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Post by katevaughn on Oct 29, 2017 17:46:49 GMT -5
This month’s journal club is presented by Jessica Hadley. She chose an article written by our own Hopkin’s surgeons regarding the care of free flaps and the numerous factors that can contribute to the success or failure of the flap outcomes. It is a fantastic read for all of us because of the critical role we play in the outcomes of these cases. Enjoy! Here is the link to the article. November Journal Club.pdf (102.96 KB) Questions to encompass within your response: 1. Based on the article what would your fluid plan look like for a 10 hour mandibular tumor resection and fibula free flap on an otherwise healthy patient. 2. Do you feel vasopressors are an absolute contraindication during free flap? If so, how do you prefer to treat hypotension intraoperatively.
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Post by Mary SH CRNA on Oct 31, 2017 8:38:57 GMT -5
Thanks Jessica for the article! It's been awhile since I have done free flaps in adults.
1. Based on the article what would your fluid plan look like for a 10 hour mandibular tumor resection and fibula free flap on an otherwise healthy patient. Well, according to the article, it would consist of less than 7 liters of fluid! According to the article, both crystalloids and colloids in large volumes cause sequelae (flap failure, increased length of stay. However, preferred fluids and volumes aren't presented.
2. Do you feel vasopressors are an absolute contraindication during free flap? No, and according to the article, there is no data to support that stance.
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Post by Kristen Horsman on Oct 31, 2017 12:48:23 GMT -5
1. My approximate fluid plan for a 70 kg patient would be: Deficit: 110 x 8 hrs= 880 cc Maintenance: 110 x 10= 1100 Evaporative: 4-6 cc/kg/hr (depending on size of flap and time of exposure) 2800-4200 Replace blood loss with colloid/PRBCs depending on pt comorbidities/starting hgb, etc.
Total crystalloid fluids would be 5-6L. Under the 7L recommended.
2. I don't believe vasopressors are an absolute contraindication. However, because of the dogmas explained in the article, I try to avoid them and use other measures to combat hypotension so that anesthesia is not blamed for any post-op complications.
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Post by Jennifer Hannon on Nov 1, 2017 9:19:46 GMT -5
1. My fluid plan is similar to Kristen above and I think if you need to cut back you can take it from the evaporative loss, since the whole body is draped and there is the whole under body fluid warmer utilized. I find it interesting that since Richmon has left, the 7L seems like way too much fluid now to other surgeons, but I site this article as my reference. Also they want to know if you are considering blood, because most I've worked with are against giving blood unless absolutely life threatening.
2.I use phenylephrine as a vasopressor when everything else won't work, and Richmon was ok with phenylephrine (again citing this article in my discussion with the surgeon, when nothing else works) The everything else: Glyco Albumin 2% saline Less gas/Nitrous calcium gluconate (itty bit) phenylephrine
I've seen IM ephedrine used before to be a softer way of delivery, but have not used that in my free flap practice here at Hopkins.
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Post by Katya on Nov 2, 2017 14:16:55 GMT -5
1. My fluid plan includes deficit replacement and start 2% saline if no contraindication at 100-200 ml/hr, I can adjust rate according to BP. Usually blood loss is not that significant, so I use Albumin 5% as a fluid bolus to maintain BP, less inhalation agent/use of nitrous. 2. I don't think that vasopressors are an absolute contraindication. I usually try to communicate with surgeon and give Phenilephrine to maintain BP. I think the low BP and under perfusion of tissues is more detrimental to a flap.
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Post by Moishe Mayer on Nov 6, 2017 15:52:10 GMT -5
Thanks for the article.
1. The article does not offer specific guidelines for fluid administration. However, I would run a drip of crystalloids in mL/hr, in order to avoid large fluid shifts. I would consider also running albumin in mL/hr, in order to maintain stability. After that, I would titrate other products based on patient and procedure specifics.
2. Vasopressors are not contraindicated as presented in the article. However, depending on the surgeon, I would use other methods of increasing blood pressure, but would give pressors if other methods are ineffective.
