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Anesthesia Free Flap

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RECONSTRUCTIVE SURGERY

Anaesthesia for plastic and Learning objectives


reconstructive surgery After reading this article you should be able to:
Henry CY Mak
C recognize the reconstructive ladder and the anaesthetic
implications
Michael G Irwin C describe the physiology of the microcirculation in free flap
surgery and factors which may affect it
C formulate strategies to improve flap survival in free flap surgery
Abstract
Plastic and reconstructive surgery aims to restore normal and functional by promoting blood flow
anatomy following tissue destruction or impaired wound healing. The tech-
niques required depend on the complexity of the wound, from simple
closure to flap reconstruction. More complicated wounds with large skin de- free flap transfer. Any tissue that can be isolated with a suitable
fects may need free flap transfer for optimal functional and cosmetic results. vascular pedicle can be used, and this may include skin, fascia,
Flap failure is a major potential complication and perioperative anaesthetic fat, muscle, nerve, and bone. It offers the best functional and
management plays an important role in successful surgery. Factors which cosmetic results, but it also bears a higher risk of flap failure.
may lead to vasoconstriction must be avoided, including pain, hypothermia Complications can arise due to primary ischaemia at the time of
and hypovolaemia. Blood flow is also improved by maintaining an adequate surgery, reperfusion injury or impaired postoperative blood flow
blood pressure, moderate haemodilution and normocarbia. Free flap failure causing secondary ischaemia.
occurs mainly during the first three postoperative days. Venous thrombosis Intraoperative and postoperative airway management can
secondary to congestion is more common than arterial obstruction. Prompt also be a concern in reconstructive earenoseethroat and
surgical re-exploration is the key to flap salvage. maxillofacial surgery. In the presence of an upper airway lesion,
Keywords Fluid management; free flap; haemodilution; microcirculation; the anatomy could be distorted and increase the risk of a difficult
reconstructive ladder; reconstructive surgery; vasopressor airway. An airway management plan should be formulated with
back-up plans in place. Often the plan may include awake
Royal College of Anaesthetists CPD Matrix: 2A07 fibreoptic intubation or even elective tracheostomy. Likewise the
same attention to detail should be directed to extubation and the
possibility of elective postoperative ventilation, particularly in
the presence of oedema or intermaxillary fixation.1 This should
be well communicated with the patient and other members in the
Introduction operating team.

Plastic and reconstructive surgery aims to restore normal and


Preoperative assessment
functional anatomy following tissue destruction or impaired
wound healing. The abnormality could be congenital, traumatic Perioperative medical complications increase the economic costs
or as a result of a disease process such as cancer or infection. of microsurgery more than surgical complications. This high-
In considering how to close a surgical wound, the plastic lights the importance of careful preoperative assessment, espe-
surgeon can ascend the ‘reconstructive ladder’ (Box 1), starting cially for free flap transfer, where the operating time can be
from the simplest option and ascending to a more advanced one prolonged (e.g. >6 hours).
depending on the complexity of the surgical wound and the Both high American Society of Anesthesiologists (ASA)
clinical conditions. grading and advanced Charlson grade have been reported as
The lower rungs of the ladder have limited implications for predictors of postoperative medical complications. Age alone is
anaesthesia, and many simple elective plastic surgery procedures not an independent risk factor for postoperative medical or
can be done in an office setting under local anaesthesia with little
or no sedation. Strategies higher up the ladder require more
intervention, in particular split skin grafts require good pain The reconstructive ladder
management for the donor site, preferably using regional anaes-
thesia, for example a lateral cutaneous nerve block in for the 9. Free flap transfer (e.g. latissimus dorsi myocutaneous flap)
lateral thigh, from where split skin grafts are frequently harvested. 8. Pedicled flap (e.g. pedicled transverse rectus abdominis
If there are no options for local wound cover, tissue can be myocutaneous (TRAM) flap)
harvested from elsewhere in the body, a technique known as a 7. Random pattern flap
6. Tissue expansion
5. Full-thickness skin graft
Henry CY Mak MBBS is a Trainee in Anaesthesiology at Queen Mary 4. Split-thickness skin graft
Hospital, Hong Kong, China. Conflicts of interest: none. 3. Delayed primary closure
2. Primary closure
Michael G Irwin MB ChB MD FCAI FRCA FANZCA FHKAM is Head of the
1. Secondary intention
Department of Anaesthesiology of the University of Hong Kong, China.
Conflict of interests: none. Box 1

