Head and neck free-flap microvascular surgeries are complex and resource-intensive procedures where proper conduct of anaesthesia plays a crucial role in the outcome. Flap failure and postoperative complications can be attributed to multiple factors, whether surgical- or anaesthesia-related. The anesthesiologist should ensure optimised physiological conditions to guarantee the survival of the flap and simultaneously decrease perioperative morbidity. Institutions employ different anaesthetic techniques and results vary across centres. In our institution, two different total intravenous approaches have been in use: a remifentanil-based approach and a multimodal opioid-sparing approach, which is further divided into an opioid-free anaesthesia (OFA) subgroup. We studied every consecutive case performed between 2015 and 2022, including 107 patients. Our results show a significant reduction in overall complications (53.3 vs. 78.9%, p = 0.012), length of stay in the intensive care unit (3.43 ± 5.51 vs. 5.16 ± 4.23 days, p = 0.046), duration of postoperative mechanical ventilation (67 ± 107 vs. 9 ± 38 h, p = 0.029), and the need for postoperative vasopressors (10% vs. 46.6%, p = 0.001) in the OFA group (vs. all other patients). The multimodal and OFA strategies have multiple differences regarding the fluid therapy, intraoperative type of vasopressor used, perioperative pathways, and various drug choices compared to the opioid-based technique. Due to the small number of cases in our study, we could not isolate any attitude, as an independent factor, from the success of the OFA strategy as a whole. Large randomised controlled trials are needed to improve knowledge and help define the ideal anaesthetic management of these patients.

Opioid-Free Anaesthesia Reduces Complications in Head and Neck Microvascular Free-Flap Reconstruction

Multiple surgical revisions in patients with anastomotic leakage: a retrospective cohort analysis

The hemoglobin examination instructed by Dr. Sardjito General Hospital attending doctors was 6 hours after the PRC transfusion. It is recommended that a hemoglobin examination be carried out 24 hours after transfusion to determine the patient's hemoglobin after complete equilibrium occurs. This study aimed to determine the mean increase in Hb levels 6 hours and 24 hours after PRC transfusion and to examine the difference in Hb levels 6 hours and 24 hours after PRC transfusion, respectively, compared with baseline Hb levels in non-hematological malignancy patients. This prospective analytic observational study examined hemoglobin at 6 hours and 24 hours after PRC transfusion. The differential test between delta Hb levels 6 hours after PRC transfusion compared to baseline Hb levels and delta Hb levels 24 hours after PRC transfusion compared to baseline Hb levels were analyzed using paired T-test. There was a statistically significant difference between baseline Hb levels and Hb levels 6 hours after PRC transfusion (p<0.0001) and a statistically significant difference between baseline Hb levels and Hb levels 24 hours after PRC transfusion (p<0.0001). The differential test between delta Hb levels 6 hours after PRC transfusion compared to baseline Hb levels and delta Hb levels 24 hours after PRC transfusion compared to baseline Hb levels obtained a statistically significant difference (p=0.0024). The mean increase in hemoglobin was 1.76+0.78 g/dL 6 hours after PRC transfusion and 1.9+0.78 g/dL 24 hours after PRC transfusion. There were differences in delta Hb levels 6 hours and 24 hours after PRC transfusion, respectively, compared with baseline Hb levels in non-hematological malignancy patients, which were statistically significant but not clinically significant.

Differences in Hemoglobin Levels 6 Hours and 24 Hours After Packed Red Cells Transfusion

Abstract Background There is a growing concern with inappropriate, excessive perioperative blood transfusions. Understanding the influence of low preoperative hemoglobin (Hgb) on perioperative blood transfusion (PBT) in head and neck cancer (HNC) surgery with free flap reconstruction may help guide clinical practice to reduce inappropriate treatment among these patients. The objective is to synthesize evidence regarding the association between preoperative Hgb and PBT among major HNC free flap surgeries. Methods Terms and synonyms for HNC surgical procedures, Hgb and PBT were used to search MEDLINE, Embase, CINAHL, Cochrane Central Register of Controlled Trials and Cochrane Database of Reviews from inception to February 2020. Reference lists of included full texts and studies reporting the preoperative Hgb, anemia or hematocrit (exposure) and the PBT (outcome) in major HNC surgery with free flap reconstruction were eligible. Studies examining esophageal, thyroid and parathyroid neoplasms were excluded; as were case reports, case series (n &lt; 20), editorials, reviews, perspectives, viewpoints and responses. Two independent, blinded reviewers screened titles, abstracts and full texts in duplicate. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses was followed. A random-effects model was used to pool reported data. The primary outcome was the proportion of patients who had a PBT. Subgroup analysis examined sources of heterogeneity for perioperative predictors of PBT (age, sex, flap type, flap site and preoperative Hgb). We also examined mean preoperative Hgb in the PBT and no PBT groups. Results Patients with low preoperative Hgb were transfused more than those with normal Hgb (47.62%, 95% CI = 41.19–54.06, I 2 = 0.00% and 13.92%, 95% CI = 10.19–17.65, I 2 = 20.69%, respectively). None of the predictor variables explained PBT. The overall pooled mean preoperative Hgb was 12.96 g/dL (95% CI = 11.33–14.59, I 2 = 0.00%) and was 13.58 g/dL (95% CI = 11.95–15.21, I 2 = 0.00%) in the no PBT group and 12.05 g/dL (95% CI = 10.01 to 14.09, I 2 = 0.00%) in the PBT group. Conclusions The heterogeneity between studies, especially around the trigger for PBT, highlights the need for additional research to guide clinical practice of preoperative Hgb related to PBT to enhance patient outcomes and improve healthcare stewardship. Graphical abstract 

/pdf/preoperative-hemoglobin-and-perioperative-blood-transfusion-kw3xq2h3.pdf

Preoperative hemoglobin and perioperative blood transfusion in major head and neck surgery: a systematic review and meta-analysis

The Effect of Preoperative Anemia on Blood Transfusion Outcomes in Major Head and Neck Cancer Surgery

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Preoperative hemoglobin and perioperative blood transfusion in major head and neck surgery: a systematic review and meta-analysis

The Effect of Preoperative Anemia on Blood Transfusion Outcomes in Major Head and Neck Cancer Surgery