J Reconstr Microsurg 2021; 37(05): 453-557
DOI: 10.1055/s-0040-1719048
Original Article

The False Positive Rate of Transcutaneous Tissue Oximetry Alarms in Microvascular Breast Reconstruction Rises after 24 Hours

Phu C. Tran
1   Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
,
Will DeBrock
1   Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
,
Mary E. Lester
1   Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
,
Brett C. Hartman
1   Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
,
Juan Socas
1   Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
,
Aladdin H. Hassanein
1   Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
› Author Affiliations

Abstract

Background Transcutaneous tissue oximetry is widely used as an adjunct for postoperative monitoring after microvascular breast reconstruction. Despite a high sensitivity at detecting vascular issues, alarms from probe malfunctions/errors can generate unnecessary nursing calls, concerns, and evaluations. The purpose of this study is to analyze the false positive rate of transcutaneous tissue oximetry monitoring over the postoperative period and assess changes in its utility over time.

Methods Consecutive patients undergoing microvascular breast reconstruction at our institution with monitoring using transcutaneous tissue oximetry were assessed between 2017 and 2019. Variables of interest were transcutaneous tissue oximetry alarms, flap loss, re-exploration, and salvage rates.

Results The study included 175 patients (286 flaps). The flap loss rate was 1.0% (3/286). Twelve patients (6.8%) required re-exploration, with 9 patients found to have actual flap compromise (all within 24 hours). The salvage rate was 67.0%. The 3 takebacks after 24 hours were for bleeding concerns rather than anastomotic problems. Within the initial 24-hour postoperative period, 43 tissue oximetry alarms triggered nursing calls; 7 alarms (16.2%) were confirmed to be for flap issues secondary to vascular compromise. After 24 hours, none of the 44 alarms were associated with flap compromise. The false positive rate within 24 hours was 83.7% (36/43) compared with 100% (44/44) after 24 hours (p = 0.01).

Conclusion The transcutaneous tissue oximetry false positive rate significantly rises after 24 hours. The benefit may not outweigh the concerns, labor, and effort that results from alarms after postoperative day 1. We recommend considering discontinuing this monitoring after 24 hours.



Publication History

Received: 17 June 2020

Accepted: 20 September 2020

Article published online:
31 October 2020

© 2020. Thieme. All rights reserved.

