- Microvascular free tissue transfer
- May involve skin, bone, muscle or bowel
- Types of flap
- Local
- Rotated around their neuro vascular bundle
- Free flaps
- Procedures
- Reconstructive hand surgery
- Trauma
- Burns
- Malignancy
- Breast
- Flap sites
- Radius
- Ulnar
- Forearm
- Latissiums dorsi
- Rectus abdominis
- Hagen-Puiseille equation
- Aim for H'ct 30% to get best balance between O₂ transport and flow
- Flaps have no lymphatic supply therefore are prone to oedema
- Pre-op
- Head and neck
- Investigations as necessary with G&S
- Discussion re: PCA, epidural, catheter etc
- Post-op
- Clinical observation
- Skin
- Colour
- Capillary refil
- Temperature radiolabelled red cells
- Dermoflowmetry
- Laser/USS flowmetry
- Hyperdynamic circulation, normal BP
- H'ct 30%
- U.o. > 1ml/kg/hr
- SpO₂ > 94%
- Flap failure
- Arterial
- Venous
- Thrombosis
- Spasm
- Compression
- Oedema
- Crystalloid Xs
- Haemodilution
- Ischaemic
- Histamine release
- Excess handling
- Vasoconstriction
- Low circulating volume
- Hypothermia
- Pain
- Resp alkalosis
- Hypotension
- Hypovolaemia
- SNS blockade (epidural)
- Profound vasodilatation
- CCF
- Anaesthesia
- Hyperdynamic circulation & maintenance of body temperature are key
- Large bore access, arterial line, CVC & catheter
- Positioning and passive limb movement
- BH/FW to keep core-peripheral gradient <1ᵒC
- Pneumatic compression devices
- Avoid N₂O as long procedures
- Consider TIVA/remifentanil
- Consider extubation to reduce risk of BP surges
- Deflate cuff
- Exchange ETT for LMA
- 0.5mg/kg lignocaine
- Esmolol
- Fluid administration
- High c.o. and peripheral vasodilatation
- Large pulse pressure
- CVP 10-15 cm H₂O
- Colloids and crystalloids (albumin, hypertonic saline ?)
- Inotropes
- Probably best to use dopexamine or dobutamine
- Analgesia
- COX2/NSAIDS avoided
- Opioid, regional or combination
- Regional
- Vasodilatation, but reduced MAP. Probably useful if patient WELL filled.
- Can cause steal phenomenon
- CEACCP
Link:ceaccp.oxfordjournals.org/content/3/2/33.full.pdf