Major head and neck free flap surgery presents unique challenges. We explore the role of hemodynamic monitoring in this key clinical area.
Abdul-Galil et al. 2010 describe the challenges of using oesophageal Doppler ultrasound during major resection of the head and neck. The authors compared this wit the use of minimally invasive LiDCOrapid approach for goal -directed fluid therapy.
Patients undergoing head and neck free flap reconstruction are high risk and fluid management within this group is challenging.
The complexity of the surgery means cases can last for in excess of 8 hours with some blood loss expected.
As a result, identifying whether hypotension is as a result of a fluid requirement or loss of venous tone is essential in not prescribing too much fluid.
There is also the added challenge of using vasopressors. If used excessively, there is the potential for an increase in afterload, reduction in stroke volume and reduced perfusion to the free flap causing complications.
Advanced hemodynamic monitoring is required to achieve careful administration of fluids and drugs in patients undergoing free flap reconstruction.
Fluid responsiveness parameters on the LiDCO monitor indicate when fluid is required.
More importantly in this patient group, they also indicate when fluid is not required, preventing complications from over filling.
With regards to vasopressors, the LiDCO monitor helps guide an adequate level of vasopressor to maintain venous tone whilst not over squeezing the patient and reducing perfusion to the free flap.
Patient Population
Head & neck surgery.
LiDCO Monitor
LiDCOrapid.
Abstract
Short communication describing the use of a protocol for intraoperative fluid management with early experience in patients having major head and neck surgery, where oesophageal Doppler ultrasound is impractical.
MATERIALS AND METHODS
Fluid administered by the anesthetist in guided by the LiDCOrapid monitor.
CONCLUSIONS
The authors intend to assess the efficacy of this protocol compared with existing practice through an RCT.
“We have found that the [LiDCOrapid] monitor’s continuously available, beat-to-beat, haemodynamic data are helpful in facilitating the giving of optimal fluids and drugs in a substantial number of our patients who are having moderate and high-risk anaesthesia.”
Patient Population
Head & neck free flap reconstruction.
LiDCO Monitor
LiDCOrapid.
Trial Design
Prospective comparison of blood flow in free flap versus control tissue in 24 patients.
Outcome Impact
Norepinephrine most consistently elevated the mean arterial pressure and caused by far the largest increase in flap skin blood flow, making it the pressor agent of choice (of those studied), following free tissue transfer.
PURPOSE
This study sought
MATERIALS AND METHODS
24 patients undergoing free flap surgery for head and neck cancer resection with a standard planned post-operative ICU admission.
RESULTS
Dose-dependenr, increased free flap skin blood flow was observed with norepinephrine and dobutamine. Both dopamine and epinephrine infusions decreased blood flow.
CONCLUSIONS
“Both dobutamine and norepinephrine had beneficial effects on flap skin flow. The maximal improvement in flow occurred with norepinephrine, making it the optimal pressor to use in patients with hypotension after free flap surgery .”
“Norepinephrine most consistently elevated the mean arterial pressure and caused by far the largest increase in flap skin blood flow, making it the pressor agent of choice (of those studied), following free tissue transfer.”
“We have found that the [LiDCOrapid] monitor’s continuously available, beat-to-beat, haemodynamic data are helpful in facilitating the giving of optimal fluids and drugs in a substantial number of our patients who are having moderate and high-risk anaesthesia.”
Abdel-Galil et al. 2010
The LiDCOunity monitor is a single platform which combines both the LiDCOplus and LiDCOrapid functions. This provides a single solution to monitoring needs throughout the hospital. The clinician can choose which mode is most appropriate to the clinical situation. The LiDCOunity can be used non-invasively, minimally invasively with a radial arterial line and can be calibrated with the lithium dilution technique. Find out more
The LiDCOplus hemodynamic monitor provides a continuous, reliable and accurate assessment of the hemodynamic status of critical care and surgery patients. The LiDCOplus is comprised of two technologies: a continuous arterial waveform analysis system (PulseCO™) coupled to a single point lithium indicator dilution calibration system. Find out more
The LiDCOrapid monitor analyses the blood pressure waveform to provide more information in high-risk surgical and critically ill patients to help with fluid and drug management. The LiDCOrapid uses the PulseCO™ algorithm which converts blood pressure to its constituent parts of flow (CO, SV) and resistance (SVR). The PulseCO™ algorithm is scaled to each patient with a nomogram using age, height, and weight. Find out more