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The effect of timing of intraoperative vasopressor use on failure of digital replantation
Floris V. Raasveld, MD
1; Yannick AJ Hoftiezer, MD
2; Karan Amin, BA
3; Krystle R. Tuaņo, MD
4; Abhiram R. Bhashyam, MD PhD
3; Neal C. Chen, MD
3; Kyle R. Eberlin, MD
11Massachusetts General Hospital/Harvard Medical School, Boston, MA; 2Massachusetts General Hospital/ Harvard Medical School, Boston, MA; 3Massachusetts General Hospital, Boston, MA; 4Massachusetts General Hospital | Harvard Medical School, Boston, MA
Introduction: Amongst several factors, the intraoperative timing of vasopressor use has been suggested to affect the success rate of digital replantation. Therefore, we aimed to analyze factors associated with digital replantation failure, including the timing of intraoperative vasopressor use, to further understand the potential impact on the success rate of replantation.
Methods: In this retrospective matched control study focusing on digital replantation, participants were included into two categories: those who experienced a successful replantation and those had a failed replantation and underwent secondary amputation. Initially, we included all patients who underwent digital replantation followed by secondary amputation at a tertiary care center from 2009 to 2020. Then, a control cohort was established, comprising patients who achieved successful replantation, with demographics and sample size matched to those of the failure group. Chart review was conducted of patient factors and surgery characteristics. Data on the use of vasopressors (epinephrine, ephedrine, or phenylephrine) and details about intraoperative timing with regard to tourniquet deflation were collected from surgery and anesthesiology reports. Multivariable analysis was conducted to assess for factors independently associated with secondary amputation following digital replantation.
Results: In this study, 183 replanted digits from 126 patients who sustained traumatic digital amputations were analyzed. Among them, 63 patients (50.0%) had successful digital replantation, and 63 patients (50.0%) experienced failed digital replantation. Following multivariable analysis, crush (OR 3.11, p=0.045) and avulsion injuries (OR 3.55, p=0.015) were independently associated with replantation failure, as were smoking (OR 3.45, p=008) and development of infection after replantation (OR 4.99, p=0.033). Whether patients hada vasopressors administered or not during replantation surgery did not affect the risk of replantation failure. However, among the 51 patients (40.9%) who received intraoperative vasopressors, more patients who received a vasopressor after tourniquet deflation (n=17/30, 56.7%) experienced replantation failure (OR=1.9, p=0.025), compared to patients who received vasopressors before tourniquet deflation (n=5/21, 23.8%).
Discussion: In this retrospective matched control study examining digital replantation success versus failure, we found that crush and avulsion injuries, as well as smoking increase the risk of replantation failure. Additionally, patients who experienced postoperative infections were more likely to undergo secondary amputation. Furthermore, the intraoperative use of vasopressors after tourniquet deflation, rather than before tourniquet deflation, may affect the risk of replantation failure, and should be avoided when possible. These findings may contribute to our understanding of the risks and prevention of secondary amputation after digital replantation.
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