Perioperatives Management in der Mikrochirurgie – Konsensus-Statement der Deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie der peripheren Nerven und Gefäße

Zusammenfassung

Zum perioperativen Management im Rahmen der Mikrochirurgie besteht derzeit kein einheitlicher Konsens. Aufgrund eines Mangels an systematischer Evidenz werden abhängig von individuellen Erfahrungen der Mikrochirurgen uneinheitliche Therapiestandards angewendet. Trotzdem können in den letzten Jahren zunehmend einheitliche Vorgehensweisen identifiziert werden, die generell dadurch geprägt sind, dass mit der zunehmender Erfahrung und Standardisierung in der Mikrochirurgie Vorgehensweisen ohne zugrunde liegende Evidenz eher unterlassen werden. Im Rahmen des Konsensus-Workshops der 37. Jahrestagung der Deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie der peripheren Nerven und Gefäße zum Thema „perioperatives Management“ wurden daher zu den Themen Temperaturmanagement, Flüssigkeitssubstitution, Bluttransfusion, Gabe von Vasodilatatoren oder – pressoren sowie Antikoagulantien zunächst die vorhandene Evidenz diskutiert und dann gemeinsame Standards der Teilnehmer konsentiert. Die Ergebnisse dieser Arbeitsgruppe werden im Folgenden dargestellt.

Abstract

Perioperative management of microsurgery is not well standardised. Due to a lack of evidence, different regimes are established in different microsurgical centres. However, trends towards less aggressive perioperative interventions can be identified in recent years, since treatment algorithms without systematic evidence are being progressively abandoned. The available evidence on perioperative issues, such as temperature control, fluid resuscitation, blood transfusions, application of vasodilators or – pressors, as well as anticoagulants, were discussed during the consensus conference on perioperative management at the annual meeting of the German Speaking Society for Microsurgery of Peripheral Nerves and Vessels. Common basic standards were identified and a consensus was reached that is described in the following manuscript.

