Effects of goal-directed crystalloid vs. colloid fluid therapy on microcirculation during free flap surgery

Cardioprotective effects of the electrolyte solution sterofundin and the possible underlying mechanisms

Background

Sterofundin (SF) is one of the most widely used electrolyte solutions in almost all areas of medicine, with particular importance in intensive care. It provides powerful correction of acid-base imbalances, ion fluctuations, and impaired energy metabolism, which are the three most important characteristics after myocardial infarction (MI). However, whether and how SF protects the heart from post-MI damage are largely unknown.

Methods and Results

Pretreating mice with SF before MI surgery reduced the number of reactive oxygen species (ROS)-positive and TUNEL-positive cells. As a result, the infarcted area cardiac fibrosis in the MI mice was reduced and cardiac performance in the MI mice improved. Moreover, RNA-seq analysis demonstrated that SF caused the gene expression profile of MI mice to shift toward that of sham mice, with a significant decrease in apoptosis-, ROS-, and inflammation-associated gene enrichment. RNA-seq analysis also demonstrated that SF induced the upregulation of autophagy-associated gene enrichment. Western blotting confirmed the RNA-seq analysis results, showing that SF induced the upregulation of an autophagic flux. When the autophagic flux was blocked with the autophagy inhibitor 3-methyladenine, the protective effect of SF was reduced.

Conclusion

SF protects the heart from post-MI damage, and one of the underlying mechanisms could be its autophagy modifications. This study is the first to reveal a previously unrecognized role of electrolyte solutions in post-MI intensive care.

Evidence based recommendations for perioperative vasopressor use and fluid resuscitation in microsurgery

Blood pressure regulation is critical in patients undergoing microsurgical free tissue transfer; however, guidelines for addressing and preventing perioperative hypotension remain highly debated, with two current thought paradigms: (1) intravenous fluid administration with a balanced salt solution (e.g., lactate ringer and normal saline) and/or colloid (e.g., albumin) and (2) vasoactive pharmacological support with vasopressors (e.g., dobutamine, norepinephrine, epinephrine), with fluid administration being the preferred conventional approach. Here, we review the most up to date available literature and summarize currents perspectives and practices for fluid resuscitation and vasopressor use, while offering evidence-based guidelines to each.

Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care: Second update 2022

BACKGROUND

Management of peri-operative bleeding is complex and involves multiple assessment tools and strategies to ensure optimal patient care with the goal of reducing morbidity and mortality. These updated guidelines from the European Society of Anaesthesiology and Intensive Care (ESAIC) aim to provide an evidence-based set of recommendations for healthcare professionals to help ensure improved clinical management.

DESIGN

A systematic literature search from 2015 to 2021 of several electronic databases was performed without language restrictions. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to assess the methodological quality of the included studies and to formulate recommendations. A Delphi methodology was used to prepare a clinical practice guideline.

RESULTS

These searches identified 137 999 articles. All articles were assessed, and the existing 2017 guidelines were revised to incorporate new evidence. Sixteen recommendations derived from the systematic literature search, and four clinical guidances retained from previous ESAIC guidelines were formulated. Using the Delphi process on 253 sentences of guidance, strong consensus (>90% agreement) was achieved in 97% and consensus (75 to 90% agreement) in 3%.

DISCUSSION

Peri-operative bleeding management encompasses the patient's journey from the pre-operative state through the postoperative period. Along this journey, many features of the patient's pre-operative coagulation status, underlying comorbidities, general health and the procedures that they are undergoing need to be taken into account. Due to the many important aspects in peri-operative nontrauma bleeding management, guidance as to how best approach and treat each individual patient are key. Understanding which therapeutic approaches are most valuable at each timepoint can only enhance patient care, ensuring the best outcomes by reducing blood loss and, therefore, overall morbidity and mortality.

CONCLUSION

All healthcare professionals involved in the management of patients at risk for surgical bleeding should be aware of the current therapeutic options and approaches that are available to them. These guidelines aim to provide specific guidance for bleeding management in a variety of clinical situations.

Infusion management associated with prolonged length of stay following free flap reconstruction of head and neck defects: A propensity score matching study

BACKGROUND

Surgical resection of the primary lesion and reconstruction of the defects with free flaps are common treatments for head and neck cancer (HNC). However, various variables can lead to prolonged length of stay (LOS). The aim of this study is to investigate risk factors correlated with prolonged LOS following free flap reconstruction of head and neck defects.

METHODS

A retrospective study of patients with all types of free flaps reconstruction of HNC between January 2011 and January 2019 at Sun Yat-sen Memorial Hospital was performed. We recorded predictive variables and divided them into: personal and clinical, hemodynamic, anesthetic and surgical. The primary endpoint was prolonged length of stay. Univariate and multivariate analyses were applied to identify risk factors that associated with prolonged LOS. Propensity score matching was performed with the identified risk variables and other perioperative factors that may impact transfusion decision to explore the independent influence of intraoperative blood transfusion on prolonged LOS.

RESULTS

A total of 1047 patients were included in this study. The median LOS was 13.00 (11.00, 16.00) days. Multivariate analysis suggested that blood transfusion, duration of surgery, postoperative complications and unplanned reoperation were associated with prolonged LOS. After propensity score matching, unnecessary blood transfusion and inadequate fluid rate over 24 h, postoperative complications and unplanned reoperation were identified risk factors that led to prolonged LOS.

