Pittsburgh upper extremity transplant anesthesiology protocol
The PUETAP recommends intravenous (internal jugular) access via a large bore (Cordis or Shiley) catheter. Central venous pressure (CVP) monitoring is via a single lumen infusion catheter (SLIC) inserted through the introducer for unilateral hand/extremity transplant (UHT). An additional 14-gauge IV catheter is recommended in the nonoperative arm for UHT. Bilateral hand transplant (BHT) has limited upper extremity IV access requiring an additional 7-French double lumen or equivalent central venous internal jugular catheter. A 20-gauge radial artery catheter in the nonoperative arm for UHT and an 18-gauge femoral artery catheter for BHT are recommended. Monitoring of coagulation with ROTEM or TEG is essential. A rapid infusion system (RIS) such as the fluid management system (FMS) is also indispensible. Transesophageal echocardiolgraphy (TEE) should be available if required.
The blood bank must be prepared to provide the operating room with 10 units of RBC, 10 units of FFP and 10 units of PLT at the beginning of the procedure and maintain these same volumes of products in the blood bank immediately available to the OR at all times.
The PUETAP follows the trauma resuscitation protocol of 1 unit packed red blood cells (PRBC) : 1 unit fresh frozen plasma (FFP) : 250 cc normal saline (NS). This ratio achieves a hematocrit of 26–28 % in the RIS reservoir. A fluid warmer is used for the infusion of cold solutions. An increase in ambient room temperature, use of forced air warmers, and extensive surgical draping help maintain body temperature throughout the procedure. Alpha agonists should be avoided as they may affect graft perfusion. Dopamine is instituted when hypotension is not adequately corrected by infusion of IV fluids or blood products, such as vasodilation in response to donor extremity reperfusion. Low dose dopamine maintains regional blood flow by increasing cardiac contractility through beta-1 agonist effects and sustains renal perfusion via dopaminergic receptors.
Laboratory services must be able to process hourly or more frequently stat labs. The PUETAP protocol recommends monitoring of arterial blood gases (ABG), sodium, potassium, calcium, glucose, lactate, hemoglobin, and serum osmolality during surgery in all patients. ABGs are documented at baseline and hourly. Additionally, after reperfusion of the transplant, 30-s, 30-min, and 60-min ABGs are determined along with the above laboratory values. These times points are defined to help assess peak potassium concentrations as well as other immediate metabolic and physiologic changes associated with reperfusion.