Download PDF
J Reconstr Microsurg 2011; 27(2): 121-126
DOI: 10.1055/s-0030-1268211
© Thieme Medical Publishers

Mild Intraoperative Hypothermia Reduces Free Tissue Transfer Thrombosis

Yuen-Jong Liu1 , 2 , Brandon P. Hirsch2 , Asad A. Shah2 , 3 , Marjorie A. Reid2 , J. Grant Thomson2
  • 1Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
  • 2Yale University School of Medicine, New Haven, Connecticut
  • 3Duke University School of Medicine, Durham, North Carolina
Further Information

Publication History

Publication Date:
27 October 2010 (online)

    Permissions and Reprints

ABSTRACT

Patients undergoing free tissue transfer are particularly susceptible to hypothermia. The goal was to investigate the impact of intraoperative core body temperature on free flap thrombosis. Two hundred twelve cases of free flap reconstruction at Yale-New Haven Hospital between 1992 and 2008 were reviewed. Free flap thrombosis was defined by complete flap necrosis or direct visualization of arterial or venous thrombosis. Temperature measurements were calibrated to bladder temperatures as measured by Foley catheter sensor. Through logistic regression analysis, maximum and minimum intraoperative temperatures were determined to be statistically significant predictors of free flap thrombosis. The optimal temperature was calculated to be 36.2°C, and maximum intraoperative temperatures between 36.0°C and 36.4°C showed lower thrombosis rates than superwarmed patients (p < 0.03). Therefore, free flap patients should be mildly hypothermic at 36.0°C to 36.4°C, compared with normothermia at 37.5°C, as measured in the bladder. A prospective randomized trial investigating thrombosis rates and intraoperative temperature should be undertaken.