Schlüsselwörter

Mikrochirurgie - Replantation - Anästhesie - perioperatives Management

Key words

microsurgery - replantation - anesthesia - perioperative management

• Literatur

• 1 Xiong L, Gazyakan E, Kremer T et al. Free flaps for reconstruction of soft tissue defects in lower extremity: A meta-analysis on microsurgical outcome and safety. Microsurgery 2016; [Epub ahead of print]
• 2 Senchenkov A, Lemaine V, Tran NV. Management of perioperative microvascular thrombotic complications – The use of multiagent anticoagulation algorithm in 395 consecutive free flaps. J Plast Reconstr Aesthet Surg 2015; 68: 1293-1303
• 3 Massey MF, Spiegel AJ, Levine JL et al. Group for the Advancement of Breast Reconstruction. Perforator flaps: recent experience, current trends, and future directions based on 3974 microsurgical breast reconstructions. Plast Reconstr Surg 2009; 124: 737-751
• 4 Grammatica A, Piazza C, Paderno A et al. Free flaps in head and neck reconstruction after oncologic surgery: expected outcomes in the elderly. Otolaryngol Head Neck Surg 2015; 152: 796-802
• 5 Kolbenschlag J, Gehl B, Daigeler A et al. Mikrochirurgische Ausbildung in Deutschland – Ergebnisse einer Umfrage unter Weiterbildungsassistenten und Weiterbildern. Handchir Mikrochir Plast Chir 2014; 46: 234-241
• 6 Daigeler A, Kaempfen A, Beier JP et al. Mikrochirurgische Aus- und Weiterbildung – Bericht des Consensus-Workshops im Rahmen der 31. Jahrestagung der Deutschsprachigen Gemeinschaft für Mikrochirurgie der peripheren Nerven und Gefäße 2009 in Erlangen. Handchir Mikrochir Plast Chir 2010; 42: 273-276
• 7 Thomson JG, Mine R, Shah A et al. The effect of core temperature on the success of free tissue transfer. J Reconstr Microsurg 2009; 25: 411-416
• 8 Kinnunen I, Laurikainen E, Schrey A et al. Effect of hypothermia on blood-flow responses in pedicled groin flaps in rats. Br J Plast Surg 2002; 55: 657-663
• 9 Liu YJ, Hirsch BP, Shah AA et al. Mild intraoperative hypothermia reduces free tissue transfer thrombosis. J Reconstr Microsurg 2011; 27: 121-126
• 10 Sumer BD, Myers LL, Leach J et al. Correlation between intraoperative hypothermia and perioperative morbidity in patients with head and neck cancer. Arch Otolaryngol Head Neck Surg 2009; 135: 682-686
• 11 Hill JB, Sexton KW, Bartlett EL et al. The Clinical Role of Intraoperative Core Temperature in Free Tissue Transfer. Ann Plast Surg 2015; 75: 620-624
• 12 Vyas K, Wong L. Intraoperative management of free flaps: current practice. Ann Plast Surg 2014; 72: S220-S223
• 13 Clark JR, McCluskey SA, Hall F et al. Predictors of morbidity following free flap reconstruction for cancer of the head and neck. Head Neck 2007; 29: 1090-1101
• 14 Zhong T, Neinstein R, Massey C et al. Intravenous fluid infusion rate in microsurgical breast reconstruction: important lessons learned from 354 free flaps. Plast Reconstr Surg 2011; 128: 1153-1160
• 15 Haughey BH, Wilson E, Kluwe L et al. Free flap reconstruction of the head and neck: analysis of 241 cases. Otolaryngol Head Neck Surg 2001; 125: 10-17
• 16 Booi DI. Perioperative fluid overload increases anastomosis thrombosis in the free TRAM flap used for breast reconstruction. Eur J Plast Surg 2011; 34: 81-86
• 17 Arellano R, Gan BS, Salpeter MJ et al. A triple-blinded randomized trial comparing the hemostatic effects of large-dose 10% hydroxyethyl starch 264/0.45 versus 5% albumin during major reconstructive surgery. Anesth Analg 2005; 100: 1846-1853
• 18 Lecoq JP, Joris JL, Nelissen XP et al. Effect of adrenergic stimulation on cutaneous microcirculation immediately after surgical adventitiectomy in a rat skin flap model. Microsurgery 2008; 28: 480-486
• 19 Cordeiro PG, Santamaria E, Hu QY et al. Effects of vasoactive medications on the blood flow of island musculocutaneous flaps in swine. Ann Plast Surg 1997; 39: 524-531
• 20 Eley KA, Young JD, Watt-Smith SR. Power spectral analysis of the effects of epinephrine, norepinephrine, dobutamine and dopexamine on microcirculation following free tissue transfer. Microsurgery 2013; 33: 275-281
• 21 Eley KA, Young JD, Watt-Smith SR. Epinephrine, norepinephrine, dobutamine, and dopexamine effects on free flap skin blood flow. Plast Reconstr Surg 2012; 130: 564-570
• 22 Chen C, Nguyen MD, Bar-Meir E et al. Effects of vasopressor administration on the outcomes of microsurgical breast reconstruction. Ann Plast Surg 2010; 65: 28-31
• 23 Monroe MM, Cannady SB, Ghanem TA et al. Safety of vasopressor use in head and neck microvascular reconstruction: a prospective observational study. Otolaryngol Head Neck Surg 2011; 144: 877-882
• 24 Monroe MM, McClelland J, Swide C et al. Vasopressor use in free tissue transfer surgery. Otolaryngol Head Neck Surg 2010; 142: 169-173
• 25 Kelly DA, Reynolds M, Crantford C et al. Impact of intraoperative vasopressor use in free tissue transfer for head, neck, and extremity reconstruction. Ann Plast Surg 2014; 72: S135-S138
• 26 Harris L, Goldstein D, Hofer S et al. Impact of vasopressors on outcomes in head and neck free tissue transfer. Microsurgery 2012; 32: 15-19
• 27 Swanson EW, Cheng HT, Susarla SM et al. Intraoperative Use of Vasopressors Is Safe in Head and Neck Free Tissue Transfer. J Reconstr Microsurg 2016; 32: 87-93
• 28 Motakef S, Mountziaris PM, Ismail IK et al. Emerging paradigms in perioperative management for microsurgical free tissue transfer: review of the literature and evidence-based guidelines. Plast Reconstr Surg 2015; 135: 290-299
• 29 Weinzweig N, Lukash F, Weinzweig J. Topical and systemic calcium channel blockers in the prevention and treatment of microvascular spasm in a rat epigastric island skin flap model. Ann Plast Surg 1999; 42: 320-326
