ABSTRACT
Patients undergoing free tissue transfer are particularly susceptible to hypothermia. The goal was to investigate the impact of intraoperative core body temperature on free flap thrombosis. Two hundred twelve cases of free flap reconstruction at Yale-New Haven Hospital between 1992 and 2008 were reviewed. Free flap thrombosis was defined by complete flap necrosis or direct visualization of arterial or venous thrombosis. Temperature measurements were calibrated to bladder temperatures as measured by Foley catheter sensor. Through logistic regression analysis, maximum and minimum intraoperative temperatures were determined to be statistically significant predictors of free flap thrombosis. The optimal temperature was calculated to be 36.2°C, and maximum intraoperative temperatures between 36.0°C and 36.4°C showed lower thrombosis rates than superwarmed patients (p < 0.03). Therefore, free flap patients should be mildly hypothermic at 36.0°C to 36.4°C, compared with normothermia at 37.5°C, as measured in the bladder. A prospective randomized trial investigating thrombosis rates and intraoperative temperature should be undertaken.
KEYWORDS
Free flap - hypothermia - thrombosis
REFERENCES
-
1
Salemark L.
International survey of current microvascular practices in free tissue transfer and replantation surgery.
Microsurgery.
1991;
12
308-311
-
2
Serletti J M, Deuber M A, Guidera P M et al..
Atherosclerosis of the lower extremity and free-tissue reconstruction for limb salvage.
Plast Reconstr Surg.
1995;
96
1136-1144
-
3
Rieck B, Mailänder P, Machens H G.
Vascular complications after free tissue transfer.
Microsurgery.
1995;
16
400-403
-
4
Ozkan O, Ozgentas H E, Islamoglu K, Boztug N, Bigat Z, Dikici M B.
Experiences with microsurgical tissue transfers in elderly patients.
Microsurgery.
2005;
25
390-395
-
5
Genden E M, Rinaldo A, Suárez C, Wei W I, Bradley P J, Ferlito A.
Complications of free flap transfers for head and neck reconstruction following cancer resection.
Oral Oncol.
2004;
40
979-984
-
6
Okazaki M, Asato H, Takushima A et al..
Analysis of salvage treatments following the failure of free flap transfer caused by vascular thrombosis in reconstruction for head and neck cancer.
Plast Reconstr Surg.
2007;
119
1223-1232
-
7
Doufas A G, Sessler D I.
Physiology and clinical relevance of induced hypothermia.
Neurocrit Care.
2004;
1
489-498
-
8
Bui D T, Cordeiro P G, Hu Q Y, Disa J J, Pusic A, Mehrara B J.
Free flap reexploration: indications, treatment, and outcomes in 1193 free flaps.
Plast Reconstr Surg.
2007;
119
2092-2100
-
9
Thomson J G, 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
-
10
Ilsley A H, Rutten A J, Runciman W B.
An evaluation of body temperature measurement.
Anaesth Intensive Care.
1983;
11
31-39
-
11
Fulbrook P.
Core temperature measurement in adults: a literature review.
J Adv Nurs.
1993;
18
1451-1460
-
12
Hooper V D, Andrews J O.
Accuracy of noninvasive core temperature measurement in acutely ill adults: the state of the science.
Biol Res Nurs.
2006;
8
24-34
-
13
Byrne C, Lim C L.
The ingestible telemetric body core temperature sensor: a review of validity and exercise applications.
Br J Sports Med.
2007;
41
126-133
-
14
Kolka M, Levine L, Stephenson L.
Use of an ingestible telemetry sensor to measure core temperature under chemical protective clothing.
J Therm Biol.
1997;
22
343-349
-
15
Longfield J N, Morris M J, Moran K A, Kragh Jr J F, Wolf R, Baskin T W.
Community meetings for emergency research community consultation.
Crit Care Med.
2008;
36
731-736
-
16
Moran J L, Peter J V, Solomon P J et al..
Tympanic temperature measurements: are they reliable in the critically ill? A clinical study of measures of agreement.
Crit Care Med.
2007;
35
155-164
-
17
Camboni D, Philipp A, Schebesch K M, Schmid C.
Accuracy of core temperature measurement in deep hypothermic circulatory arrest.
Interact Cardiovasc Thorac Surg.
2008;
7
922-924
-
18
Lim C L, Byrne C, Lee J K.
Human thermoregulation and measurement of body temperature in exercise and clinical settings.
Ann Acad Med Singapore.
2008;
37
347-353
-
19 Dobson A J. An Introduction to Generalized Linear Models. Chapman & Hall/CRC Texts in Statistical Science Series. 2nd ed. Boca Raton, FL: Chapman & Hall/CRC; 2002
-
20 McCullagh P, Nelder J A. Generalized Linear Models. 2nd ed. London, New York: Chapman & Hall/CRC; 1989
-
21 Collett D. Modelling Binary Data. 2nd ed. Boca Raton, FL: Chapman & Hall/CRC; 2003
-
22
Schusterman M A, Miller M J, Reece G P, Kroll S S, Marchi M, Goepfert H.
A single center's experience with 308 free flaps for repair of head and neck cancer defects.
Plast Reconstr Surg.
1994;
93
472-478
discussion 479-480
-
23
Jones N F, Johnson J T, Shestak K C, Myers E N, Swartz W M.
Microsurgical reconstruction of the head and neck: interdisciplinary collaboration between head and neck surgeons and plastic surgeons in 305 cases.
Ann Plast Surg.
1996;
36
37-43
-
24
Hess J R, Brohi K, Dutton R P et al..
The coagulopathy of trauma: a review of mechanisms.
