title: Comparing the Outcomes of Different Agents to Treat Vasospasm at Microsurgical Anastomosis during the Papaverine Shortage.
abstract: BACKGROUND
  Papaverine remains popular for treating intraoperative vasospasm, but the recent shortage has forced surgeons to trial antispasmodic agents unproven in microsurgery but commonly used in other body areas. During this shortage, the authors have used topical lidocaine and nicardipine to break intraoperative vasospasm. This study aims to analyze the outcomes of these medications on flap complications compared with papaverine.
  
  
  METHODS
  All consecutive free flaps performed for breast reconstruction at a single institution were reviewed. Data collected included patient demographics, comorbidities, complications, and type of antispasmodic agent. Rates of reexploration, complications, and flap salvage were compared between patients receiving antispasmodic agents and matched papaverine controls.
  
  
  RESULTS
  Of the 1087 flaps treated with antispasmodic agents, nicardipine was used on 59 flaps and lidocaine was used on 55 flaps. Patients treated with lidocaine had higher body mass indexes (31.0 kg/m versus 27.4 kg/m; p = 0.001). Patients treated with nicardipine tended to be older (64.0 versus 48.5; p < 0.01) and have a history of hypertension (22.0 percent versus 10.4 percent; p = 0.08) or preoperative irradiation (32.2 percent versus 13.6 percent; p = 0.016) compared with papaverine controls. No differences in the rates of total or partial flap loss, unplanned return to the operating room, or fat necrosis were observed between any of the groups. However, the nicardipine group demonstrated a higher rate of infection (15.3 percent versus 3.4 percent; p = 0.027).
  
  
  CONCLUSIONS
  Substituting lidocaine or nicardipine for papaverine to treat vasospasm did not demonstrate an increased rate of flap loss or return to the operating room, making these medications safe and efficacious alternatives to papaverine.
  
  
  METHODS
  Therapeutic, III.
authors.affiliation: Boston, Mass.; and Amsterdam, The Netherlands.|From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School; and the Department of Plastic Surgery, Vrije Universiteit Medical Center, Vrije Universiteit.
authors.forename: Joseph A
authors.initials: JA
authors.lastname: Ricci
authors.affiliation: Boston, Mass.; and Amsterdam, The Netherlands.|From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School; and the Department of Plastic Surgery, Vrije Universiteit Medical Center, Vrije Universiteit.
authors.forename: Pieter G
authors.initials: PG
authors.lastname: Koolen
authors.affiliation: Boston, Mass.; and Amsterdam, The Netherlands.|From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School; and the Department of Plastic Surgery, Vrije Universiteit Medical Center, Vrije Universiteit.
authors.forename: Jinesh
authors.initials: J
authors.lastname: Shah
authors.affiliation: Boston, Mass.; and Amsterdam, The Netherlands.|From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School; and the Department of Plastic Surgery, Vrije Universiteit Medical Center, Vrije Universiteit.
authors.forename: Adam M
authors.initials: AM
authors.lastname: Tobias
authors.affiliation: Boston, Mass.; and Amsterdam, The Netherlands.|From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School; and the Department of Plastic Surgery, Vrije Universiteit Medical Center, Vrije Universiteit.
authors.forename: Bernard T
authors.initials: BT
authors.lastname: Lee
authors.affiliation: Boston, Mass.; and Amsterdam, The Netherlands.|From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School; and the Department of Plastic Surgery, Vrije Universiteit Medical Center, Vrije Universiteit.
authors.forename: Samuel J
authors.initials: SJ
authors.lastname: Lin
mesh_terms: D000287:Administration, Topical; D000368:Aged; D000714:Anastomosis, Surgical / Q000379:methods*; D057915:Drug Substitution; D005260:Female; D058752:Free Tissue Flaps / Q000098:blood supply* / Q000601:surgery*; D006085:Graft Survival / Q000187:drug effects; D006801:Humans; D007431:Intraoperative Complications / Q000188:drug therapy*; D008012:Lidocaine / Q000627:therapeutic use*; D008866:Microsurgery / Q000379:methods*; D008875:Middle Aged; D009529:Nicardipine / Q000627:therapeutic use*; D017063:Outcome Assessment, Health Care / Q000379:methods*; D010208:Papaverine / Q000600:supply & distribution*; D010276:Parasympatholytics / Q000600:supply & distribution* / Q000627:therapeutic use*; D012189:Retrospective Studies; D014661:Vasoconstriction / Q000187:drug effects*
chemical_list: D010276:Parasympatholytics; D008012:Lidocaine; D009529:Nicardipine; D010208:Papaverine