1.92)], use of the superficial venous system [0.03 (0.01, 0.26)], operative time [1.98 (1.97, 1.99)] and age>50 [5.60 (1.10, 28.52)]. A cut – off analysis identified 6 ml/kg/hr as the cut off point for fluid administration. Liberal fluid administration (≥6 ml/kg/hr) was independently associated with a higher incidence of venous congestion and return to the OR for flap debridement, both overall and after exclusion of anastomotic revisions. Venous congestion in free flap reconstruction following traumatic defects of the extremities remains high. Several factors are associated with congestion. Liberal fluid administration ≥6 ml/kg/hr is independently associated with this complications and should be avoided when possible. • Free Fasciocutaneous tissue transfer in lower extremity trauma is challenging. • Venous congestion can result in complete or partial flap loss. • Peri – operative fluid administration has been shown to increase the complication rate infree flaps. • Fluid administration intra – operative of more than 6 ml/kg/hr resulted in a higher incidence of venous congestion. • Judicious fluid administration may be warranted.