ANAESTHESIA AND INTENSIVE CARE MEDICINE 16:3 136 Ó 2014 Elsevier Ltd. All rights reserved.
RECONSTRUCTIVE SURGERY

surgical complications. However, medical co-morbidities are number of patients requiring blood transfusion, while not
more common in the elderly and tend to increase postoperative increasing the rate of postoperative complications.6 Thus the
medical but not surgical complications.2 Ischaemic heart dis- haematocrit target could be as low as 25e30% but further
ease and alcohol abuse have been reported as independent studies are required.
predictors of overall complications following free tissue
transfer. Perioperative management for free flap surgery (Table 1)
Diabetes mellitus affects a substantial percentage of the pop-
The perioperative care goal should be to improve free flap sur-
ulation and increases overall postoperative complications.
vival and prevent of complications. The exposed skin area can be
Although a large series of transverse rectus abdominis myocu-
large as multiple surgical sites may be involved. This, com-
taneous (TRAM) flap breast reconstructions showed no signifi-
pounded with the loss of thermoregulation after induction, and
cant difference in flap survival or complications between those
an increase in evaporative water loss from the surgical field, can
with or without diabetes mellitus,3 it is prudent to maintain
lead to the rapid development of hypothermia. The importance of
perioperative normoglycaemia.
normothermia in promoting free flap blood flow mandates the
Smoking, while not a significant risk factor for free flap fail-
use of body temperature monitoring. Active warming device
ure,4 is associated with an increase in wound complications.
such as forced air warming device and/or warming mattress
Three weeks of smoking cessation preoperatively is required to
should be used, and the theatre temperature should be controlled
reduce wound complication rates. Obesity is associated with
to reduce the temperature gradient for heat loss. Intravenous and
both increased medical and flap complications.
irrigation fluids should be pre-warmed.
Careful patient positioning and protection of pressure points is
Physiology of blood flow to free flap mandatory. Endotracheal intubation is usually preferred for head
If the flow in a blood vessel is laminar, the flow can be predicted and neck procedures, although supraglottic airway devices can
by the HagenePoiseuille equation, which states that flow is also be used with controlled ventilation for body surface surgery.
directly proportional to the pressure difference (DP), and the Head and neck lesions can distort the airway anatomy and
fourth power of the radius (r), and is inversely proportional to fibreoptic intubation may be necessary. The nasal route may be
the length of the vessel (L) and the dynamic viscosity (m). preferred if the presence of an oral tube is likely to obstruct
surgical assess. Reinforced endotracheal tubes are useful if pa-
DPpr 4 tient positioning and draping may subject the tube to kinking.
Blood flow ¼ Invasive arterial pressure monitoring can be useful due to the
8mL
importance of maintaining the perfusion pressure to the free flap,
The systemic blood pressure is the main driving force for blood and for checking the haematocrit and blood gas analysis. Central
flow through the flap, therefore the adapted mean arterial pressure venous assess may be necessary depending on patient’s cardio-
for the patient should be maintained. The vessel radius also has a vascular status and the anticipated need for vasopressor and
significant impact on the blood flow, and vasoconstriction should inotropic support.
be avoided. Hypovolaemia, hypocapnia, hypothermia and pain Cardiac output monitoring can be considered to help direct
can cause vasoconstriction and should be treated accordingly. intraoperative fluid management and vasoactive drug use. The
Hyperventilation resulting in respiratory alkalosis is associ- placement of oesophageal Doppler may not be practical in head
ated with peripheral vasoconstriction, but hypoventilation and neck surgery due to interference with the operating site. In
resulting in respiratory acidosis can also reduce erythrocytes such cases, alternative non-invasive cardiac output monitoring
deformability and increase catecholamine release, which can such as using pulse contour analysis is feasible.
also cause vasoconstriction. Individual risk assessment venous thromboembolism (VTE)
The use of vasopressors to treat hypotension is controversial, prophylaxis should be undertaken according to the National
and is generally unpopular among plastic surgeons. Animal Institute for Health and Care Excellence (NICE) guidelines. Thigh
studies have shown that the use of vasopressors can lead to length anti-embolism stockings can be given upon admission to
vasoconstriction in the microcirculation of the free flap but hospital. Intermittent pneumatic compression is started once the
clinical studies show the use of vasopressor have no effect on patient is positioned in the operation theatre. Pharmacological
flap survival. One study showed that dobutamine and norepi- therapy, subcutaneous low-molecular-weight heparin (LMWH)
nephrine both improve the flap skin blood flow with maximal prophylaxis can be used if the risk for major bleeding is low.
improvement with norepinephrine.5 Dobutamine may improve Evidence from a plastic surgery series showed LMWH signifi-
blood flow by increasing cardiac output. cantly reduced the rate of venous thromboembolism without a
Blood viscosity is determined by the haematocrit, in which a significant increase in bleeding or haematoma formation versus
balance is struck between oxygen carrying capacity and blood mechanical prophylaxis alone.
flow. The optimal haematocrit is thought to be about 30%. If Volatile anaesthetics as sevoflurane and opioids may atten-
the haematocrit increases above 40%, viscosity increases uate ischaemia-reperfusion injury which is hard to avoid
considerably in the microcirculation which offsets the completely in free flap transfer. On the other hand, propofol has
increased oxygen carrying capacity and increases the risk of antioxidant and free radical scavenging properties so there is not
thrombosis. A recent study on the appropriate transfusion enough evidence to support the use of any particular agent.
trigger in free flap transfer surgery suggested that a lower Metaraminol, phenylephrine and noradrenaline are common
haematocrit of 25% in contrast to a trigger of 30% reduced the first- and second-line choices to maintain the systemic arterial

