How do you do your free flaps?

[urge]

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What's your usual cocktail? What do you use for hypotension when no pressors are desired? A-line or no?

I'm stuck doing one now.

 

[cchoukal]

We do a lot of head and neck oncologic surgery, so it seems we've got at least 2 cases per week that are some combination of a pharyngectomy and stapling some component of the patient's a$$ to their face. Many of these cases go 12-18 hrs. We recently had a take back of a guy that ultimately resulted in a ruptured carotid, a bypass run, and, obviously, death.

For the primary case, we typically go pretty basic: Couple big IVs, aline, iso, and low flow. I do the a-line because it's a long case, I want to follow labs, and there are always a bunch of people leaning on my BP cuff. Ancillary stuff: fluid warmers all around, Bair warmer on whatever isn't prepped, humidivent, and a keen eye on EBL (much of which ends up in the drapes or on the floor). For whatever reason, in our institution, these pts are generally not on death's door (well, pre-op, anyway). Usually 60-ish and having had a pretty good cardiac workup.

We avoid central access mostly because the neck is obviously occupied, and they'll often prep both legs, just in case, but in addition, we want to avoid line sepsis in these pts who frequently have long-ish ICU stays. Hypotension = colloid and, if desperate, ephedrine. You'll improve contractility and maybe some of the B2 will dilate peripherally. I've done probably 8 or 10 of these, and my recollection is that I rarely have had to use anything other than colloid for BP.

For the ICU trip, you'd think just turning the iso off on the way out of the room would be sufficient, but I've had a couple of these people emerge in the hallway (they're trached, of course), so I started giving a mg or 2 of hydromorphone and some midazolam for the road.

Like I said, we go pretty basic....

 

[coprolalia]

Uggh! I hate these cases. The room is usually so goddamn hot. The Plastic Surgeon is inevitably an a-hole. And, the no-pressors thing... here's the deal with that...

A Plastic Surgeon, as much as he/she thinks he/she does, does not understand what we do. They are focusing on an outcome for the case, and not necessarily the patient. They will demand that you don't use any pressors at all. And, they will show you data that demonstrates flap failure if pressors are used.

Now, I've used phenylephrine, when needed, in free-flap cases. Have I ever had a case of flap failure? No. You treat the patient first and, if you need to bring their pressure up, you do it. But, of course you try other means (fluid, lightening your anesthetic, etc.) before you reach for the purple stuff.

The point is, there is a huge difference between the occassional 50mcg bolus of phenylephrine than there is at running an infusion, which is really what they're trying to tell you they don't want when they say "no pressors". They actually don't know that we bolus a little ephedrine or phenylephrine here or there when we need to, because they don't understand what we do. Again, I've done this when absolutely necessary during a case, and I've never had a graft fail because of it.

-copro

 

[jwk]

Uggh! I hate these cases. The room is usually so goddamn hot. The Plastic Surgeon is inevitably an a-hole. And, the no-pressors thing... here's the deal with that...

A Plastic Surgeon, as much as he/she thinks he/she does, does not understand what we do. They are focusing on an outcome for the case, and not necessarily the patient. They will demand that you don't use any pressors at all. And, they will show you data that demonstrates flap failure if pressors are used.

Now, I've used phenylephrine, when needed, in free-flap cases. Have I ever had a case of flap failure? No. You treat the patient first and, if you need to bring their pressure up, you do it. But, of course you try other means (fluid, lightening your anesthetic, etc.) before you reach for the purple stuff.

The point is, there is a huge difference between the occassional 50mcg bolus of phenylephrine than there is at running an infusion, which is really what they're trying to tell you they don't want when they say "no pressors". They actually don't know that we bolus a little ephedrine or phenylephrine here or there when we need to, because they don't understand what we do. Again, I've done this when absolutely necessary during a case, and I've never had a graft fail because of it.

-copro

Ditto on the pressors - they'll be just as pissed if the flap fails from not having any flow at all due to hypotension. An occasional dink shouldn't be an issue.

Most of our flaps are exclusively free-TRAM's, but the technique is the same for others. We wouldn't have an a-line or do anything really extraordinary unless it was indicated for the primary procedure. Single mastectomy and free TRAM here is about 2.5-4 hours, bilat 3.5-7, depending on the surgeon.

All our flap patients get either Dextran or heparin infusions once the arterial anastomosis is completed. Most of the flap failure we see is related to vessel size, tension on the graft or flap, etc. I've never heard of one blamed on the use of pressors.

 

[ranvier]

Bump. Did a big flap recently and found the thread useful.

 

[deleted162650]

Didn't catch that it was an old thread until I saw mention of Dextran and TRAMs. My-o-my how times change.

 

[pgg]

I think phenylephrine is fine for these cases, despite surgeon objections, as a low background infusion to counter iatrogenic hypotension. The free flap is obviously denervated and effectively sympathectomized, so I'm not sure why the surgeons are so freaked about a little alpha.

