Microvascular flap surgery is a widely acknowledged procedure for significant defect reconstruction. Multiple flap complication risk factors have been identified, yet there are limited data on laboratory biomarkers for the prediction of flap loss. The controlling nutritional status (CONUT) score has demonstrated good postoperative outcome assessment ability in diverse surgical populations. We aim to assess the predictive value of the CONUT score for complications in microvascular flap surgery. This prospective cohort study includes 72 adult patients undergoing elective microvascular flap surgery. Preoperative blood draws for analysis of full blood count, total plasma cholesterol, and albumin concentrations were collected on the day of surgery before crystalloid infusion. Postoperative data on flap complications and duration of hospitalization were obtained. The overall complication rate was 15.2%. True flap loss with vascular compromise occurred in 5.6%. No differences in flap complications were found between different areas of reconstruction, anatomical flap types, or indications for surgery. Obesity was more common in patients with flap complications (p = 0.01). The CONUT score had an AUC of 0.813 (0.659–0.967, p = 0.012) for predicting complications other than true flap loss due to vascular compromise. A CONUT score > 2 was indicated as optimal during cut-off analysis (p = 0.022). Patients with flap complications had a longer duration of hospitalization (13.55, 10.99–16.11 vs. 25.38, 14.82–35.93; p = 0.004). Our findings indicate that the CONUT score has considerable predictive value in microvascular flap surgery.

Complex microvascular techniques and in-depth knowledge of blood rheology and microanastomosis function are required for success in microvascular flap surgery. Substantial progress has been achieved in preventing complications, but the rate of flap loss is still significant and can have significant adverse effects on the patient. Flap thrombosis, flap hematoma, and flap loss are the most frequent and severe major surgical complications. Advances in understanding the pathophysiology of different flap complications, the use of preoperative risk assessment and new treatment concepts could improve the perioperative care of microvascular flap surgery patients. Our aim was to outline novel avenues for best practice and provide an outlook for further research of anesthesia and perioperative care concepts in microvascular flap surgery.

Background: Microvascular flap surgery has become a routine option for defect correction. The role of von Willebrand factor antigen (VWF:Ag) in the pathophysiology of flap complications is not fully understood. We aim to investigate the predictive value of VWF:Ag for microvascular flap complications and explore the relationship between chronic inflammation and VWF:Ag. Methods: This prospective cohort study included 88 adult patients undergoing elective microvascular flap surgery. Preoperative blood draws were collected on the day of surgery before initiation of crystalloids. The plasma concentration of VWF:Ag as well as albumin, neutrophil-to-lymphocyte ratio (NLR), interleukin-6, and fibrinogen were determined. Results: The overall complication rate was 27.3%, and true flap loss occurred in 11.4%. VWF:Ag levels were higher in true flap loss when compared to patients without complications (217.94 IU/dL [137.27–298.45] vs. 114.14 [95.67–132.71], p = 0.001). Regression analysis revealed the association between VWF:Ag and true flap loss at the cutoff of 163.73 IU/dL (OR 70.22 [10.74–485.28], p = 0.043). Increased VWF:Ag concentrations were linked to increases in plasma fibrinogen (p < 0.001), C-reactive protein (p < 0.001), interleukin-6 (p = 0.032), and NLR (p = 0.019). Conclusions: Preoperative plasma VWF:Ag concentration is linked to biomarkers of inflammation and may be valuable in predicting complications in microvascular flap surgery.