• 30 Panagiotopoulos KE, Koutsouris M, Panagiotopoulos E et al. The effect of nifedipine on the patency of microvascular anastomosis in rats. Acta Chir Plast 2008; 50: 33-35
• 31 Hyza P, Streit L, Schwarz D et al. Vasospasm of the flap pedicle: the effect of 11 of the most often used vasodilating drugs. Comparative study in a rat model. Plast Reconstr Surg 2014; 134: 574e-584e
• 32 Evans GR, Gherardini G, Gürlek A et al. Drug-induced vasodilation in an in vitro and in vivo study: the effects of nicardipine, papaverine, and lidocaine on the rabbit carotid artery. Plast Reconstr Surg 1997; 100: 1475-1481
• 33 Gherardini G, Gürlek A, Cromeens D et al. Drug-induced vasodilation: in vitro and in vivo study on the effects of lidocaine and papaverine on rabbit carotid artery. Microsurgery 1998; 18: 90-96
• 34 Hill JB, Patel A, Del Corral GA et al. Preoperative anemia predicts thrombosis and free flap failure in microvascular reconstruction. Ann Plast Surg 2012; 69: 364-367
• 35 Kim BD, Ver Halen JP, Mlodinow AS et al. Intraoperative transfusion of packed red blood cells in microvascular free tissue transfer patients: assessment of 30-day morbidity using the NSQIP dataset. J Reconstr Microsurg 2014; 30: 103-114
• 36 Woolley AL, Hogikyan ND, Gates GA et al. Effect of blood transfusion on recurrence of head and neck carcinoma. Retrospective review and meta-analysis. Ann Otol Rhinol Laryngol 1992; 101: 724-730
• 37 Jackson RM, Rice DH. Blood transfusions and recurrence in head and neck cancer. Ann Otol Rhinol Laryngol 1989; 98: 171-173
• 38 Jones KR, Weissler MC. Blood transfusion and other risk factors for recurrence of cancer of the head and neck. Arch Otolaryngol Head Neck Surg 1990; 116: 304-309
• 39 Durnig P, Meier M, Reichert B. Monitoring bei freien Lappenplastiken und Replantationen. Eine Bestandsaufnahme im deutschsprachigen Raum. Handchir Mikrochir Plast Chir 2008; 40: 392-399
• 40 Disa JJ, Polvora VP, Pusic AL et al. Dextran-related complications in head and neck microsurgery: do the benefits outweigh the risks? A prospective randomized analysis. Plast Reconstr Surg 2003; 112: 1534-1539
• 41 Riva FM, Chen YC, Tan NC et al. The outcome of prostaglandin-E1 and dextran-40 compared to no antithrombotic therapy in head and neck free tissue transfer: analysis of 1,351 cases in a single center. Microsurgery 2012; 32: 339-343
• 42 Khouri RK, Cooley BC, Kunselman AR et al. A prospective study of microvascular free-flap surgery and outcome. Plast Reconstr Surg 1998; 102: 711-721
• 43 Chen CM, Ashjian P, Disa JJ et al. Is the use of intraoperative heparin safe?. Plast Reconstr Surg 2008; 121: 49e-53e
• 44 Ashjian P, Chen CM, Pusic A et al. The effect of postoperative anticoagulation on microvascular thrombosis. Ann Plast Surg 2007; 59: 36-39
• 45 Pannucci CJ, Kovach SJ, Cuker A. Microsurgery and the Hypercoagulable State: A Hematologist’s Perspective. Plast Reconstr Surg 2015; 136: 545e-552e
• 46 Friedman T, O’Brien Coon D, Michaels VJ et al. Hereditary coagulopathies: practical diagnosis and management for the plastic surgeon. Plast Reconstr Surg 2010; 125: 1544-1552
• 47 Warnecke IC, Kretschmer F, Brüner S et al. Hereditäre Thrombophilie und ihre Bedeutung für die freie mikrovaskuläre Gewebetransplantation anhand einer Falldarstellung. Handchir Mikrochir Plast Chir 2007; 39: 220-224
• 48 Daigeler A, Kneser U, Fansa H et al. Rekonstruktion der vaskulär kompromittierten unteren Extremität – Bericht des Konsensus-Workshops auf der 35. Jahrestagung der DAM (Deutschsprachige Gemeinschaft für Mikrochirurgie der peripheren Nerven und Gefäße) 2013 in Deidesheim. Handchir Mikrochir Plast Chir 2014; 46: 248-255
• 49 Schmitz M, Riss R, Kneser U et al. Perioperatives Gerinnungsmanagement in der Mikrochirurgie – Bericht der Konsensus-Workshops im Rahmen der 31. und 32. Jahrestagung der Deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie der peripheren Nerven und Gefäße (DAM) im November 2009 in Erlangen und November 2010 in Basel“. Handchir Mikrochir plast Chir 2011; 43: 376-383
• 50 Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: risk factors and prevention. Lancet 2006; 367: 1618-1625 Review
• 51 Phelps DB, Rutherford RB, Boswick Jr JA. Control of vasospasm following trauma and microvascular surgery. J Hand Surg Am 1979; 4: 109-117
• 52 Su HH, Lui PW, Yu CL et al. The effects of continuous axillary brachial plexus block with ropivacaine infusion on skin temperature and survival of crushed fingers after microsurgical replantation. Chang Gung Med J 2005; 28: 567-574
• 53 Wheble GA, Tan EK, Turner M et al. Surgeon-administered, intra-operative transversus abdominis plane block in autologous breast reconstruction: a UK hospital experience. J Plast Reconstr Aesthet Surg 2013; 66: 1665-1670
• 54 Gerlach A, Bunge M, Bohlmann L et al. S3 Leitlinie „Behandlng akuter perioperativer und posttraumatischer Schmerzen, AWMF-Register Nr. 041/001, Stand 2009
• 55 Chou R, Gordon DB, de Leon-Casasola OA et al. Management of Postoperative Pain: A Clinical Practice Guideline From the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain 2016; 17: 131-157
• 56 Schmitz M, Riss R, Kneser U et al. Perioperatives Gerinnungsmanagement in der Mikrochirurgie – Bericht der Konsensus-Workshops im Rahmen der 31. und 32. Jahrestagung der Deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie der peripheren Nerven und Gefäße (DAM) im November 2009 in Erlangen und November 2010 in Basel“. Handchir Mikrochir Plast Chir 2011; 43: 376-383
• 57 Buckley T, Hammert WC. Anticoagulation following digital replantation. J Hand Surg Am 2011; 36: 1374-1376