I think where people get into trouble with these cases is underestimating blood loss and treating hypovolemia with pressors. Crystalloid and blood should be fine.

It's probably been a year since I've done one. Seems like when I was a resident, every other call I was taking over one of these 18 hour marathons. Not sure where all those cases have gone.

 

[deleted162650]

Not sure where all those cases have gone.

Battlefield isn't quite as active these days.

 

[Robotic Wis-Hipple]

From their own journal (sorry I don't have the full access link):

What makes a good flap go bad?: A critical analysis of the literature of intraoperative factors related to free flap failure†‡

http://onlinelibrary.wiley.com/doi/...nticated=false&deniedAccessCustomisedMessage=

We used to do the avoid pressors thing but in reality most of the cases were being given phenylephrine by the residents/CRNA anyway and just not telling the surgeon. More recently they've relaxed on this as they've come to realize perfusion is good.

 

[vector2]

I believe the literature and consensus is starting to turn. Our onc ENT surgeons are both fine with background phenylephrine infusions. However, flooding with a bunch of crystalloid over an 8 hr case is pretty frowned upon.

 

[Ronin786]

Medium range dopamine is always an option as well. You get the B1 without the vasoconstriction.

 

[deleted171991]

I believe the literature and consensus is starting to turn. Our onc ENT surgeons are both fine with background phenylephrine infusions. However, flooding with a bunch of crystalloid over an 8 hr case is pretty frowned upon.

Most studies for various types of procedures, both in intensive care and surgery, tend to show better outcomes with pressors instead of just fluids. The reason being decreased inflammation, and decreased abdominal compartment syndrome (i.e. AKI).

While I can understand why one would try to avoid pressors in any vascular anastomosis, not using any pressors, while flooding a 50 kg patient with 5-8 liters of positive fluid balance, is idiotic.

 

[deleted171991]

I think phenylephrine is fine for these cases, despite surgeon objections, as a low background infusion to counter iatrogenic hypotension. The free flap is obviously denervated and effectively sympathectomized, so I'm not sure why the surgeons are so freaked about a little alpha.

Probably because the artery the flap is anastomosed on is not denervated. 😉

 

[pgg]

Probably because the vessel the flap is anastomosed on is not. 😉

Plastic surgeons think they're gods, but I've yet to meet one godlike enough to sew a proximal arteriole small enough for that to really matter ...

 

[Ignatius J]

IM ephedrine.

 

[deleted171991]

By the way, I remember how proud I used to be, as a resident, when I would get an ICU patient on 3 pressors for a procedure, and then I would return him on just one, after flooding him with fluids. Of course he would look well postop for a couple of hours, before the fluids turned into interstitial edema. I still see the same crap being done to my patients in the OR, except that now I am on the receiving end. (I do know that the intensity of inflammation and leakage is not the same as for a relatively healthy flap recipient.)

Only hypovolemia should be treated (or prevented, when very likely) with fluids. That rule can be bent, up to a point, which for me is about 30 ml/kg positive balance at the end of a procedure.

 

[nimbus]

Avoid knee jerk opioids at induction. Greatly reduces iatrogenic hypotension and the need for fluids and pressors. I induce with propofol and roc, no fentanyl, and maintain with low dose vapor and paralysis.

 

[deleted162650]

Avoid knee jerk opioids at induction. Greatly reduces iatrogenic hypotension. Just low dose vapor and paralysis.

Or better yet, no dose vapor and paralysis. I've never seen any hypotension using this approach.

 

[psychbender]

Or better yet, no dose vapor and paralysis. I've never seen any hypotension using this approach.

That's like my sux drip and esmolol anesthetic (with glyco to dry the tears). Very stable.

Sent from my SM-G920V using SDN mobile

 

[ranvier]

http://www.sbccp.org.br/arquivos/OTO-06-2011_safety-of-vasopressor-use-in.pdf

 

[fakin' the funk]

I think phenylephrine is fine for these cases, despite surgeon objections, as a low background infusion to counter iatrogenic hypotension. The free flap is obviously denervated and effectively sympathectomized, so I'm not sure why the surgeons are so freaked about a little alpha.

This.

It's one thing to use phenylephrine to bring the SVR from in-the-toilet to just-below-normal, another to bring it from normal to supranormal.

 

[fakin' the funk]

glyco to dry the tears

hahahaha

 

[fakin' the funk]

From their own journal (sorry I don't have the full access link):

What makes a good flap go bad?: A critical analysis of the literature of intraoperative factors related to free flap failure†‡

http://onlinelibrary.wiley.com/doi/...nticated=false&deniedAccessCustomisedMessage=

I feel like "The Laryngoscope" should be an anesthesiology journal, not ENT...