Association Of Intraoperative Vasopressor Use On Intraoperative Vasospasm In Replantation Surgery
Xiya Ma, MD, MSc1; Linda Zhu2; David Wang, BSc2; Ariane Gelinas3; Jessie Li4; Bruno Mastropasqua, MD4; Jenny Lin, MD, PhD5
1University of Montreal, Montreal, QC, Canada; 2McGill University, Montreal, QC, Canada; 3Universite de Sherbrooke, Sherbrooke, QC, Canada; 4Universite de Montreal, Montreal, QC, Canada; 5Plastic Surgery, Research Centre CHU-Sainte-Justine, University of Montreal, Montreal, QC, Canada
Introduction: Replantation surgery relies on successfully performing vascular microanatomoses to reconnect the amputated digit or limb to the patientís body, and are frequently performed under general anesthesia. Hypotension at induction and during surgery is often managed using intraoperative vasopressors, but their impact on the risk of replant failure due to vasoconstriction has yet to be studied in a large cohort. The objective of this study is to characterize the effect of intraoperative vasopressor use on the incidence of vasospasm and digit or limb survival in replantation surgery.
Material and Methods: All patients who have undergone replantation or revascularization surgery at the Quebec provincial replantation program from April 2004 to June 2021 were reviewed. Data on demographics, injury characteristics, intraoperative use of vasopressors, heparin and topical vasodilators, postoperative use of chlorpromazine and heparin, as well as complications and replant survival were collected. Descriptive statistics and multivariate logistic regression with multicollinearity verification check were performed.
Results: A total of 1320 upper limb replants were included, with 772 receiving vasopressors and 548 without. While the vasopressor group was significantly older (p< 0.001) with a higher incidence of cardiovascular disease (p< 0.001), intraoperative vasospasm (p= 0.276) and replant survival (p= 0.141) were comparable between the two groups. Multivariate logistic regression showed that avulsion injuries (p= 0.017), presence of post-operative complications (p< 0.001), return to OR within 24 hours of the initial surgery (p= 0.006), and intraoperative vasospasm (p= 0.004) have lower odds of replant survival. However, intraoperative vasopressor use itself was not significantly associated with worse outcomes (p= 0.553). Moreover, intraoperative vasospasm was not associated with intraoperative vasopressor use (p=0.673), but it was significantly associated with post-operative complications (p< 0.001), use of intraoperative heparin (p< 0.001) and topical vasodilators (p= 0.001). A subanalysis of 333 replants examining the timing of vasopressor administration relative to tourniquet use did not show any significant difference in replant survival regardless of when the medication was given (p=0.751). Conclusions: This is the largest retrospective cohort study demonstrating that intraoperative use of vasopressors is not associated with replant survival, regardless of the timing of its administration. However, intraoperative vasospasm, for which the etiology is likely multifactorial, increases the odds of replant failure.
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