Vasopressor support vs. liberal fluid administration in deep inferior epigastric perforator (DIEP) free flap breast reconstruction – a randomized controlled trial

Issue title: Special Issue in Honour of the Editor-in-Chief Prof. Dr. Ing. Friedrich Jung on his 70th Birthday

Article type: Research Article

Authors: Anker, A.M.^a | Prantl, L.^a | Strauss, C.^a | Brébant, V.^a | Heine, N.^a | Lamby, P.^a | Geis, S.^a | Schenkhoff, F.^b | Pawlik, M.^b | Klein, S.M.^{a; *}

Affiliations: [a] Center for Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany | [b] Department of Anaesthesiology, Caritas Hospital St. Josef, Regensburg, Germany

Correspondence: [*] Corresponding author: S.M. Klein, University Hospital Regensburg, Regensburg, Germany. Tel.: +49 941 782 3110; Fax: +49 941 782 3115; Email: silvan.klein@extern.uni-regensburg.de.

Abstract: BACKGROUND:Perioperatively, patients’ hemodynamics are modulated predominantly by intravenous fluid administration and vasoactive pharmacological support. Vasopressor agents are suspected to be detrimental on free flap survival by the cause of vasoconstriction of the pedicle with consecutive reduced overall flap perfusion and by aggravation of flap dissection. OBJECTIVE:A novel, standardized fluid restrictive perioperative hemodynamic management was assessed for its feasibility in clinical practice in free flap patients undergoing breast reconstruction. METHODS:Patients were randomized to two perioperative regimens with different fluid and vasopressor limits. The primary endpoint regarded flap survival. Secondary endpoints included surgery times, time of patient ambulation and length of hospital stay. RESULTS:There was one total flap failure with liberal fluid administration (LFA). No total or partial flap failure was noted in the fluid restrictive regimen with norepinephrine administration up to 0.04μg/kg/min (FRV). No delay regarding operation time (p = 0.217), patient mobilization (p = 0.550) or hospital discharge (p = 0.662) was registered in the FRV study subpopulation compared to LFA. CONCLUSIONS:The results of this prospective interventional trial could not detect any negative impact of vasopressors, neither for the primary endpoint of flap survival nor for the overall patient outcome. The fear of vasopressor associated flap complications has led to a traditional liberal fluid administration, which failed to demonstrate any benefits when compared to a fluid restrictive vasopressor strategy.

Keywords: Deep inferior epigastric perforator (DIEP) flap, free flap, breast reconstruction, vasopressors, norepinephrine, liberal fluid administration

DOI: 10.3233/CH-189129

Journal: Clinical Hemorheology and Microcirculation, vol. 69, no. 1-2, pp. 37-44, 2018