ANAESTHESIA AND INTENSIVE CARE MEDICINE 16:3 137 Ó 2014 Elsevier Ltd. All rights reserved.
RECONSTRUCTIVE SURGERY

Summary of anaesthetic intervention for free flap transfer surgery


Problem Anaesthetic intervention

Preoperative Assessment of medical conditions Blood pressure control and normoglycaemia.


Smoking cessation
Upon admission Venous thromboembolism (VTE) risk Consider VTE prophylaxis
assessment
Induction General anaesthesia causes peripheral Temperature monitoring
vasodilation, increases heat loss and causes Fluid replacement
relative intravascular hypovolaemia
Tissue resection Large surgical site, potential for heat and fluid Use of active warming device to maintain
loss normothermia
Flap harvest Flap in ischaemia while removed from its
original blood supply
Flap reperfusion Possible ischaemia-reperfusion injury, with Maintain an adequate blood pressure, may
release of vasoconstrictive substances use vasoconstrictor/inotropes if necessary
At risk for flap oedema due to lack of Reduce blood viscosity, target haematocrit
lymphatic supply 25e30%
Limit crystalloid fluid use
Emergence Cough and straining increase venous pressure Aim for smooth emergence
Recovery Hypothermia, shivering and pain can cause Ensure normothermia, good analgesia
vasoconstriction
Postoperative care Highest risk for flap failure within first 3 days Continue strategies to maintain good flap
perfusion and minimize flap oedema. Flap
monitoring to detect signs of flap failure

Table 1

pressure. However, no safe therapeutic range nor an ideal blood compared to gelatine based products. However in 2013 the
pressure target has been established. Clinical judgement and Pharmacovigilance Risk Assessment Committee (PRAC) of the
careful titration is necessary to avoid excessive vasoconstriction European Medicines Agency (EMA), the US FDA and the Cana-
which can be detrimental to flap survival. If an inotrope is dian authorities issued cautions on the use of HES in critically ill
required, dobutamine may be the preferred option. patients and those with severe sepsis, renal and liver insuffi-
Upon emergence, coughing and retching can increase venous ciency. Further studies are now required to determine the safety
pressure, compromising flap perfusion. The use of remifentanil of HES solutions in comparison with other colloid solutions in
and dexmedetomidine can help smooth emergence as described this subgroup of patients.
in other surgeries and their use is also likely to be beneficial in
free flap surgery. Postoperative care
The general principle of good postoperative care applies. These
Fluid therapy and free flap surgery
include maintaining normothermia, normal blood pressure, a
A free flap initially is devoid of lymphatic drainage, and thus is haematocrit of 25e30%, satisfactory urine output, and good pain
highly susceptible to tissue oedema, which could predispose to control.
venous thrombosis and flap failure. In addition the free flap In particular, shivering should be avoided, as it can increase
capillary endothelium is likely damaged leading to increased myocardial oxygen consumption and can cause peripheral
vascular permeability. High-volume crystalloid fluid adminis- vasoconstriction. External warming, pethidine, alpha-2 agonists
tration has been shown to be an independent risk factor for or sedation may be required to stop shivering.
increased flap oedema and thrombosis due to a pro-coagulant Excellent analgesia is required to prevent the release of cate-
effect.7 When crystalloids are administered rapidly, the mecha- cholamines and the vasoconstrictor response to pain. This can be
nism for increased coagulability may result from a dilutional achieved by continuous regional block infusion which also has
effect resulting in an imbalance between circulating pro- and the advantage of sympathectomy, or by intravenous patient-
anti-coagulant factors. Therefore, crystalloids should be used controlled analgesia.
cautiously and limited to the replacement of preoperative deficits Many anaesthetists keep patients with head and neck free
and intraoperative insensible losses. This increased coagulability flaps sedated and ventilated post-operatively. This was thought
is not seen with colloid solutions and, therefore, they are a better to protect the free flap and was also partly due to the extended
choice when plasma volume expansion is required. Hydrox- length of the procedures. However, studies have shown that
yethyl starch (HES) was the colloid of choice as it can decrease immediate postoperative extubation does not increase the inci-
blood viscosity and gives greater plasma expansion when dence of flap or wound-related complications, and may actually

