title: Perioperative hemodynamics in free flap breast reconstruction: incidence, predictors, and management of tachycardia.
abstract: BACKGROUND
  The physiologic and hemodynamic changes occurring after abdominally based free flap breast reconstruction have not been well described. In this study, we examine perioperative circulatory and physiologic changes in an effort to identify risk factors and complications associated with postoperative tachycardia.
  
  
  METHODS
  A retrospective review of all immediate abdominal free flaps performed by the senior author (J.M.S.) between 2005 and 2009 was performed. End points of interest included patient demographics, comorbidities, preoperative and postoperative heart rate (HR), mean arterial pressure, operating room fluid, pain score, urine output, and preoperative and postoperative hemoglobin. We define tachycardia as a sustained HR of 100 beats per minute or greater. Tachycardic patients were compared to patients with normal sinus rhythm.
  
  
  RESULTS
  In 237 patients, 371 flaps were identified (103 unilateral and 268 bilateral). There was a 36% overall incidence of tachycardia, with a 20% and 47% incidence in unilateral and bilateral flaps, respectively (P<0.0001). Preoperative HR, operating room fluid, estimated blood loss, and bilateral reconstruction predicted postoperative tachycardia. Regression analysis revealed that preoperative HR and internal mammary artery predicted tachycardia in unilateral flaps, whereas preoperative HR, operative time, and estimated blood loss predicted tachycardia in bilateral flaps. We found higher rates of wound healing complications and delayed venous thrombosis in tachycardic patients.
  
  
  CONCLUSIONS
  Patient and perioperative factors associated with tachycardia include preoperative HR, bilateral reconstruction, recipient artery choice, and operative time. These results suggest that postoperative tachycardia may be associated with perfusion-related complications such as delayed wound healing and thrombosis. Preoperative assessment should include an evaluation of patient risk factors for postoperative tachycardia.
authors.affiliation: Division of Plastic Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA. John.Fischer2@uphs.upenn.edu
authors.forename: John P
authors.initials: JP
authors.lastname: Fischer
authors.forename: Jonas A
authors.initials: JA
authors.lastname: Nelson
authors.forename: Michael N
authors.initials: MN
authors.lastname: Mirzabeigi
authors.forename: Joseph M
authors.initials: JM
authors.lastname: Serletti
authors.forename: Suhail
authors.initials: S
authors.lastname: Kanchwala
mesh_terms: D000328:Adult; D016022:Case-Control Studies; D005260:Female; D058752:Free Tissue Flaps; D006439:Hemodynamics; D006801:Humans; D015994:Incidence; D016015:Logistic Models; D016462:Mammaplasty / Q000379:methods*; D008875:Middle Aged; D059035:Perioperative Period; D011183:Postoperative Complications / Q000453:epidemiology / Q000209:etiology* / Q000628:therapy; D012189:Retrospective Studies; D012307:Risk Factors; D013610:Tachycardia / Q000453:epidemiology / Q000209:etiology* / Q000628:therapy