Impact of goal-directed hemodynamic therapy on perioperative outcomes in head and neck free flap surgery: A before-and-after pilot study

Justine Philteos; Stuart A McCluskey; Sophia Emerson; George Djaiani; David Goldstein; Sabri Soussi

doi:10.1002/hsr2.1943

Impact of goal-directed hemodynamic therapy on perioperative outcomes in head and neck free flap surgery: A before-and-after pilot study

Health Sci Rep. 2024 Mar 22;7(3):e1943. doi: 10.1002/hsr2.1943. eCollection 2024 Mar.

Authors

Justine Philteos¹, Stuart A McCluskey^{2

3}, Sophia Emerson^{2

3}, George Djaiani^{2

3}, David Goldstein¹, Sabri Soussi^{2

4}

Affiliations

¹ Department of Otolaryngology-Head and Neck Surgery University Health Network, University of Toronto Toronto Ontario Canada.
² Department of Anesthesiology and Pain Medicine University of Toronto Toronto Ontario Canada.
³ Department of Anesthesia and Pain Management Toronto General Hospital, University Health Network Toronto Ontario Canada.
⁴ Department of Anesthesia and Pain Management Toronto Western Hospital, University Health Network Toronto Ontario Canada.

Abstract

Background: Free flap reconstruction for head and neck cancer is associated with a high risk of perioperative complications. One of the modifiable risk factors associated with perioperative morbidity is intraoperative hypotension (IOH). The main aim of this pilot study is to determine if the intraoperative use of goal-directed hemodynamic therapy (GDHT) is associated with a reduction in the number of IOH events in this population.

Methods: A before-and-after study design. The patients who had intraoperative GDHT were compared to patients from a previous period before the implementation of GDHT. The primary outcome was the number of IOH episodes defined as five or more successive minutes with a mean arterial pressure <65 mmHg. The secondary outcomes included major postoperative morbidity and 30-day mortality.

Results: A total of 414 patients were included. These were divided into two groups. The control group (n = 346; January 1, 2018, to December 31, 2019), and the monitored group (n = 68; January 1, 2020, to May 1, 2021). The median intraoperative administered fluid volume was similar between the control and monitored groups (2250 interquartile range [IQR] [1607-3050] vs. 2210 IQR [1700-2807] mL). The monitored group was found to have an increased use of norepinephrine and dobutamine (respectively, 1.2% vs. 5.9% and 2.4% vs. 30.9%; p < 0.05). When adjusting for confounders (comorbidities, estimated blood loss, and duration of anesthesia) the incidence rate ratio (95% confidence interval) of number of IOH events was 0.94 (0.86-1.03), p = 0.24. The rate of postoperative flap and medical complications did not differ between the two groups.

Conclusions: Even though the use of vasopressors/inotropes was higher in the monitored group, the number of IOH episodes and postoperative morbidity and mortality were similar between the two groups. Further change in hemodynamic management will require the use of specific blood pressure targets in the GDHT fluid algorithm.

Keywords: cardiac output; head and neck free flap surgery; hemodynamic monitoring; intraoperative hypotension; postoperative outcomes.