Our patient was an eight-year-old male with a medical history of Staphylococcus aureus
sepsis at one year of age that resulted in
end-stage renal disease as well as bilateral upper and lower extremity
amputations. After referral for bilateral
hand transplantation, the
transplantation team, with expertise in all aspects of
perioperative care (surgery, anesthesiology, nephrology,
renal transplantation, pediatric
intensive care, and therapeutic pharmacy), was consulted to help develop
anesthetic and other perioperative protocols for surgery. Prior to activation of the
transplantation team, the lead surgeon evaluated potential donors by comparing a three-dimensional printed model of the recipient's forearm with the donor's upper extremities to ensure an adequate match. The
anesthesia team inserted bilateral ultrasound-guided infraclavicular
catheters to provide a sympathetic block to facilitate blood flow to the upper extremities and to provide both intraoperative and
postoperative pain control. The patient remained in the operating room for 13 hr 37 min for a
surgical time of ten hours 39 min. He remained in the hospital for 34 days after the procedure and was then transferred to an inpatient rehabilitation facility for a further 15 days. The patient is currently doing well in a postoperative rehabilitation program. He has demonstrated motor power to the hands using the forearm muscles but is not expected to reach his maximum sensory function for at least one to two years.
CONCLUSION: This report describes the
anesthetic management of the first pediatric bilateral hand transplant. This procedure required considerable preoperative planning and communication between various teams to ensure all resources needed to deliver the care for this complex and novel transplant surgery were readily available.