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Post by Ben Waldbaum on Nov 6, 2017 16:37:42 GMT -5
Fluid plan Plasmalyte on alaris pump at 150-250 mL/hr, goal under 2 liters of crystaloid Albumin 5% on alaris pump at 50-150 mL/hr, goal under 1 liter of albumin
Vasopressors are clearly not contraindicated. Ephedrine may theoretically be a better first line vasopressor than phenylephrine given its MOA.
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Post by emedina1 on Nov 6, 2017 21:58:54 GMT -5
I agree with Ben. As a matter of fact, that is exactly what I would do. Ephedrine will be my first choice for vasopressors since the article mentioned that the use of this does not have a negative effect. I will be very careful in giving PRBC due to the other complications that goes with it.
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Post by Belinda Gardner on Nov 7, 2017 12:12:34 GMT -5
I would begin with a fluid calculation: 4/2/1 rule as above just to get a sense of the deficit for the length of the case. Beginning with P-Lyte carrier to cover maintenance/deficit as well as drizzling in Albumin earlier than later will help fill the tank and prevent hypotension related to hypovolemia (up to 1L). We generally try to avoid vasopressors in these cases however communication with the surgeon regarding hemodynamics and pressor requirements should occur if necessary. This article is a great reference and should help a research supported discussion.
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Post by Jessica Hadley on Nov 10, 2017 16:18:31 GMT -5
1. I would start with a 2% NS infusion at around 150 cc/hr. I would replace blood loss with Albumin, starting early on up to 1 Liter. I use crystalloids judiciously and usually blood products aren't indicated unless the hgb is less than 7-8. A conversation with surgeon would definitely happen prior to giving blood. I try to give much less than 5-6 liters total.
2. I do my best to avoid pressors, however if they are needed I also would use Ephedrine first and tell the surgeons.
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Post by vania on Nov 14, 2017 10:10:19 GMT -5
1.) I would replace for NPO deficit over the course of the case along with maintenance plasmalyte. I would use 5% albumin to support BP/replace for blood loss. In the case of Hgb<7, I would have a discussion with the surgeon about PRBC's, esp if the patient is hemodynamically unstable. Goal <5L.
2.) I would try to stay ahead of hypotension with fluids, but use ephedrine if needed and notify the surgical team.
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Post by Soo-Ok Kim on Nov 14, 2017 12:18:30 GMT -5
1. There was no recommendation on which fluid or how much of fluid on this article. However, <7liter of fluid for 10hr case seems to be reasonable. Generally speaking, free flap in head and neck location doesn't have much insensible loss compared to bowel or big vascular surgery. So, I will use 2% saline as a maintenance fluid and plasmalyte as fluid bolus as needed. Since I believe colloid fluid is not any better in overall mortality or morbidity, I will stay in crystalloid fluid.
2.No clear outcome benefit or disadvantage with pressor use for free flap survival. This article doesn't not guide us what to use or not to use. It seems like the practice varies between practitioner what one believes, not by research guidance. One thing they mention most critical factors are the surgeon's proper surgical technique and length of surgery, which I cannot agree more.
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Post by jswitzman on Nov 16, 2017 10:07:50 GMT -5
I would use the start with crystalloid using formula 110 x 10 for a 70 kg pt = 1100. Consider albumin, maintain urine output 30cc/hr and watch for blood loss; usually not a issue
If blood pressure and thus perfusion could not be maintained I would consider low dose vasopressors but communicate with surgeon.
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Post by Wai-Ling Lo on Nov 16, 2017 13:38:39 GMT -5
1. I will too use the 4/2/1 rule for preop fluid deficit and intraop maintenance replacement. There shouldn't be much insensible loss, I will add another 1-2ml/kg/hr. Bld loss can be replaced with colloid 1:1 ratio. The goal of fluid replacement is less than 7L.
2. Pressors are not contraindicated. Both ephedrine or phenylephrine is acceptable as the drug of choice although a lot of us prefer to use Ephedrine (less vasoconstrictive).
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Post by lmeginnis on Nov 19, 2017 18:14:47 GMT -5
Based on the article my fluid administration would be less than 7 liters. I typically use the 4/2/1 rule also. Ephedrine and phenylephrine if necessary while communicating with the surgeon.
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