KEYWORDS

Free flap - hypothermia - thrombosis

REFERENCES

  • 1 Salemark L. International survey of current microvascular practices in free tissue transfer and replantation surgery.  Microsurgery. 1991;  12 308-311
    CrossrefPubMedGoogle Scholar
  • 2 Serletti J M, Deuber M A, Guidera P M et al.. Atherosclerosis of the lower extremity and free-tissue reconstruction for limb salvage.  Plast Reconstr Surg. 1995;  96 1136-1144
    CrossrefPubMedGoogle Scholar
  • 3 Rieck B, Mailänder P, Machens H G. Vascular complications after free tissue transfer.  Microsurgery. 1995;  16 400-403
    CrossrefPubMedGoogle Scholar
  • 4 Ozkan O, Ozgentas H E, Islamoglu K, Boztug N, Bigat Z, Dikici M B. Experiences with microsurgical tissue transfers in elderly patients.  Microsurgery. 2005;  25 390-395
    CrossrefPubMedGoogle Scholar
  • 5 Genden E M, Rinaldo A, Suárez C, Wei W I, Bradley P J, Ferlito A. Complications of free flap transfers for head and neck reconstruction following cancer resection.  Oral Oncol. 2004;  40 979-984
    CrossrefPubMedGoogle Scholar
  • 6 Okazaki M, Asato H, Takushima A et al.. Analysis of salvage treatments following the failure of free flap transfer caused by vascular thrombosis in reconstruction for head and neck cancer.  Plast Reconstr Surg. 2007;  119 1223-1232
    CrossrefPubMedGoogle Scholar
  • 7 Doufas A G, Sessler D I. Physiology and clinical relevance of induced hypothermia.  Neurocrit Care. 2004;  1 489-498
    CrossrefPubMedGoogle Scholar
  • 8 Bui D T, Cordeiro P G, Hu Q Y, Disa J J, Pusic A, Mehrara B J. Free flap reexploration: indications, treatment, and outcomes in 1193 free flaps.  Plast Reconstr Surg. 2007;  119 2092-2100
    CrossrefPubMedGoogle Scholar
  • 9 Thomson J G, Mine R, Shah A et al.. The effect of core temperature on the success of free tissue transfer.  J Reconstr Microsurg. 2009;  25 411-416
    Article in Thieme ConnectPubMedGoogle Scholar
  • 10 Ilsley A H, Rutten A J, Runciman W B. An evaluation of body temperature measurement.  Anaesth Intensive Care. 1983;  11 31-39
    PubMedGoogle Scholar
  • 11 Fulbrook P. Core temperature measurement in adults: a literature review.  J Adv Nurs. 1993;  18 1451-1460
    CrossrefPubMedGoogle Scholar
  • 12 Hooper V D, Andrews J O. Accuracy of noninvasive core temperature measurement in acutely ill adults: the state of the science.  Biol Res Nurs. 2006;  8 24-34
    CrossrefPubMedGoogle Scholar
  • 13 Byrne C, Lim C L. The ingestible telemetric body core temperature sensor: a review of validity and exercise applications.  Br J Sports Med. 2007;  41 126-133
    CrossrefPubMedGoogle Scholar
  • 14 Kolka M, Levine L, Stephenson L. Use of an ingestible telemetry sensor to measure core temperature under chemical protective clothing.  J Therm Biol. 1997;  22 343-349
    CrossrefPubMedGoogle Scholar
  • 15 Longfield J N, Morris M J, Moran K A, Kragh Jr J F, Wolf R, Baskin T W. Community meetings for emergency research community consultation.  Crit Care Med. 2008;  36 731-736
    CrossrefPubMedGoogle Scholar
  • 16 Moran J L, Peter J V, Solomon P J et al.. Tympanic temperature measurements: are they reliable in the critically ill? A clinical study of measures of agreement.  Crit Care Med. 2007;  35 155-164
    CrossrefPubMedGoogle Scholar
  • 17 Camboni D, Philipp A, Schebesch K M, Schmid C. Accuracy of core temperature measurement in deep hypothermic circulatory arrest.  Interact Cardiovasc Thorac Surg. 2008;  7 922-924
    CrossrefPubMedGoogle Scholar
  • 18 Lim C L, Byrne C, Lee J K. Human thermoregulation and measurement of body temperature in exercise and clinical settings.  Ann Acad Med Singapore. 2008;  37 347-353
    CrossrefPubMedGoogle Scholar
  • 19 Dobson A J. An Introduction to Generalized Linear Models. Chapman & Hall/CRC Texts in Statistical Science Series. 2nd ed. Boca Raton, FL: Chapman & Hall/CRC; 2002
    Google Scholar
  • 20 McCullagh P, Nelder J A. Generalized Linear Models. 2nd ed. London, New York: Chapman & Hall/CRC; 1989
    Google Scholar
  • 21 Collett D. Modelling Binary Data. 2nd ed. Boca Raton, FL: Chapman & Hall/CRC; 2003
    Google Scholar
  • 22 Schusterman M A, Miller M J, Reece G P, Kroll S S, Marchi M, Goepfert H. A single center's experience with 308 free flaps for repair of head and neck cancer defects.  Plast Reconstr Surg. 1994;  93 472-478 discussion 479-480
    CrossrefPubMedGoogle Scholar
  • 23 Jones N F, Johnson J T, Shestak K C, Myers E N, Swartz W M. Microsurgical reconstruction of the head and neck: interdisciplinary collaboration between head and neck surgeons and plastic surgeons in 305 cases.  Ann Plast Surg. 1996;  36 37-43
    CrossrefPubMedGoogle Scholar
  • 24 Hess J R, Brohi K, Dutton R P et al.. The coagulopathy of trauma: a review of mechanisms.  J Trauma. 2008;  65 748-754
    CrossrefPubMedGoogle Scholar
  • 25 Michelson A D, Barnard M R, Khuri S F, Rohrer M J, MacGregor H, Valeri C R. The effects of aspirin and hypothermia on platelet function in vivo.  Br J Haematol. 1999;  104 64-68
    CrossrefPubMedGoogle Scholar
  • 26 Valeri C R, MacGregor H, Cassidy G, Tinney R, Pompei F. Effects of temperature on bleeding time and clotting time in normal male and female volunteers.  Crit Care Med. 1995;  23 698-704
