The national variation in peri-operative anaesthetic technique for breast free flap reconstruction in the UK: is it time to define best practice?

Abstract

Peri-operative anaesthetic techniques are important in maximising microsurgical success and analgesic delivery. The National Mastectomy and Breast Reconstruction Audit highlighted variation in breast free flap reconstruction success. As current UK peri-operative anaesthetic practice is unknown, a national survey was conducted. A link to an online questionnaire was sent to lead consultant anaesthetists in each UK unit undertaking breast free flap reconstruction. Data was collected on important aspects of peri-operative anaesthetic technique including fluid therapy, haemodynamic monitoring, analgesic strategy and transfusion practice. A response was received from 34 of the 41 units identified (83 %). Twice as many units undertook deep inferior epigastric artery perforator (DIEP) flap reconstruction compared with transversus abdominis musculocutaneous (TRAM) flap reconstruction. Peri-operative fluid therapy was mainly ‘liberal’ in nature with little evidence of a ‘goal-directed’ approach. The intraoperative haemodynamic monitor of choice was continuous arterial blood pressure monitoring. Use of oesophageal Doppler or lithium diluted cardiac output (LiDCO) monitoring is not widespread. Many units undertake some form of regional analgesic strategy, with transversus abdominis plane and rectus sheath blocks the commonest techniques. Peri-operative blood transfusion practice showed considerable variation between units. There is a wide national variation in reported peri-operative anaesthetic technique for breast free flap reconstruction. Further research is recommended to confirm whether this translates into varied clinical outcomes. Although modern breast free flap reconstruction failure rates are currently low, targeting peri-operative anaesthetic technique could lead to improved clinical outcomes. In addition, improved peri-operative anaesthetic technique has a key role to play if enhanced recovery programmes after surgery (ERAS) for breast free flap reconstruction are to be created. Level of Evidence: Not ratable.