Chapter 2 Discussion Breast reconstructive surgery and flap failure pose a great burden on the self‐image and the quality of life of patients recovering from breast cancer.6 Increased anatomical and physiological flap knowledge has improved the outcome after autologous breast reconstructive surgery. However, there are still some uncertainties on perioperative management and the effect it may have on the final outcome. The results in this retrospective study suggest that aggressive fluid management may trigger anastomosis failure, which, in a majority of patients, leads to further complications such as TFL and increased incidence of ma‐FC. Anesthetic management in free flap surgery has been described in the literature.1,2,7,8 A series of principles such as maintenance of a high cardiac output, systolic pressure >100 mmHg, low systemic vascular resistance, normothermia, high urine output and effective analgesia, together with a mild haemodilution to a haematocrit value of 30– 35%, results in compromise. These are usually obtained by the use of a deliberate fluid management.1,7‐10 These studies also advocate not using vasoactive agents due to either the increase in systemic vascular resistance or decrease in cardiac output. However, these basic principles are more based on animal studies rather than on evidence‐based medicine. Anesthesiologists view the entire body as having flow that is dependent on systemic perfusion pressure, whereas reconstructive surgeons convene that systemic administration of vasoactive agents cause vasoconstriction of the pedicle artery and the microvasculature. Clinically, vasoactive agents may lead to increased difficulty during dissecting due to vasoconstriction of perforating vessels. However, Massey et al. demonstrated the safe and effective use of epinephrine in an experimental model.11 In addition, a clinical study comparing dopamine with dobutamine demonstrated that if vasoactive agents are needed during microvascular surgery, dobutamine seems to be more beneficial than dopamine in terms of cardiac output and flap perfusion.12 In this study, only a minor bolus of ephedrine was used in 14 patients with no adverse effects on the complication rates. Ephedrine did lead to a reduced fluid volume therapy in this group; however, this was not significant (Figure 2.3). Perioperative fluid therapy is the subject of much controversy in general surgery. In respect to reconstructive free flap surgery, little is known. The flaps used in reconstructive surgery are prone to ischemia and hypoxia, which implies a considerable risk of wound healing and flap complications. Deliberate fluid therapy causes haemodilution, which may further deteriorate oxygenation because of the lack of erythrocytes. On the other hand, it could improve oxygenation because of increased microcirculatory blood flow. In experimental studies, normovolaemic haemodilution reduces risk of thrombosis13 and increases flap oxygenation.14 In clinical studies, the debate of deliberate fluid therapy versus restrictive fluid therapy is still ongoing15,16, although a recent review favors restrictive fluid therapy.3 34
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