Anesthesia for hand or face transplants -- initial guidelines

The University of Pittsburgh hand transplant group shares their guidelines for anesthesia management, emphasizing the range of important roles played by anesthesiologists throughout the perioperative period -- before, during, and after surgery. A separate paper identifies key issues in the management of facial transplant recipients, based on worldwide experience.

First Guidelines for Anesthesia during Hand Transplantation

Dr R. Scott Lang and the Pitt group present the "Pittsburgh Upper Extremity Transplant Anesthesiology Protocol" (PUETAP) -- the first guidelines for anesthetic management of upper extremity transplantation. The recommendations were derived from the authors' experience with eight hand/forearm/arm transplants in five patients, performed from 2008 to 2010.

Like face transplantation, hand transplants are classified as "vascularized composite tissue allotransplants" (CTAs). In contrast to organ transplants, CTAs "are composed of multiple tissues, including skin, muscle, tendons, vessels, nerves, lymph nodes, bone, and bone marrow," the authors explain. These are obviously complex procedures in which anesthesiologists play multiple, critical roles -- not only providing anesthesia and monitoring the patient during the prolonged surgery, but also playing active roles in patient evaluation and follow-up.

The PUETAP proposes a set of recommendations to help guide anesthetic management of patients undergoing hand transplantation. It includes detailed information on management of the patient during surgery, such as:

• Fluid management, including monitoring catheters and likely requirements for transfused blood products
• Intraoperative monitoring, including regular lab tests performed throughout the operation.
• Anesthesia, including regional anesthesia strategies to block the nerves supplying the shoulder, arm, and hand (brachial plexus).

The article includes two cases illustrating how experience informed development of the PUETAP, and its subsequent effects on anesthetic management. "The success of the PUETAP required the anesthesiologists to become true perioperative physicians," Dr Lang and coauthors write. They emphasize the need to meet with the patient before surgery to explain anesthesia plans, and after surgery to evaluate immediate and long-term pain management.

Follow-up also includes monitoring for immune system function and possible rejection of the transplanted tissues. The Pitt team used cutting-edge immunomodulatory approaches, including infusion of bone marrow from the tissue donor in an attempt to induce long-term immune tolerance of the transplanted tissue. The authors plan a complete review of the "immunologic, functional, and graft survival outcomes" of their hand transplant patients.

In the second article, led by Dr Thomas Edrich of Brigham and Women's Hospital, the researchers surveyed facial transplantation centers worldwide regarding their perioperative management. Data on 13 face transplants reported a median 19 hours of surgery and anesthesia. Blood loss was "considerable," requiring large amounts of fluids and blood transfusions. The results findings emphasize the importance of preparing for and managing -- which can occur rapidly once blood flow is restored to the transplanted facial tissues.

"Though most anesthesiologists will not be responsible for CTA patients, the advanced that facilitated transplantation of upper and lower extremities and faces will affect all of organ transplantation," according to an accompanying editorial by Dr Marie Csete of University of California, San Diego. Pointing out the "surprising territorial overlap" between research in anesthesiology and immunology, she believes anesthesiologists have an important role to play "at this pivotal time in the history of transplantation."