Table 8.
Summary of Anesthetic Considerations in Facial Transplantation Based on Our Institutional Experience and Literature Review
| Preoperative Considerations | Supporting Literature* |
|---|---|
| • Development of a “Face Transplant Anesthesia Protocol” | [1,5,17,18,20,44–49] |
| • Team cadaveric simulations and/or research procurement rehearsals | [1,2,4,5,16,31,32,38,45,48,50–54] |
| Recipient | |
| • Evaluation of anesthetic, surgical and medical histories, risk of bleeding, possibility of difficult airway | [1,17,18,32,34,40–42,55–60] |
| • Pain management evaluation, particularly assessment of chronic pain | [61,62] |
| • Establishment of central and peripheral vascular access and monitoring | [5,11,17,20] |
| • Additional procedure(s): tracheostomy, gastrostomy, CT head/neck, formal angiography, reconstructive procedures in preparation for transplantation | [1,11,16–18,25,26,32,34,37, 38,41,42,47,60,63–66] |
| Donor | |
| • Management protocol for heart-beating brain-dead donors | [1,4,20,25,34,44–46,54,67,68] |
| • Monitoring during transfer from an outside hospital | [4,16,21,25] |
| • Establishment of central and peripheral vascular access and monitoring | [5,20,25,46] |
| • Additional procedure(s): tracheostomy, bronchoscopy, CT chest/abdomen/pelvis, echocardiography, solid organ biopsies, CT cerebral angiography, formal angiography, mask production | [1,2,4,16,17,24–26,34, 38,42–45,47,63–65,69–71] |
| Intraoperative Considerations | |
| • Coordination between recipient and donor rooms | [1,16,32,37,39,40,43,45,51,53] |
| Recipient | |
| • Prevention of pressure injury by offloading and appropriate padding | [5] |
| • Regular suction with placement of throat packs to avoid airway occlusion | |
| • Maintenance of body temperature using lower and underbody forced-air warming blankets | [17,18] |
| • Anticipation of blood loss particularly during allograft reperfusion | [11,17,30,33,35,46,52,65,72,73] |
| • Controlled hypotension (case and surgeon-specific) | [17,20] |
| • Administration of induction immunosuppression and antimicrobial prophylaxis | [1,17,20,25,27,32,34–39,42,43,54,74–80] |
| Donor | |
| • Planning for prolonged allograft procurement time | [1,16,25,33,34,44,45,54,65,67,75] |
| • Positioning within communication distance of all procurement teams | [5,44–46] |
| • Management protocol for “face-first” procurement from heart-beating brain-dead donors | [1,5,44,45,50,52,67] |
| • Maintenance of body temperature using lower and underbody forced-air warming blankets | |
| • Anticipation of blood loss particularly during skeletal osteotomies and after initiation of abdominal organ recovery | [4,25,45,53] |
| Acute Postoperative Considerations | |
| • Administration of immunosuppression, antimicrobial, and antithrombotic prophylaxis | [1,5,17,25,27,31,32,34–40,42,43, 65,66,74–84] |
| • Elevation of head of bed >30° with frequent allograft monitoring for viability or rejection | [5,19,20,32] |
| • Multimodal pain management with close monitoring of end tidal CO2 levels | [19,32,62] |
| • Implementation of a rehabilitation protocol | [5,31,39,40,47,66,85–87] |
| Long-term postoperative considerations | |
| • Outpatient pain management strategy and follow-up | [88–90] |
| • Planning for revision procedures as needed | [77,91,92] |
*
Supporting literature highlights select representative references from the facial transplantation literature review that are elaborated on in the narrative synthesis.
CO2, carbon dioxide; CT, computed tomography.