Anaesthesia for reconstructive free flap surgery for head and neck cancer

Head and neck cancer surgery presents significant challenges for the anaesthetist. A thorough multidisciplinary preoperative assessment and optimisation of the patient is essential, including nutritional and psychological evaluation. The incidence of a difficult airway is high, and the anaesthetist must be skilled in advanced airway techniques. Surgery is extensive, often requiring reconstructive surgery with either a pedicled or free flap. Detailed knowledge of flap physiology and anatomy is needed, and anaesthesia comprises careful management of mean arterial pressure, fluid administration, temperature control and oxygenation. The Enhanced Recovery after Surgery Society and the Society for Head and Neck Anaesthesia consensus recommendations provide guidance on current best practice. Despite continued debate, it now appears that this constitutes goal-directed fluid therapy, coupled with judicious vasopressor therapy sufficient to achieve an adequate mean arterial pressure. Emerging techniques such as prehabilitation and postoperative near-infrared spectroscopy flap monitoring provide hope of improved outcomes going forward.