A “Free Flap Timeout” Improves Maintenance Of Blood Pressure Goals In Cases Of Free Tissue Transfer
Nicholas J. Albano, MD, Kirsten Gunderson, BS, Kishan Thadikonda, MD, Tetyana Osadchuk, BS, Samuel O. Poore, MD, PhD.
University of Wisconsin - Madison, Madison, WI, USA.
PURPOSE: Free tissue transfer has been established as an invaluable technique within the field of reconstructive surgery. While there is no consensus regarding the optimal intraoperative blood pressure during cases of free tissue transfer, it has been demonstrated that intraoperative hypotension confers an increased risk of complication and flap failure. Blood pressure preferences vary from surgeon to surgeon. Maintenance of goal blood pressure is carried out by the anesthesia team but is heavily dependent on “across-curtain” communication. We chose to study the effect of a formal “free flap timeout” on maintenance of intraoperative blood pressure during cases of free tissue transfer at the University of Wisconsin.
A formal free flap timeout card was created containing a script, which was performed following the standard surgical timeout. The script included: 1) A statement that blood pressure is a major factor in the case, 2) A goal systolic blood pressure of 110mmHg (determined by a staff survey), 3) A prompt to share preferred interventions for maintenance of blood pressure, and 4) The specific request that anesthesia notify the surgical team when such measures are being employed. The anesthesia team was provided a “hand-off card” to keep at their station, which was used to record the blood pressure goals and preferred interventions during the timeout. Chart review was used to assess blood pressure during free flap cases prior to and following the installment of our “free flap timeout.” We recorded the number of instances systolic blood pressure dropped below the set goal during each case, how long each episode of sub-goal blood pressure lasted, the trough blood pressure of each episode, and the total amount of time the blood pressure spent below goal for the entire case. Data from pre- and post-intervention groups were compared using unpaired t-tests.
A total of 68 pre-intervention and 55 post-intervention cases were assessed. Following our intervention, the duration of blood pressure episodes below goal significantly improved from a mean of 25.8 minutes to 15.8 minutes (p<0.0001). We also saw a significant improvement in the number of blood pressure dips per hour, decreasing from a mean of 4.4 dips to 1.7 dips (p<0.0001). The percentage of the case spent below the goal pressure significantly decreased from 48.1% to 36.9% (p=0.0045). The average trough blood pressure of each episode showed improvement from 97.8 mmHg to 99.0 mmHg, though was not significant (p=0.15).
CONCLUSION: We have demonstrated that a formal “free flap timeout” improves maintenance of intraoperative blood pressure during cases of free tissue transfer at the University of Wisconsin. Opportunities for explicit discussion of goals and preferences may ultimately lead to improved outcomes following free flap reconstruction.
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