Perioperative fluid overload increases anastomosis thrombosis in the free TRAM flap used for breast reconstruction

To increase perfusion pressure with vasoactive drugs may be in conflict with the opinion of the reconstructive surgeon who maintains that the systemic administration of vasoactive agents causes vasoconstriction of the pedicle artery and the microvasculature. In free flap surgery, deliberate fluid therapy is used with a minimum of vasoactive drugs. This retrospective study was performed to analyse the perioperative fluid therapy, its effect on hemodynamic parameters and on the outcome of free flap surgery. One hundred and four patients were included in this retrospective study. The muscle sparing free transverse rectus abdominis myocutaneous flap was used for breast reconstruction. Perioperative hemodynamic data was used for this study. Twenty-seven patients had one or two complications requiring return to the operating room (OR). Two cases returned to the OR because of postoperative bleeding; in 11 patients, the anastomosis was revised. The reason for surgery in the latter group was venous stasis, due to thrombus formation at the venous anastomosis. The volume of fluid therapy was significantly higher in patients who returned to the OR due to thrombus formation at the anastomosis. Based on the results of this study, restricted intravenous fluid therapy or guided fluid therapy is recommended. Invasive monitoring such as central venous pressure and invasive arterial monitoring is recommended. Fluid loss should be replaced, and fluid overload should be avoided when the breast is reconstructed using free-tissue transfers

Randomised trial of the fascia iliaca block versus the ‘3-in-1’ block for femoral neck fractures in the emergency department

Introduction: Femoral neck fractures are a common and painful injury. Femoral nerve blocks, and a variant of this technique termed the ‘3-in-1’ block, are often used in this patient group, but their effect is variable. The fascia iliaca compartment block (FIB) has been proposed as an alternative, but the relative effectiveness of the two techniques in the early stages of care is unknown. We therefore compared the FIB versus the 3-in-1 block in a randomised trial conducted in two UK emergency departments. Methods: Parallel, two-group randomised equivalence trial. Consenting patients >18 years with a femoral neck fracture were randomly allocated to receive either a FIB or a 3-in-1 block. The primary outcome was pain measured on a 100 mm visual analogue scale at 60 min. The between-group difference was adjusted for centre, age, sex, fracture type, pre-block analgesia and pre-block pain score. Results: 178 patients were randomised and 162 included in the primary analysis. The mean 100 mm visual analogue pain scale score at 60 min was 38 mm in the FIB arm and 35 mm in the 3-in-1 arm. The adjusted difference between the arms was 3 mm, with a 95% CI (−4.7 to 10.8) that excluded a clinically important difference between the two interventions. Conclusions: FIB is equivalent to the 3-in-1 block for immediate pain relief in adult neck of femur fractures