Intraoperative hypotension management for microvascular reconstruction surgery using free tissue transfer: An integrative review
Author DetailsLyndsie LaFleur, DNAP, CRNA
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Introduction: Anesthetic management for free flap surgery contributes to flap survival, as hypotension is an independent predictor of flap loss. The optimal blood pressure range is unknown and there are no standardized guidelines available in this area. The aim of this integrative review was to provide evidence-based recommendations for hypotension management during microvascular free flap reconstruction surgery. Methods: Articles evaluating anesthetic related predictors of flap survival were critically appraised for validity, reliability, and rigor of study. Results: Current practice favors the use of fluids over vasopressors, supported by animal studies and anecdotal evidence. Clinical data demonstrated vasopressor use does not affect flap survival, and norepinephrine and dobutamine may improve flap outcomes. Both high and low fluid volumes affect flap complications (<3.5 mL/kg/hr; >6 mL/kg/hr). Over-resuscitation contributes to flap edema and under-resuscitation contributes to flap thrombosis. Excessively high fluid volumes are associated with increased rates of flap failure (>7 L total). Discussion: Hypotension management should aim for mean arterial pressures (MAP) > 65 mmHg. Vasopressors are recommended in the setting of normovolemia. Fluids should be titrated in a goal-directed manner via non-invasive monitors (urine output > 0.5-1.0 mL/kg/hr) and invasive monitors when possible (stroke volume variation < 13%). More research is needed to determine the exact type of fluid with minimal negative effects. Larger, prospective clinical trials are needed to strengthen findings of the existing evidence.
Repository Posting Date2021-02-19T17:52:18Z
TypeOther Graduate Paper
Level of EvidenceIntegrative Review