Perioperative fluid resuscitation in free flap breast reconstruction: When is enough enough?

Background: Perioperative liberal fluid resuscitation (LFR) can result in interstitial edema and venous congestion and may be associated with compromised perfusion of free flaps and higher incidence of wound complications. We hypothesized that restrictive intraoperative fluid resuscitation improves flap perfusion and lowers the wound complication rate in free flap breast reconstruction. Methods: Patients undergoing free flap reconstruction of the breast from 2010 to 2018 were retrospectively reviewed. The study population was divided into 2 groups, LFR (7 ml/kg/h) and restrictive fluid resuscitation (RFR) (7 ml/ kg/h). Mean percutaneous oximetry readings of the flap over the first 24 hours were recorded. Primary outcome was development of any wound complication. Secondary outcomes were mean percutaneous oximetry readings within the first 24 hours, length of stay, and development of acute kidney injury. Results: One hundred twenty-six patients were identified, with 41 patients undergoing LFR. The mean fluid received for the RFR group was 5.5 versus 10.2 ml/ kg/h for the LFR group (P 0.001). LFR resulted in a significantly higher incidence of wound complications (76% versus 15%, P 0.001). The mean oximetry readings within 24 hours were significantly lower for the LFR group (41% versus 56%, P 0.001). Urine output intraoperatively and within the first 24 hours was similar between the 2 groups. No patients developed acute kidney injury. Conclusion: RFR in free flap breast reconstruction is associated with increased flap perfusion and lower incidence of wound-related complications and should be considered whenever possible.