Archives of plastic surgery anoxi

Archives of plastic surgery temperature curve showing induced hypothermia to 32℃–34℃, from postoperative day three until postoperative day five.

Arch plast surg arch plast surg APS archives of plastic surgery 2234-6163 2234-6171 the korean society of plastic and reconstructive surgeons 27019815 4807178 10.5999/aps.2016.43.2.212 image induced hypothermia: implications for free flap survival chu michael W 1 kulkarni anita R 2 matros evan 3 1division of plastic and reconstructive surgery, indiana university school of medicine, indianapolis, IN, USA. 2Plastic surgery institute of washington, washington, DC, USA. 3Division of plastic and reconstructive surgery, memorial sloan-kettering cancer center, new york, NY, USA.Anoxi


correspondence: michael W chu. Division of plastic and reconstructive surgery, indiana university school of medicine, 545 barnhill drive suite #232, indianapolis, IN 46202, USA. Tel: +1-317-217-3636, fax: +1-317-217-3636, dr.Michael.Chu@gmail.Com 3 2016 18 3 2016 43 2 212 214 15 10 2015 14 12 2015 copyright © 2016 the korean society of plastic and reconstructive surgeons 2016 this is an open access article distributed under the terms of the creative commons attribution non-commercial license ( http://creativecommons.Org/licenses/by-nc/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Plastic surgeons may not be aware that the new advanced cardiac life support (ACLS) guidelines released in 2010 include induced hypothermia as an adjuvant treatment to improve neurologic outcomes following cardiac arrest [ 1].Anoxi induced hypothermia (IH) is thought to mitigate ischemic damage by lowering metabolic demand and preventing noxious byproducts of resuscitation. IH is recommended for patients who experience the return of spontaneous circulation after cardiac arrest, but remain unconscious [ 2]. The hypothermia protocol involves the reduction of body temperature to 32℃–34℃ for 12 to 24 hours, followed by slow rewarming [ 1 2]. However, the use of induced hypothermia in microvascular free tissue transfer has not been studied. We present the case of a patient who underwent IH following free-flap reconstruction of a head and neck cancer defect.

A 69-year-old male with a history of coronary artery disease and three-vessel coronary artery bypass grafting presented with recurrent basal cell carcinoma of the left ear canal.Anoxi he underwent total auriculectomy and lateral temporal bone resection, and the defect was reconstructed with a left vertical rectus abdominis myocutaneous free flap. On the second postoperative day, the patient was found unresponsive in pulseless electrical activity cardiac arrest. The ACLS protocol was initiated, including mechanical ventilation and vasopressors for hemodynamic support. The patient was successfully resuscitated but suffered a second cardiac arrest with ventricular fibrillations. He was resuscitated again but remained unresponsive. Hypothermia was induced, with the patient cooled to 32℃ for 48 hours ( fig. 1). The free flap remained well perfused with an audible doppler signal during the cardiac arrests, vasopressor therapy, hypothermic cooling, and the remainder of his hospitalization ( fig. 2).Anoxi unfortunately, the patient had no meaningful neurologic recovery and magnetic resonance imaging showed diffuse hypoxic brain injury. Therefore, the family elected to withdraw care on postoperative day 10.

The effects of systemic hypothermia on free tissue transfer are not fully understood. Limited animal and human studies have demonstrated conflicting results. Some data have suggested that hypothermia causes decreased perfusion, vasospasm, and thrombosis, while other animal experiments have shown a protective effect of mild hypothermia on free flaps [ 3 4 5]. Clotting enzymes, platelets, and leukocytes function less effectively in a hypothermic setting; however, no reports have been published on the effect of severe hypothermia (34℃) on free flap survival in humans.Anoxi

This is the first reported case of induced hypothermia after free tissue transfer. Plastic surgeons should be aware of ongoing changes to the ACLS algorithm and its impact on perioperative care. In this case, a free tissue transfer remained viable despite induced hypothermia and vasopressors, which is a single data point suggesting that free flaps can tolerate such interventions. However, further research is needed to clarify the effects of hypothermia on free tissue transfer.

No potential conflict of interest relevant to this article was reported. 1 O’connor RE bossaert L arntz HR part 9: acute coronary syndromes: 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations circulation 2010 122 S422 S465 20956257 2 arrich J holzer M havel C hypothermia for neuroprotection in adults after cardiopulmonary resuscitation cochrane database syst rev 2012 9 CD004128 22972067 3 kinnunen I laurikainen E schrey A effect of hypothermia on blood-flow responses in pedicled groin flaps in rats br J plast surg 2002 55 657 663 12550119 4 liu YJ hirsch BP shah AA mild intraoperative hypothermia reduces free tissue transfer thrombosis J reconstr microsurg 2011 27 121 126 20981640 5 thomson JG mine R shah A the effect of core temperature on the success of free tissue transfer J reconstr microsurg 2009 25 411 416 19455487 fig. 1