    CrossrefPubMedGoogle Scholar
  • 27 Wolberg A S, Meng Z H, Monroe III D M, Hoffman M. A systematic evaluation of the effect of temperature on coagulation enzyme activity and platelet function.  J Trauma. 2004;  56 1221-1228
    CrossrefPubMedGoogle Scholar
  • 28 Kermode J C, Zheng Q, Milner E P. Marked temperature dependence of the platelet calcium signal induced by human von Willebrand factor.  Blood. 1999;  94 199-207
    PubMedGoogle Scholar
  • 29 Reed II R L, Bracey Jr A W, Hudson J D, Miller T A, Fischer R P. Hypothermia and blood coagulation: dissociation between enzyme activity and clotting factor levels.  Circ Shock. 1990;  32 141-152
    PubMedGoogle Scholar
  • 30 Rohrer M J, Natale A M. Effect of hypothermia on the coagulation cascade.  Crit Care Med. 1992;  20 1402-1405
    CrossrefPubMedGoogle Scholar
  • 31 Johnston T D, Chen Y, Reed II R L. Functional equivalence of hypothermia to specific clotting factor deficiencies.  J Trauma. 1994;  37 413-417
    CrossrefPubMedGoogle Scholar
  • 32 Kroll S S, Schusterman M A, Reece G P et al.. Timing of pedicle thrombosis and flap loss after free-tissue transfer.  Plast Reconstr Surg. 1996;  98 1230-1233
    CrossrefPubMedGoogle Scholar
  • 33 Khouri R K, Cooley B C, Kunselman A R et al.. A prospective study of microvascular free-flap surgery and outcome.  Plast Reconstr Surg. 1998;  102 711-721
    Google Scholar
  • 34 Chen C M, Ashjian P, Disa J J, Cordeiro P G, Pusic A L, Mehrara B J. Is the use of intraoperative heparin safe?.  Plast Reconstr Surg. 2008;  121 49e-53e
    CrossrefPubMedGoogle Scholar
  • 35 Martini W Z. Coagulopathy by hypothermia and acidosis: mechanisms of thrombin generation and fibrinogen availability.  J Trauma. 2009;  67 202-208 discussion 208-209
    CrossrefPubMedGoogle Scholar
  • 36 Martini W Z, Pusateri A E, Uscilowicz J M, Delgado A V, Holcomb J B. Independent contributions of hypothermia and acidosis to coagulopathy in swine.  J Trauma. 2005;  58 1002-1009 discussion 1009-1010
    CrossrefPubMedGoogle Scholar
  • 37 Jokuszies A, Niederbichler A, Meyer-Marcotty M, Lahoda L U, Reimers K, Vogt P M. Influence of transendothelial mechanisms on microcirculation: consequences for reperfusion injury after free flap transfer. Previous, current, and future aspects.  J Reconstr Microsurg. 2006;  22 513-518
    Article in Thieme ConnectPubMedGoogle Scholar
  • 38 Kelly J L, Eadie P A, Orr D, Al-Rawi M, O'Donnell M, Lawlor D. Prospective evaluation of outcome measures in free-flap surgery.  J Reconstr Microsurg. 2004;  20 435-438 discussion 439
    Article in Thieme ConnectPubMedGoogle Scholar
  • 39 Wang H E, Callaway C W, Peitzman A B, Tisherman S A. Admission hypothermia and outcome after major trauma.  Crit Care Med. 2005;  33 1296-1301
    CrossrefPubMedGoogle Scholar
  • 40 Martin R S, Kilgo P D, Miller P R, Hoth J J, Meredith J W, Chang M C. Injury-associated hypothermia: an analysis of the 2004 National Trauma Data Bank.  Shock. 2005;  24 114-118
    CrossrefPubMedGoogle Scholar
  • 41 Aitken L M, Hendrikz J K, Dulhunty J M, Rudd M J. Hypothermia and associated outcomes in seriously injured trauma patients in a predominantly sub-tropical climate.  Resuscitation. 2009;  80 217-223
    CrossrefPubMedGoogle Scholar
  • 42 Frank S M, Beattie C, Christopherson R The Perioperative Ischemia Randomized Anesthesia Trial Study Group et al. Unintentional hypothermia is associated with postoperative myocardial ischemia.  Anesthesiology. 1993;  78 468-476
    CrossrefPubMedGoogle Scholar
  • 43 Frank S M, Fleisher L A, Breslow M J et al.. Perioperative maintenance of normothermia reduces the incidence of morbid cardiac events. A randomized clinical trial.  JAMA. 1997;  277 1127-1134
    CrossrefPubMedGoogle Scholar
  • 44 Kurz A, Sessler D I, Lenhardt R. Study of Wound Infection and Temperature Group . Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization.  N Engl J Med. 1996;  334 1209-1215
    CrossrefPubMedGoogle Scholar
  • 45 Schmied H, Kurz A, Sessler D I, Kozek S, Reiter A. Mild hypothermia increases blood loss and transfusion requirements during total hip arthroplasty.  Lancet. 1996;  347 289-292
    CrossrefPubMedGoogle Scholar
  • 46 Nathan H J, Parlea L, Dupuis J Y et al.. Safety of deliberate intraoperative and postoperative hypothermia for patients undergoing coronary artery surgery: a randomized trial.  J Thorac Cardiovasc Surg. 2004;  127 1270-1275
    CrossrefPubMedGoogle Scholar
  • 47 Kimme P, Fridrikssen S, Engdahl O, Hillman J, Vegfors M, Sjöberg F. Moderate hypothermia for 359 operations to clip cerebral aneurysms.  Br J Anaesth. 2004;  93 343-347
    CrossrefPubMedGoogle Scholar
  • 48 Harrington D K, Lilley J P, Rooney S J, Bonser R S. Nonneurologic morbidity and profound hypothermia in aortic surgery.  Ann Thorac Surg. 2004;  78 596-601
    CrossrefPubMedGoogle Scholar

J. Grant ThomsonM.D. M.Sc. F.R.C.S.C. 

Section of Plastic and Reconstructive Surgery, Yale University School of Medicine

P.O. Box 208041, New Haven, CT 06520-8041

Email: grant.thomson@yale.edu

      >