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LETTER TO EDITOR
Year : 2021  |  Volume : 15  |  Issue : 4  |  Page : 390-391

Anesthetic management of bilateral upper extremity allotransplantation


Department of Anaesthesiology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India

Date of Submission02-Sep-2020
Date of Acceptance19-Jan-2021
Date of Web Publication30-Dec-2021

Correspondence Address:
Dr. Sunil Rajan
Department of Anaesthesiology, Amrita Institute of Medical Sciences, Kochi, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijot.ijot_112_20

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How to cite this article:
Abraham AS, Suresh S, Kumar N, Rajan S. Anesthetic management of bilateral upper extremity allotransplantation. Indian J Transplant 2021;15:390-1

How to cite this URL:
Abraham AS, Suresh S, Kumar N, Rajan S. Anesthetic management of bilateral upper extremity allotransplantation. Indian J Transplant [serial online] 2021 [cited 2022 Jan 26];15:390-1. Available from: https://www.ijtonline.in/text.asp?2021/15/4/390/334296



Sir,

Hand transplantation, a vascularized composite allotransplantation, is a complex procedure involving multidisciplinary collaboration.[1] A 21-year-old man who lost both his forearms was put on the transplant waiting list. Three years later, a 24-year-old brain-dead male donor was selected on basis of blood typing and human leukocyte antigen typing.

Immunosuppression of the recipient was initiated preoperatively with tacrolimus, mycophenolate mofetil, and antithymocyte globulin (ATG) 1 mg/kg infusion over 6 h. Methyl prednisolone 500 mg was give before ATG. Intravenous (IV) meropenem 2 g stat followed by 8 hourly and levofloxacin 500 mg stat followed by once-daily dosing were administered preoperatively for antimicrobial prophylaxis.

Under local anesthesia, right internal jugular vein was cannulated with a 7F triple-lumen catheter. The recipient was induced with propofol and vecuronium for muscle relaxation and morphine as analgesic. He was intubated and maintained in oxygen and nitrous oxide (1:2) mixture with isoflurane (1%), under mechanical ventilation. Supraclavicular brachial plexus block was given bilaterally with 10 mL bupivacaine 0.25% under ultrasonic guidance. Left femoral arterial line and two 16G venous access were secured on the left saphenous and right femoral veins.

Preparation of donor's forearms and dissection of the recipient's forearms were performed simultaneously by two teams of surgeons. The forearm preparation was followed by bony fixation, followed by end-to-end anastomoses of the arteries, veins, and nerves. Methyl prednisolone 500 mg IV was given before reperfusion. Although revascularization was stormy due to continuous ooze from the surgical site, the mean arterial pressure was maintained at 65–85 mmHg by administration of fluids, packed red blood cells (PRBCs), and blood products. The patient developed transient hyperkalemia and metabolic acidosis immediately following reperfusion and was managed with calcium gluconate, glucose insulin bolus, and sodium bicarbonate administration.

The surgery lasted for 14 h, and a total of 11.5 L of crystalloids, 1.5 L of hydroxyl ethyl starch, 8 units of PRBCs, 6 units of fresh frozen plasma, 4 units of pooled platelets, and 300 mL albumin were given. Intraoperatively, adequate urine output of >0.5 ml/kg/h was maintained. The estimated blood loss was around 5200 ml.

Postoperatively, the patient was ventilated for 5 h until fully awake and normothermic. After 2 weeks under intensive unit care, he was shifted to the ward and made an uneventful recovery [Figure 1].
Figure 1: Patient on the 14th postoperative day

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The anesthetic goal in such cases is to maintain optimum blood flow to the allograft and avoidance of vasopressors to prevent vasospasm. Because of hemodynamic instability, necessitating massive transfusion, coagulopathy, and rhabdomyolysis acute kidney injury could happen.[2],[3] Improved oxygenation to donor hands is ensured by hemodilution and controlled hypertension by means of volume expansion. Hemoglobin of around 10 g/dL is usually sufficient.

Postoperatively, the aim is to maintain good graft perfusion and detect the occurrence of immediate complications, acute rejection, or infections. Postoperative regional blocks cause vasodilatation and improve blood flow, in addition to postoperative analgesia.[4] The Pittsburgh Upper Extremity Transplant Anesthesiology Protocol offers guidelines and recommendations for the management of hand transplantation. It mainly focuses on fluid management, intraoperative monitoring of the patient, and regional anesthesia strategies.[5]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Shores JT, Imbriglia JE, Lee WP. The current state of hand transplantation. J Hand Surg Am 2011;36:1862-7.  Back to cited text no. 1
    
2.
Lantieri L, Hivelin M, Audard V, Benjoar MD, Meningaud JP, Bellivier F, et al. Feasibility, reproducibility, risks and benefits of face transplantation: a prospective study of outcomes. Am J Transplant 2011;11:367-78.  Back to cited text no. 2
    
3.
Hinojosa Pérez R, Porras López M, Escoresca-Ortega AM, Herruzo Avilés A, León A, Noval JA, et al. Severe rhabdomyolysis after allogeneic transplantation of facial structures: A case report. Transplant Proc 2010;42:3081-2.  Back to cited text no. 3
    
4.
Rajan S, Suppiah RK, Paul J, Kumar L. Anaesthetic management of bilateral hand transplantation. Indian J Anaesth 2015;59:819-20.  Back to cited text no. 4
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5.
Lang RS, Gorantla VS, Esper S, Montoya M, Losee JE, Hilmi IA, et al. Anesthetic management in upper extremity transplantation: The Pittsburgh experience. Anesth Analg 2012;115:678-88.  Back to cited text no. 5
    


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