Dexmedetomidine prolongs the duration of regional block while its systemic sedative effect when administered perineurally is unknown. We aimed to evaluate the systemic sedative effect of perineural dexmedetomidine in patients after axillary brachial plexus block (ABPB). This single-blinded prospective randomized control trial included 80 patients undergoing wrist surgery receiving ABPB. Patients were randomized into two groups – Control group (CG, N = 40) and dexmedetomidine group (DG, N = 40). Both groups received ABPB with 20 ml of 0.5% Bupivacaine and 10 ml of 2% Lidocaine. Additionally, patients in DG received 100 mcg of dexmedetomidine perineurally. Depth of sedation was evaluated using Narcontrend Index (NI) and Ramsay Sedation Scale (RSS) immediately after ABPB and in several time points up to 120 min. Duration of block as well as patient satisfaction with sedation was evaluated using a postoperative survey. Our results showed that NI and RSS statistically differed between groups, presenting a deeper level of sedation during the first 90 min in DG compared to controls, P < 0.001. In the first 10 to 60 min after ABPB the median RSS was 4 (IQR within median) and median NI was 60 (IQR 44–80) in DG group, in contrast to CG patients where median RSS was 2 (IQR within median) and median NI was 97 (IQR 96–98) throughout surgery. The level of sedation became equal in both groups 90 and 120 min after ABPB when the median NI value was 98 (97–99) in DG and 97.5 (97–98) in CG, P = 0.276, and the median RSS was 2 (IQR within median) in both groups, P = 0.128. No significant intergroup differences in hemodynamic or respiratory parameters were found. Patients in DG expressed satisfaction with sedation and 86.5% noted that the sensation was similar to ordinary sleep. In DG mean duration of motor block was 13.5 ± 2.1 h and sensory block was 12.7 ± 2.8 h which was significantly longer compared to CG 6.3 ± 1.5 h, P < 0.001 and 6.4 ± 1.8 h, P < 0.001. We found that beside prolongation of analgesia, perineural administration of dexmedetomidine might provide rather safe and comfortable sedation with no significant effect on hemodynamic or respiratory stability and yields a high level of patient satisfaction.

Introduction: The aim was to investigate the impact of different ventilator strategies (non-invasive ventilation (NIV); invasive MV with tracheal tube (TT) and with tracheostomy (TS) on outcomes (mortality and intensive care unit (ICU) length of stay) in patients with COVID-19. We also assessed the impact of timing of percutaneous tracheostomy and other risk factors on mortality. Methods: The retrospective cohort included 868 patients with severe COVID-19. Demographics, MV parameters and duration, and ICU mortality were collected. Results: MV was provided in 530 (61.1%) patients, divided into three groups: NIV (n = 139), TT (n = 313), and TS (n = 78). Prevalence of tracheostomy was 14.7%, and ICU mortality was 90.4%, 60.2%, and 30.2% in TT, TS, and NIV groups, respectively (p < 0.001). Tracheostomy increased the chances of survival and being discharged from ICU (OR 6.3, p < 0.001) despite prolonging ICU stay compared to the TT group (22.2 days vs. 10.7 days, p < 0.001) without differences in survival rates between early and late tracheostomy. Patients who only received invasive MV had higher odds of survival compared to those receiving NIV in ICU prior to invasive MV (OR 2.7, p = 0.001). The odds of death increased with age (OR 1.032, p < 0.001), obesity (1.58, p = 0.041), chronic renal disease (1.57, p = 0.019), sepsis (2.8, p < 0.001), acute kidney injury (1.7, p = 0.049), multiple organ dysfunction (3.2, p < 0.001), and ARDS (3.3, p < 0.001). Conclusions: Percutaneous tracheostomy compared to MV via TT significantly increased survival and the rate of discharge from ICU, without differences between early or late tracheostomy.

Microvascular flap surgery is a widely used procedure for the reconstruction of various defects. Data on laboratory biomarkers for the prediction of flap complications are currently limited. We aimed to investigate the link between preoperative fibrinogen-to-albumin ratio (FAR) and various flap complications. This prospective cohort study included 130 adult patients who underwent elective microvascular flap surgery. Preoperative blood samples for the analysis of plasma fibrinogen (g/L) and albumin (g/L) were collected on the day of surgery before initiating crystalloid infusion. Post-operative data on various flap complications were obtained. The overall complication rate was 17.7% with true flap loss occurring in 5.4%. Binary logistic regression revealed that the patients with FAR<0.08 and FAR0.10 had increased odds of minor flap complications (OR 5.47 [1.33-22.50], p=0.019). Patients with FAR0.10 also had increased odds of any flap complications (OR 3.09 [1.08-8.81], p=0.035), implying a U-shaped link. Assessment of FAR to estimate the risk of complications has considerable predictive value in microvascular flap surgery. Patients undergoing this surgery can be evaluated to predict their nutrition and coagulation risks and optimize decision-making in their perioperative care.