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  • References

  • 1 Panchal H, Matros E. Current trends in postmastectomy breast reconstruction. Plast Reconstr Surg 2017; 140 (5S Advances in Breast Reconstruction): 7S-13S
  • 2 Albornoz CR, Bach PB, Mehrara BJ. et al. A paradigm shift in U.S. breast reconstruction: increasing implant rates. Plast Reconstr Surg 2013; 131 (01) 15-23
  • 3 Bellamy JL, Mundinger GS, Flores JM. et al. Do adjunctive flap-monitoring technologies impact clinical decision making? An analysis of microsurgeon preferences and behavior by body region. Plast Reconstr Surg 2015; 135 (03) 883-892
  • 4 Lin SJ, Nguyen MD, Chen C. et al. Tissue oximetry monitoring in microsurgical breast reconstruction decreases flap loss and improves rate of flap salvage. Plast Reconstr Surg 2011; 127 (03) 1080-1085
  • 5 Ricci JA, Vargas CR, Ho OA, Lin SJ, Tobias AM, Lee BT. Evaluating the use of tissue oximetry to decrease intensive unit monitoring for free flap breast reconstruction. Ann Plast Surg 2017; 79 (01) 42-46
  • 6 Lohman RF, Langevin CJ, Bozkurt M, Kundu N, Djohan R. A prospective analysis of free flap monitoring techniques: physical examination, external Doppler, implantable Doppler, and tissue oximetry. J Reconstr Microsurg 2013; 29 (01) 51-56
  • 7 Keller A. Noninvasive tissue oximetry for flap monitoring: an initial study. J Reconstr Microsurg 2007; 23 (04) 189-197
  • 8 Chae MP, Rozen WM, Whitaker IS. et al. Current evidence for postoperative monitoring of microvascular free flaps: a systematic review. Ann Plast Surg 2015; 74 (05) 621-632
  • 9 Keller A. A new diagnostic algorithm for early prediction of vascular compromise in 208 microsurgical flaps using tissue oxygen saturation measurements. Ann Plast Surg 2009; 62 (05) 538-543
  • 10 Repez A, Oroszy D, Arnez ZM. Continuous postoperative monitoring of cutaneous free flaps using near infrared spectroscopy. J Plast Reconstr Aesthet Surg 2008; 61 (01) 71-77
  • 11 Wu GJ, Loewenstein SN, Mailey BA, Sasor S, Cook J, Hassanein AH. Unique complications of venous anastomotic couplers: a systematic review of the literature. J Reconstr Microsurg 2020; 36 (06) 403-411
  • 12 Pittelkow EM, DeBrock WC, McLaughlin BE. et al. Preoperatively identified sarcopenia leads to increased postoperative complications, hospital and ICU length of stay in autologous microsurgical breast reconstruction. J Reconstr Microsurg 2020; 36 (01) 59-63
  • 13 Spera LJ, Cook JA, Dolejs S, Fisher C, Lester ME, Hassanein AH. Perioperative use of antiestrogen therapies in breast reconstruction: a systematic review and treatment recommendations. Ann Plast Surg 2020; 85 (04) 448-455
  • 14 Fadavi D, Haley A, Khavanin N. et al. Postoperative free flap breast protocol optimizing resources and patient safety. J Reconstr Microsurg 2020; 36 (05) 379-385
  • 15 Steele MH. Three-year experience using near infrared spectroscopy tissue oximetry monitoring of free tissue transfers. Ann Plast Surg 2011; 66 (05) 540-545
  • 16 Ricci JA, Vargas CR, Lin SJ, Tobias AM, Taghinia AH, Lee BT. A novel free flap monitoring system using tissue oximetry with text message alerts. J Reconstr Microsurg 2016; 32 (05) 415-420
  • 17 Pelletier A, Tseng C, Agarwal S, Park J, Song D. Cost analysis of near-infrared spectroscopy tissue oximetry for monitoring autologous free tissue breast reconstruction. J Reconstr Microsurg 2011; 27 (08) 487-494
  • 18 Yuen JC. Comparison between near-infrared spectroscopy and laser Doppler flowmetry in free flap adjunct monitoring. Plast Reconstr Surg Glob Open 2019; 7 (08) 109
  • 19 Koolen PG, Vargas CR, Ho OA. et al. Does increased experience with tissue oximetry monitoring in microsurgical breast reconstruction lead to decreased flap loss? The learning effect. Plast Reconstr Surg 2016; 137 (04) 1093-1101
  • 20 Salgarello M, Pagliara D, Rossi M, Visconti G, Barone-Adesi L. Postoperative monitoring of free DIEP flap in breast reconstruction with near-infrared spectroscopy: variables affecting the regional oxygen saturation. J Reconstr Microsurg 2018; 34 (06) 383-388
  • 21 Saad N, Wang H, Karamanos E. Tissue oximetry readings accurately predict late complications in patients undergoing free flap breast reconstruction: exploring the optimal cut point value. J Reconstr Microsurg 2020; 36 (07) 534-540
  • 22 Carruthers KH, Tiwari P, Yoshida S, Kocak E. Inpatient flap monitoring after deep inferior epigastric artery perforator flap breast reconstruction: how long is long enough?. J Reconstr Microsurg 2019; 35 (09) 682-687
  • 23 Baltodano PA, Schalet G, Rezak K. et al. Early discontinuation of breast free flap monitoring: a strategy driven by national data. Plast Reconstr Surg 2020; 146 (03) 258e-264e
  • 24 Kroll SS, Schusterman MA, Reece GP. et al. Timing of pedicle thrombosis and flap loss after free-tissue transfer. Plast Reconstr Surg 1996; 98 (07) 1230-1233
  • 25 Tran NV, Buchel EW, Convery PA. Microvascular complications of DIEP flaps. Plast Reconstr Surg 2007; 119 (05) 1397-1405 , discussion 1406–1408
  • 26 Chen KT, Mardini S, Chuang DC. et al. Timing of presentation of the first signs of vascular compromise dictates the salvage outcome of free flap transfers. Plast Reconstr Surg 2007; 120 (01) 187-195
  • 27 Khansa I, Chao AH, Taghizadeh M, Nagel T, Wang D, Tiwari P. A systematic approach to emergent breast free flap takeback: clinical outcomes, algorithm, and review of the literature. Microsurgery 2013; 33 (07) 505-513