Anesthesia for ENT cancer and free flap surgery

In my department we do around 40-50 free flap surgeries for ENT cancer per year. Here is the usual process

  • we often but no always do the endoscopy for the diagnostic
  • we often perform  a gastrostomy  before the major surgery
  • the  patient is seen by a nurse who explains the process during the hospitalization and thee major challenges for the patient
  • so do we as anesthetists during our consultation prior to the surgery
  • Since  I can do basic echocardiography, I do it by myself when I have  a doubt
  • I am not a great  believer in iron injections but we check the ferritin and transferrin saturation coefficient prior to the surgery
  • The day before  and the day of the surgery the patient is given gabapentine 600 mg
  • antibiotics : amox/clavulanate for 48h
  • common anesthesia protocol is
    • remifentanil
    • I prefer propofol over  desflurane for the planet and for oncologic concerns bur the level of proof is rather low
    • IV lidocaine
    • ketamine infusion
    • dexamethasone (might be good against cancer ?)
    • regional anesthesia of the limb which gives the flap (sometimes a catheter  stays in place, in this  case we put it the day before the surgery)
    • we put an artery catheter  to monitor  the arterial pressure
    • I always put a BIS or Entropy monitoring  device. We  do not have NIRS devices.
    • a tracheostomy is performed in 99% of cases (we mostly do oropharyngectomies)
    • venous intermittent mechanical compression
    • we try to avoid  central venous catheterism
    • aspirin and 50 ui/kg of heparin is given for the free flap. No rinsing of the vessels, no vasodilatators, no magic bullet. I have  ideas  for free flap optimization but nothing has  proved to be great according  to this answer from Pr Lantieri

    • we use a lot of  noradrenaline/norepinephrine to optimize hemodynamics. I cannot remember precisely on the top of  my head but when I was working in the GI surgery departement there was a publication that giving  noradrenaline to maintain a MAP of 65 mmhg was better for thee gastroplasty than the alleged concerns of a « bad vasoconstriction »
    • I personaly only use Ringer Lactate for fluid maintenance  and i give  red blood cell when the patients is  obviously bleeding, I like the idea that fresh frozen plasma might be good for thee endothelium but there is no proof at all for this idea besides real hemorragic shock (Dr Jakob Stensballes’ work). I try to have  a balance  between restrictive  and liberal fluid maintenance.  I avoid too quick fluid boluses to avoid small capillaries damage. I like to be around 5 ml/kg/h of RL. Other colleaguees give macromolecules, expecially albumin. I very seldom do this (almost no macromolecules)
    • We  are more and more prone to do tranexamic  acid. But I don’t know exactly why I am biaisd against it but I am. I am still afraid of the theombo-embolic risk. Maybee it’s stupid… I need to search the litterature on the subject  of strategies to avoid transfusions in canceer surgery (we do not do EPO)
    • morphine, paracetamol and ketoprofene are given at the end  of the surgery
    • despite good surgeons, these patients often receive transfusions, especially on Day 2 to 5

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