Counting the Beats: Is Post-Operative Tachycardia a Reason to Worry in Autologous Free Flap Breast Reconstruction?
J. L. Bernstein, H. Huang, and D. M. Otterburn
New York-Presbyterian - Weill Cornell
Background: Despite intensive intraoperative surveillance and management, many patients who undergo free flap breast reconstruction develop postoperative hemodynamic changes that commonly manifest as tachycardia. While tachycardia is a non-specific finding that often reflects transient physiologic changes, it can cause physician alarm and lead to extensive workup. The purpose of this study is to determine the workup and complications associated with tachycardia in deep inferior epigastric perforator(DIEP) flap patients. Further, we aim to elucidate its incidence and predictive factors in order to raise awareness for this fairly common postoperative phenomenon and to begin to make recommendations for management.
Methods: Patients who underwent DIEP flap reconstruction from 2011-2020 were included in this study. Charts were retrospectively reviewed for patient demographics, lab values, heart rate, and intraoperative factors. Workup of postoperative tachycardia and adverse events were noted. Tachycardia was defined as persistent HR of 100 beats per minute or more for at least 12 consecutive hours following surgery. All patients found to be tachycardic were compared to those who were not tachycardic. All independent variables found significant in univariate analysis were included in a logistic regression model.
Results: 249 patients(439 flaps) were included in this study, with an average length of stay of 3.3 days. 61 patients(24.9%) developed tachycardia postoperatively. Univariate analysis demonstrated significantly higher BMI(OR 1.06, p=0.033), heavier flaps(OR 1.001, p=0.013), greater anesthesia time(OR 1.004, p=0.002), higher rate of diabetes(OR 3.89, p=0.008), and higher preoperative HR(OR 1.06, p<0.001) in tachycardic patients (Table 1). Multivariate regression revealed that preoperative HR(p=0.002) and flap weight(p=0.037) were significant predictors of tachycardia when controlling for all other variables (Table 2). In terms of workup, tachycardic patients were significantly more likely to undergo EKG, duplex ultrasound, CTPE protocol, and specialty consultations(p<0.05). Patients who developed tachycardia were not at higher risk for complications in the immediate postoperative period, including MI and DVT/PE. However, they had a higher incidence of delayed abdominal donor-site healing(16.1% vs. 3.7%, p<0.001) (Table 3).
Conclusion: This work adds to the limited literature in postoperative hemodynamics in free flap reconstruction/plastic surgery and succeeds in providing a comprehensive analysis of postoperative tachycardia. Postoperative tachycardia is common in DIEP flap breast reconstruction. While tachycardic patients tend to receive additional work-up, isolated tachycardia could be considered a relatively benign finding that does not necessarily warrant extensive workup or prolonged inpatient monitoring. This study brings awareness to tachycardia as a prevalent postoperative finding and will help ease physician alarm, decreasing unnecessary and costly workup.
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