"Occurrence of Symptomatic Hypotension in Patients Undergoing Breast Free Flaps; Is ERAS to blame?"

BACKGROUND Enhanced Recovery After Surgery (ERAS) initiatives improve postoperative function and expidite recovery leading to a decrease in length of stay (LOS). We noted a high rate of postoperative symptomatic hypotension (PoSH) in patients undergoing abdominal free flap breast reconstruction (AFFBR) and wished to explore this observation. METHODS Subjects undergoing AFFBR at our institution from 2013 to 2017 were identified. The ERAS protocol was initiated in 2015 at our hospital, thus 99 patients underwent traditional management (TM) and 138 patients underwent ERAS management. Demographics and perioperative data were collected and analyzed. PoSH was defined as mean arterial pressure (MAP) below 80% of baseline with symptoms requiring evaluation. RESULTS A significantly higher rate of PoSH was observed in the ERAS cohort versus the TM cohort (4% v. 22%, p<0.0001). Patients in the ERAS cohort received significantly less intraoperative IVF (4467 ml v. 3505 ml, p<0.0001) and had a significiantly increased amount of intraoperative time spent with low blood pressure (22% v. 32%, p=0.002). Postoperatively, the ERAS cohort had significantly lower heart rate (HR) (77 vs 88; p<0.0001), MAP (71 vs 78; p<0.0001), with no difference in urine output (UO) or adverse events. CONCLUSION We report that ERAS implementation in AFFBR may result in a unique physiologic state with low MAP, low HR, and normal UO, resulting in PoSH. Awareness of this early postoperative finding can help better direct fluid resuscitation and prevent episodes of symptomatic hypotension.