From the Guidelines
Vasopressors should be used cautiously in patients with surgical anastomoses, with norepinephrine being the preferred choice, starting at 0.01-0.05 mcg/kg/min, as recommended by the Enhanced Recovery After Surgery (ERAS) society guidelines 1. The use of vasopressors in patients with surgical anastomoses requires careful consideration to minimize the risk of anastomotic compromise.
- Norepinephrine is generally the preferred vasopressor when needed, due to its ability to maintain mean arterial pressure between 65-75 mmHg, which is essential for adequate perfusion of the anastomotic site 1.
- Phenylephrine (Neo-Synephrine) at 0.1-0.5 mcg/kg/min can be an alternative for pure alpha-adrenergic effects, but its use should be carefully monitored to avoid excessive vasoconstriction.
- Vasopressin at low doses (0.01-0.04 units/min) may be added as a second agent if needed, as it causes less splanchnic vasoconstriction than high-dose catecholamines. The ERAS society guidelines recommend the use of vasopressors, such as neosynephrine or low doses of norepinephrine, to maintain adequate haemodynamic control and prevent intraoperative hypotension, which can negatively impact perfusion of the gut and anastomosis 1.
- It is essential to maintain adequate volume status before initiating vasopressors, as hypovolemia can exacerbate vasopressor-induced tissue hypoperfusion.
- Monitoring for signs of anastomotic compromise, such as decreased distal pulses, changes in flap appearance, or abdominal distension and pain in GI anastomoses, is crucial when vasopressors are required. The evidence level for the use of vasopressors in patients with surgical anastomoses is high, with a strong recommendation grade, emphasizing the importance of careful vasopressor use in these patients 1.
From the FDA Drug Label
12 CLINICAL PHARMACOLOGY
12.1 Mechanism of Action Vasopressin causes vasoconstriction by binding to V1 receptors on vascular smooth muscle coupled to the Gq/11-phospholipase C-phosphatidyl-inositol-triphosphate pathway, resulting in the release of intracellular calcium. 12. 2 Pharmacodynamics At therapeutic doses exogenous vasopressin elicits a vasoconstrictive effect in most vascular beds including the splanchnic, renal and cutaneous circulation.
The FDA drug label does not answer the question about vasopressors with surgical anastomosis.
From the Research
Vasopressors and Surgical Anastomosis
- The use of vasopressors in surgical anastomosis is a topic of interest, with some studies suggesting that they may increase the risk of anastomotic leakage due to splanchnic vasoconstriction, deterioration of microcirculation, and local hypoxia 2.
- However, other studies have found that the use of vasopressors during surgery is not associated with an increased risk of anastomotic leak, such as in the case of esophagectomy 3.
- The relationship between vasopressor dose and anastomotic leak is still controversial, with some studies suggesting that high doses of vasopressors may actually increase blood supply to the anastomotic line by increasing cardiac output 2.
- Factors that contribute to anastomotic failure include location and systemic diseases such as sepsis and hemorrhagic shock, while factors such as stapled versus hand sewn anastomosis, continuous versus interrupted sutures, and single versus two layer anastomosis have not demonstrated any difference in outcome 4.
- Successful intestinal anastomosis necessitate adequate exposure and access, gentle tissue handling, absence of tension and distal obstruction, hemodynamic stability with adequate tissue oxygenation, and meticulous surgical technique 4.
Key Findings
- A study on the relationship between vasopressor dose and anastomotic leak in colon surgery found that high doses of dopamine increased the bursting pressures of anastomoses 2.
- A study on the use of vasopressors during esophagectomy found that vasopressor use was not associated with an increased risk of anastomotic leak 3.
- A review of the art of bowel anastomosis highlighted the importance of adequate exposure and access, gentle tissue handling, and meticulous surgical technique in preventing anastomotic failure 4.
Clinical Applications
- Vasopressors are widely used in anaesthesiology and critical care medicine to treat various conditions, including anaesthesia-induced hypotension and septic shock 5.
- The use of vasopressors in surgical anastomosis requires a thorough understanding of their pharmacology and clinical profile, as well as the fundamentals of vascular physiology and vasotonic regulation 5.