November FY22

[kristenhorsman]

The November journal club is presented by Jen Hannon. She chose an article titled "Perioperative Fluid Resuscitation in Free Flap Breast Reconstruction: When Is Enough Enough?" It is a good discussion of fluid management and vasopressor use in these cases.

Here is the link.

Please respond to the following two questions:

1. When assigned into a DIEP Flap room, how do you prepare your mental care plan for fluid administration?
2. What strategies do you use to raise the blood pressure in a Free Flap & will RFR findings change your approach?

[Katya]

1.I don't get frequent assignments to deep flap cases. I usually bring 1 Liter bag of 2%saline bag and albumin bags. I try to limit my total fluid to 1.5-2 litters total fluids.
2. I use low infusion of 2% saline during the case and use low drip of albumin. If BP still low, I tell surgeon and give pressors to increase BP.

[nanci]

1. When assigned into a DIEP Flap room, how do you prepare your mental care plan for fluid administration?
Pretty much follow the DIEP Flap best practices/ERAS and guidelines that are posted on the Intranet. Fluid goal of euvolemia, crystalloid 20-30 ml/kg minimum for the case either LR or Plasmalyte. I used to get 2% Normal Saline from the WBG Pharmacy but now use Albumin 5% also if needed.


2. What strategies do you use to raise the blood pressure in a Free Flap & will RFR findings change your approach?
If euvolemic for the part of the case and need to increase the patient's blood pressure, will adjust the anesthetic being given and possibly give a 250 cc fluid bolus once. If no response will inform the surgeons and give a vasopressor. 

[clawry]

1. When assigned into a DIEP Flap room, how do you prepare your mental care plan for fluid administration?


I usually bring 4 bags 5% albumin and use plasmalyte for the case. I try to use a goal directed therapy approach when it is a long case or if there is anticipation of a lot of blood loss. In this situation, use of the EV 1000/clearsight would be a nice option to monitor SV, SVV, and CO. IF an arterial line was preferred due to patient comorbidities, I would use a flotrac to monitor those parameters. 

2. What strategies do you use to raise the blood pressure in a Free Flap & will RFR findings change your approach?

I would bolus albumin. If that did not work, I would adjust my anesthetic using the BIS as a guide. If it was apparent that the patient had adequate fluid on board, I would notify the surgeons to discuss the use of vasopressors. 

[Patricia Brissett]

1. When assigned into a DIEP Flap room, how do you prepare your mental care plan for fluid administration?

I haven't participated in these cases in while, but have always limited crystalloid fluids per the RFR method. Albumin if permitted is a great choice for boluses. I have found that using the clearsight helped with fluid management.

2. What strategies do you use to raise the blood pressure in a Free Flap & will RFR findings change your approach?

As mentioned above, Albumin 5%/250ml in the healthy fluid tolerant patient is a great choice for boluses. Also, having a discussion ahead of time with the Physician Anesthesiologist and Primary surgeon as to what options we have for vasopressor support is key. I have found that most surgeons prefer low dose continuous infusion of choice vasopressor rather than boluses of meds. Communication is key in these cases.

[Jessica Hadley]

1. I don't typically do DIEP flap cases, so thank you for the article. I do frequently participate in ENT free flap cases and the literature also shows that liberal fluid management increases the risk of flap failure and complications. In these cases, I use a restrictive plan and usually shoot for a goal UO of .5 ml/kg/hr. I usually replace EBL 1:1 with albumin. I no longer use 2% as a strategy as I didnt see a significant decrease in total volume given.

2. During these cases, I do treat hypotension with pressors depending on where they are surgically but do try to avoid pressors while they are doing microvascular anastamosis. If continued hypotension, I usually will give a small bolus with albumin and titrate anesthetic depth.

[Soo-Ok Kim]

1. When assigned into a DIEP Flap room, how do you prepare your mental care plan for fluid administration?
I don't do many of these cases. But, as other colleagues menttioend, bring several bags of albumi and 2% saline and tolerate certain level of hypovolemia if possible with pt's comobidity.

2. What strategies do you use to raise the blood pressure in a Free Flap & will RFR findings change your approach?
Euvolemic fluid status, adjust anesthetic (muscle relaxant to decrease the needs for anesthetic, if possible), then communicate with surgeon the needs for vasopressors.