J Trauma.
2008;
65
748-754
-
25
Michelson A D, Barnard M R, Khuri S F, Rohrer M J, MacGregor H, Valeri C R.
The effects of aspirin and hypothermia on platelet function in vivo.
Br J Haematol.
1999;
104
64-68
-
26
Valeri C R, MacGregor H, Cassidy G, Tinney R, Pompei F.
Effects of temperature on bleeding time and clotting time in normal male and female volunteers.
Crit Care Med.
1995;
23
698-704
-
27
Wolberg A S, Meng Z H, Monroe III D M, Hoffman M.
A systematic evaluation of the effect of temperature on coagulation enzyme activity and platelet function.
J Trauma.
2004;
56
1221-1228
-
28
Kermode J C, Zheng Q, Milner E P.
Marked temperature dependence of the platelet calcium signal induced by human von Willebrand factor.
Blood.
1999;
94
199-207
-
29
Reed II R L, Bracey Jr A W, Hudson J D, Miller T A, Fischer R P.
Hypothermia and blood coagulation: dissociation between enzyme activity and clotting factor levels.
Circ Shock.
1990;
32
141-152
-
30
Rohrer M J, Natale A M.
Effect of hypothermia on the coagulation cascade.
Crit Care Med.
1992;
20
1402-1405
-
31
Johnston T D, Chen Y, Reed II R L.
Functional equivalence of hypothermia to specific clotting factor deficiencies.
J Trauma.
1994;
37
413-417
-
32
Kroll S S, Schusterman M A, Reece G P et al..
Timing of pedicle thrombosis and flap loss after free-tissue transfer.
Plast Reconstr Surg.
1996;
98
1230-1233
-
33
Khouri R K, Cooley B C, Kunselman A R et al..
A prospective study of microvascular free-flap surgery and outcome.
Plast Reconstr Surg.
1998;
102
711-721
-
34
Chen C M, Ashjian P, Disa J J, Cordeiro P G, Pusic A L, Mehrara B J.
Is the use of intraoperative heparin safe?.
Plast Reconstr Surg.
2008;
121
49e-53e
-
35
Martini W Z.
Coagulopathy by hypothermia and acidosis: mechanisms of thrombin generation and fibrinogen availability.
J Trauma.
2009;
67
202-208
discussion 208-209
-
36
Martini W Z, Pusateri A E, Uscilowicz J M, Delgado A V, Holcomb J B.
Independent contributions of hypothermia and acidosis to coagulopathy in swine.
J Trauma.
2005;
58
1002-1009
discussion 1009-1010
-
37
Jokuszies A, Niederbichler A, Meyer-Marcotty M, Lahoda L U, Reimers K, Vogt P M.
Influence of transendothelial mechanisms on microcirculation: consequences for reperfusion injury after free flap transfer. Previous, current, and future aspects.
J Reconstr Microsurg.
2006;
22
513-518
-
38
Kelly J L, Eadie P A, Orr D, Al-Rawi M, O'Donnell M, Lawlor D.
Prospective evaluation of outcome measures in free-flap surgery.
J Reconstr Microsurg.
2004;
20
435-438
discussion 439
-
39
Wang H E, Callaway C W, Peitzman A B, Tisherman S A.
Admission hypothermia and outcome after major trauma.
Crit Care Med.
2005;
33
1296-1301
-
40
Martin R S, Kilgo P D, Miller P R, Hoth J J, Meredith J W, Chang M C.
Injury-associated hypothermia: an analysis of the 2004 National Trauma Data Bank.
Shock.
2005;
24
114-118
-
41
Aitken L M, Hendrikz J K, Dulhunty J M, Rudd M J.
Hypothermia and associated outcomes in seriously injured trauma patients in a predominantly sub-tropical climate.
Resuscitation.
2009;
80
217-223
-
42
Frank S M, Beattie C, Christopherson R The Perioperative Ischemia Randomized Anesthesia Trial Study Group et al.
Unintentional hypothermia is associated with postoperative myocardial ischemia.
Anesthesiology.
1993;
78
468-476
-
43
Frank S M, Fleisher L A, Breslow M J et al..
Perioperative maintenance of normothermia reduces the incidence of morbid cardiac events. A randomized clinical trial.
JAMA.
1997;
277
1127-1134
-
44
Kurz A, Sessler D I, Lenhardt R. Study of Wound Infection and Temperature Group .
Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization.
N Engl J Med.
1996;
334
1209-1215
-
45
Schmied H, Kurz A, Sessler D I, Kozek S, Reiter A.
Mild hypothermia increases blood loss and transfusion requirements during total hip arthroplasty.
Lancet.
1996;
347
289-292
-
46
Nathan H J, Parlea L, Dupuis J Y et al..
Safety of deliberate intraoperative and postoperative hypothermia for patients undergoing coronary artery surgery: a randomized trial.
J Thorac Cardiovasc Surg.
2004;
127
1270-1275
-
47
Kimme P, Fridrikssen S, Engdahl O, Hillman J, Vegfors M, Sjöberg F.
Moderate hypothermia for 359 operations to clip cerebral aneurysms.
Br J Anaesth.
2004;
93
343-347
-
48
Harrington D K, Lilley J P, Rooney S J, Bonser R S.
Nonneurologic morbidity and profound hypothermia in aortic surgery.
Ann Thorac Surg.
2004;
78
596-601
J. Grant ThomsonM.D. M.Sc. F.R.C.S.C.
Section of Plastic and Reconstructive Surgery, Yale University School of Medicine
P.O. Box 208041, New Haven, CT 06520-8041
eMail: grant.thomson@yale.edu