ANAESTHESIA AND INTENSIVE CARE MEDICINE 16:3 138 Ó 2014 Elsevier Ltd. All rights reserved.
RECONSTRUCTIVE SURGERY

increase postoperative pulmonary complications.8 Therefore, 4 Chang D, Reece G, Wang B, et al. Effect of smoking on complications in
early extubation should be considered if possible. patients undergoing free TRAM flap breast reconstruction. Plast
Postoperatively the patient may be managed in an intensive- Reconstr Surg 2000; 105: 2374e80.
care or specialized high-dependency unit, with staff fully trained 5 Eley KA, Young JD, Watt-Smith SR. Epinephrine, norepinephrine,
in flap monitoring, in order to promptly detect a change in flap dobutamine, and dopexamine effects on free flap skin blood flow.
status allowing re-exploration and salvage. Many units conduct Plast Reconstr Surg 2012; 130: 564e70.
hourly clinical flap observation for 3 days. Some use adjuncts 6 Rossmiller SR, Cannady SB, Ghanem TA, Wax MK. Transfusion criteria
such as hand-held Doppler or implantable Doppler ultrasonog- in free flap surgery. Otolaryngol Head Neck Surg 2010; 142: 359e64.
raphy for assistance. Venous thrombosis is reported to be over 7 Haughey BH, Wilson E, Kluwe L, et al. Free flap reconstruction of the
twice as common as arterial thrombosis in causing free flap head and neck: analysis of 241 cases. Otolaryngol Head Neck Surg
failure. Once a compromise of the flap has been suspected, 2001; 125: 10e7.
prompt re-exploration is the key to salvage. A 8 Petrar S, Bartlett C, Hart RD, MacDougall P. Pulmonary complications
after major head and neck surgery: a retrospective cohort study.
Laryngoscope 2012; 122: 1057e61.
REFERENCES
1 Cooper RM, O’Sullivan E, Popat M, Behringer E, Hagberg CA. Difficult FURTHER READING
Airway Society guidelines for the management of tracheal extubation. Boyce DE, Shokrollahi K. ABC of wound healing: reconstructive surgery.
Anaesthesia 2013; 68: 217. Br Med J 2006; 332: 710e2.
2 Beausang ES, Ang EE, Lipa JE, et al. Microvascular free tissue transfer Gooneratne H, Lalabekyan B, Clarke S, Burdett E. Perioperative anaes-
in elderly patients: the Toronto experience. Head Neck 2003; 25: thetic practice for head and neck free tissue transfer e a UK national
549e53. survey. Acta Anaesthesiol Scand 2013; 57: 1293e300.
3 Miller RB, Reece G, Kroll SS, et al. Microvascular breast reconstruction Pattani KM, Byrne P, Boahene K, Richmon J. What makes a good flap go
in the diabetic patient. Plast Reconstr Surg 2007; 119: 38e45. dis- bad? A critical analysis of the literature of intraoperative factors
cussion 46e8. related to free flap failure. Laryngoscope 2010; 120: 717e23.

ANAESTHESIA AND INTENSIVE CARE MEDICINE 16:3 139 Ó 2014 Elsevier Ltd. All rights reserved.

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