[Anne McNulty]

(1} I have done Many of these diep flaps. I follow the ERA Protocol if the situation allows. I have never put an arterial line in any of these patients. The patients are chosen carefully. Most have healthy hearts. I use Plyte and keep the fluid intake as low as possible. If the Urine output is low , I will use some 5% albumin. When they are doing the Microscopic portion , I keep the Tiva as low as possible , with 2 twitches on TOF and BIS less than 60. (2) if the patient is in a low flow state and the BP is sagging, I discuss the issue with the surgical team . I have used an infusion of low dose phenylephrine on a few occasions.

[C. Velarde]

1. Since I do not get DIEP flaps it is interesting to know what everyone does to maintain a b/p for longer cases. It is interesting that 2% saline is used as well as albumin if necessary.
2. The strategy discussed was limit fluid and let surgeon know about hypotension. If necessary use vasopressors if surgeon agrees with plan.

[Kels]

I agree with what most of my colleges have discussed on this post . I too use albumin during the case. I usually do not give more than 1 liter of albumin during the case when BP is low . I too limit fluids and follow the best practice information about DIEP flaps that we have posted online . For sustained low BP I have not found much push back to using pressors from the surgery teams . They do appreciate being notified of any pressor use or pressor gtt use

[Dahlia Rouchon]

This is a great article that reminds us the importance of appropriate fluid resuscitation. I would agree even more so, for any free flap surgery as they are oftentimes (on the downtown campus) longer procedures -10hrs long- with microvascular anastomosis. DIEP cases are in this category.
1. For these cases, as all free flaps or any long surgery (whipples, large ex lap, spine fusions etc.), I do a written fluid plan chart which ensures I do not over/under resuscitate the patient. I employ 4:2:1 rule with a chart incorporating maintenance, deficit, 3rd spacing (IBW), EBL. I do not start 3rd spacing in the chart until incision is made and fluids are on infusion for maintenance. I often use hypertonic saline for maintenance. Additionally a push PIV line is used for boluses as needed to increase for challenges that may be indicated. EBL is replaced by crystalloid then albumin if hypotension is present but transfusion is not indicated. Accommodating the appropriate depth of anesthesia is key as requirements are lower during microanastomosis. This will prevent use of vasopressors. If lowered anesthetic use is in place, fluid boluses are given and hypotension is present despite up to 1L ablumin given, I will communicate with surgeon to inform of patient status. Preferably I will use ephedrine over phenylephrine is possible. If not, I will coordinate care to notify phenylephrine will be needed to keep MAPs within desired range.
2. Ultimately I find my practice is in the RVR range and I do not need to employ a change in my approach. I ensure U.O is at least 0.5cc/kg/hr and it is clear yellow in consistency. Staying on top of the hourly requirements and adjusting for changes in patient status using a written fluid plan chart has been very helpful to me.

[kelseyleonard]

1. When assigned into a DIEP Flap room, how do you prepare your mental care plan for fluid administration?
I typically run a carrier infusion of plasmalyte and have 4 bags of 5% albumin ready. I find that a steady replacement of volume over the duration of the procedure rather than bolus administration maintains a more stable blood pressure.

2. What strategies do you use to raise the blood pressure in a Free Flap & will RFR findings change your approach?
I minimize my anesthetic as best as I can, using the BIS as a guide. Using pharmacological agents to increase HR can help increase blood pressure. While I have not used it for a DIEP flap, Clearsite may also be a useful tool to guide fluid administration. Lastly, communication with surgeon is important and discussing the need to vasopressors.

[Wai-Ling Lo]

1. When assigned into a DIEP Flap room, how do you prepare your mental care plan for fluid administration?
I too follow the best practice and use restrictive fluid plan and replace blood loss with albumin 5%.

2. What strategies do you use to raise the blood pressure in a Free Flap & will RFR findings change your approach?
I will try to use albumin 5% for by support. If hypotension persists, will notify surgeon of the condition and use of pressors.

[mary clothier]

1. Great article on fluid management for a free flap reconstruction surgery.
Have not done a free flap in quite a while. Fluid restriction, minimizing crystalloid, using colloid replacement continues to be the standard of care for this microvascular
surgery, hoping to enhance vascularization, for the patient. We have an important role in the success of this surgery.

2. Communication with our surgical colleagues is critical, particularly when managing hypotension, although pressors not preferred, often necessary.

[Amy Swank]

1. I am not assigned these types of long DIEP flap cases, but the journal article was a good overview of current practices. Especially regarding restricting fluid intake. If I needed to do one, I would go with Albumin 5% for replacement rather than crystalloids, if possible. thought the use of 2% saline was also very interesting.

2. Usually with flaps and plastics cases, I avoid pressors unless absolutely necessary, but would keep the lines of communications open with the surgeon regarding its need.