title: Anesthetic management in upper extremity transplantation: the Pittsburgh experience.
abstract: BACKGROUND
  Hand/forearm/arm transplants are vascularized composite allografts, which, unlike solid organs, are composed of multiple tissues including skin, muscle, tendons, vessels, nerves, lymph nodes, bone, and bone marrow. Over the past decade, 26 upper extremity transplantations were performed in the United States. The University of Pittsburgh Medical Center has the largest single center experience with 8 hand/forearm transplantations performed in 5 recipients between January 2008 and September 2010. Anesthetic management in the emerging field of upper extremity transplants must address protocol and procedure-specific considerations related to the role of regional blocks, effects of immunosuppressive drugs during transplant surgery, fluid and hemodynamic management in the microsurgical setting, and rigorous intraoperative monitoring during these often protracted procedures.
  
  
  METHODS
  For the first time, we outline salient aspects of upper extremity transplant anesthesia based on our experience with 5 patients. We highlight the importance of minimizing intraoperative vasopressors and improving fluid management and blood product use.
  
  
  RESULTS
  Our approach reduced the incidence of perioperative bleeding requiring re-exploration or hemostasis and shortened in-hospital and intensive care unit stay. Functional, immunologic and graft survival outcomes have been highly encouraging in all patients.
  
  
  CONCLUSIONS
  Further experience is required for validation or standardization of specific anesthetic protocols. Meanwhile, our recommendations are intended as pertinent guidelines for centers performing these novel procedures.
authors: Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA.
authors: R Scott
authors: RS
authors: Lang
authors: Vijay S
authors: VS
authors: Gorantla
authors: Stephen
authors: S
authors: Esper
authors: Mario
authors: M
authors: Montoya
authors: Joseph E
authors: JE
authors: Losee
authors: Ibtesam A
authors: IA
authors: Hilmi
authors: Tetsuro
authors: T
authors: Sakai
authors: W P Andrew
authors: WP
authors: Lee
authors: Jay S
authors: JS
authors: Raval
authors: Joseph E
authors: JE
authors: Kiss
authors: Jaimie T
authors: JT
authors: Shores
authors: Gerald
authors: G
authors: Brandacher
authors: Raymond M
authors: RM
authors: Planinsic
mesh_terms: D000328:Adult; D000758:Anesthesia / Q000379:methods*; D001132:Arm / Q000637:transplantation*; D005260:Female; D005440:Fluid Therapy; D005542:Forearm; D063987:Hand Transplantation; D006801:Humans; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative; D017063:Outcome Assessment, Health Care; D018579:Patient Selection; D011300:Preoperative Care; D014019:Tissue Donors