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Post by A Brooks on Nov 20, 2017 15:27:42 GMT -5
Thank you very much for the article! If possible I would try to have a clear sight available for long surgery to help guide fluid administration. I would start with a 250ml bottle of 5% albumin and replace the NPO deficit with 880 ml/LR (assuming a 70 kg pt. I would run 110 ml/hr for the duration of the surgery giving 1100ml. Labs would be send at midpoint to obtain values including BE. I don't believe that vasopressors are an absolute contraindication. According to the article, there is no clear evidence that vasopressors are the cause of flap failure. Ephedrine would be my first choice related to less vasoconstrictive properties.
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Post by mdougla5 on Nov 26, 2017 15:11:29 GMT -5
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. To avoid complications with free flaps that are associated with high rates of volume replacement, my fluid administration would be less than 7 liters. My fluid plan would be: Maintenance: 110cc x 10hr NPO deficit: 110cc x 8hr Evaporative Loss: 3 cc/70kg/hr
2. Do you feel vasopressors are an absolute contraindication during free flap? If so, how do you prefer to treat hypotension intraoperatively. I do not feel that vasopressors are an absolute contraindication during free flap procedures. However, if required, I would communicate the need with the surgeon.
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Post by Kim Hall on Nov 30, 2017 13:11:22 GMT -5
1. I agree with everyone of using primarily albumin and keep my fluid administration under 7L.
2. I would use ephedrine and phenylephrine to treat hypotension while communicating with the surgical team and once other options have been unsuccessful.
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Post by krechti1 on Nov 30, 2017 15:53:29 GMT -5
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.
Definitely keep crystalloid less than 7L- try to limit as much as possible, similar to above formulas. Replace blood 1:1 w/ colloid (albumin) or blood products if indicated by Hgb. Consider running 2%NS infusion if having issues w/ hypotension.
2. Do you feel vasopressors are an absolute contraindication during free flap? If so, how do you prefer to treat hypotension intraoperatively.
No, I do not consider vasopressors to be an absolute contraindication, as referenced in the article. I would first treat hypotension with colloid/ 2%NS, but would not hesitate to use vasopressor if BP not responding to these methods. Communication with surgical team would be very important as soon as any issues with BP, etc. are evident.
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Post by Chuck Eder on Nov 30, 2017 17:18:54 GMT -5
1. I would shoot for a fluid plan that comes in <7 L with those guidelines that were presented in the article. I would use crystalloids and 1 L 5% albumin. I also tend to add N2O to decrease the amount of my other volatile. I tend to not give as much opioid throughout the case, this can help decrease the low swings in BP. Fluid plans and restrictions (<7L) are nice "guidelines", however cases range in time from 8 hours to 14 or 16 hours. So at this point, is it the extra IVF or the extended surgical time contributing to flap complications.
2. The article states that pressors have not been shown to be contraindicated in these cases. However, it's the first request of the surgeon here at Hopkins. I use them sparingly as a last resort when other methods have not helped my hypotension.
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Kristen Praesel Lang
Guest
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Post by Kristen Praesel Lang on Nov 30, 2017 18:20:01 GMT -5
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. Per the article, I would administer under 7 L of fluid. I would likely administer around 4-5 Liters of crystalloid and I would include up to 1 liter of albumin.
2. Do you feel vasopressors are an absolute contraindication during free flap? If so, how do you prefer to treat hypotension intraoperatively. Vasopressors are an absolute contraindication during free flap. I would give albumin to treat hypotension and I would consider titrating back on anesthetic gas if there were room to do so.
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nanci
Junior Member
Posts: 57
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Post by nanci on Nov 30, 2017 19:27:12 GMT -5
1. I would try to administer less than 7 L of fluid. A crystalloid infusion of 150-200 ml/hr (increasing rate if needed) and have Albumin 5% (1 - 1.5L) available and administer as needed (to replace initial blood loss). Definitely try to stay with minimal fluids and discuss issues with the surgeons as needed (i.e....excessive blood loss needing replacement and options available like Albumin vs PRBC's).
2. Ephedrine would be my first choice if hypotension not resolved with fluid bolus or anesthetic titration. Also discuss with surgeons about use of Ephedrine before administering (and Phenylephrine as well). They do not like use of vasopressors but not an absolute contraindication and also varies with which part of the procedure they are at when hypotension occurs. So discussion with the team is important so all understand the risks and benefits of planned intervention.
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