CONCLUSION

Unnecessary blood transfusion and inadequate fluid infusion rate over 24 h were independent risk factors associated with prolonged LOS in HNC patients who underwent free flap reconstruction. Our results indicated consideration of restrictive blood transfusion and adequate fluid infusion over postoperative 24 h in these patients.

“MYH9 mutation and squamous cell cancer of the tongue in a young adult: a novel case report”

Background

The incidence of tongue cancer in young adults is on the rise. This trend is more pronounced in females. Although the aetiology is still unclear, there is mounting evidence that genetic syndromes can play a key role in development of oral cancers in this patient group. We report the first case of oral squamous cell carcinoma (oSCC) in a young adult with an MYH9-related disorder (MYH9-RD).

Case presentation

A 19-year-old female with a germline MYH9 variant (missense variant in exon 2: c.287C > T, (p.Ser96Leu)) was referred to the head and neck surgery department for investigation of a painful, thick right tongue ulcer. She was diagnosed with Epstein syndrome, an MYH9-RD, at 12 years of age. Her main phenotypic features were profound thrombocytopenia and marked renal impairment. The tongue biopsy confirmed SCC. Preoperative positron emission tomography (PET) revealed avidity in the right tongue and ipsilateral level 2A neck lymph node. With substantial preoperative multidisciplinary input, she underwent cancer ablation and microvascular free flap reconstruction. Her pathology showed a 35 mm diameter, 14 mm thick moderately differentiated SCC with perineural and lymphovascular invasion. Two out of 38 right neck nodes were positive for metastasis with extranodal extension. None of the 34 left neck nodes was involved.

She had an uneventful recovery and was discharged home on day 6 postoperative day. On day 15 postoperative day, she had catastrophic bleeding in the neck with a respiratory arrest after a forceful cough. She required an emergency tracheostomy and returned to the theatre for haemostasis. Following a short inpatient stay, she was again discharged home and underwent adjuvant therapy consisting of external beam radiotherapy of 60Gy in 30 fractions. On clinical examination and PET at 6 months after surgery, she had no evidence of disease recurrence.

Conclusions

MYH9-RD can present with advanced locoregional oral cavity malignancy at an early age. The combination of profound thrombocytopenia and marked renal impairment can impact heavily on routine major head and neck cancer surgery and adjuvant treatment. This rare and challenging condition underlines the importance of early detection of cancer and multidisciplinary team input.

Liberal versus Modified Intraoperative Fluid Management in Abdominal-flap Breast Reconstructions. A Clinical Study

Background:

The outcome of reconstructive microsurgery is influenced by the intraoperative anesthetic regimen. The aim of this study was to compare the impact on the intra- and postoperative complication rates of our modified fluid management (MFM) protocol with a previously used liberal fluid management protocol in abdominal-flap breast reconstructions.

Methods:

This retrospective study analyzed adverse events related to secondary unilateral abdominal-flap breast reconstructions in two patient cohorts, one with a liberal fluid management protocol and one with a MFM protocol. In the MFM protocol, intravenous fluid resuscitation was restricted and colloid use was minimized. Both noradrenaline and propofol were implemented as standard in the MFM protocol. The primary endpoints were surgical and medical complications, as observed intraoperatively or postoperatively, during or shortly after the hospital stay.

Results:

Of the 214 patients included in the study, 172 patients followed the MFM protocol. Prior radiotherapy was more frequent in the MFM protocol. Surgical procedures to achieve venous superdrainage were more often used in the MFM cohort. Intraoperative as well as postoperative complications occurred significantly more frequently in the liberal fluid management cohort and were specifically associated with partial and total flap failures. Prior radiotherapy, additional venous drainage, or choice of inhalation agent did not have an observable impact on outcome.

Conclusions:

The incidence of adverse events during and after autologous breast reconstructive procedures was reduced with the introduction of an MFM protocol. Strict intraoperative fluid control combined with norepinephrine and propofol was both beneficial and safe.

Avoiding the night terrors: the effect of circadian rhythm on post-operative urine output and blood pressure in free flap patients

Multiple studies demonstrate the importance of goal-directed fluid regimens in avoiding complications. These regimens do not take account of circadian fluctuations in urine output (UO), MAP (mean arterial pressure) and pulse rate (PR). This is the first study that aims to demonstrate the effect of circadian rhythm on these haemodynamic parameters in post-operative patients with free flaps, as well as analysing clinicians' response to these variations. Retrospective analysis of 116 patients with free flaps. Records were assessed for UO, MAP, IV fluid infusion rate, oral fluid intake. Parameters were measured from 8 am to 8 pm (diurnal) and from 8 pm to 8 am (nocturnal) in the first 48 h post operatively. Patients with diabetes or hypertension were excluded. Mean diurnal UO rate (1.7 ml/kg/hr) was higher than nocturnal UO rate (0.7 ml/kg/hr); and mean diurnal MAP (93) was higher than nocturnal MAP (73.8). Mean diurnal IV infusion rate was 1.25 ml/kg/hr (lower) and mean nocturnal infusion rate 1.81 ml/kg/hr (higher). These differences were all statistically significant by paired student t-test (p < 0.05). This study demonstrates that circadian rhythm has a statistically significant impact on UO, MAP and PR. UO, MAP and PR are expected to dip overnight. This dip is normal and does not necessarily need to be treated by increasing IV fluids to avoid over filling of free flap patients.