Anaesthesia and intensive care management of face transplantation

Abstract

The face-grafting techniques are innovative and highly complex, requiring well-defined organization of all the teams involved. Subsequent to the first report in France in 2005, there have been 17 facial allograft transplantations performed worldwide. We describe anaesthesia and postoperative management, and the problems encountered, during the course of seven facial composite tissue grafts performed between 2007 and 2011 in our hospital. The reasons for transplantation were ballistic trauma in four patients, extensive neurofibromatosis in two patients, and severe burns in one patient. Anaesthesia for this long procedure involves advanced planning for airway management, vascular access, technique of anaesthesia, and fluid management. Preparation and grafting phases were highly haemorrhagic (>one blood volume), requiring massive transfusion. Median (range) volumes given for packed red cell (PRC) and fresh-frozen plasma (FFP) were 64.2 ml kg(-1) (35.5-227.5) and 46.2 ml kg(-1) (6.3-173.7), respectively. Blood loss quantification was difficult because of diffuse bleeding to the drapes. The management of patients with neurofibromatosis or burns involving the whole face was more difficult and haemorrhagic than the patients with lower face transplantation. Average surgical duration was 19.1 h (15-28 h). Postoperative severe graft oedema was present in most patients. Most patients encountered complications in ICU, such as renal insufficiency, acute respiratory distress syndrome, and jugular thrombosis. Opportunistic bacterial infections were a feature during the postoperative period in these highly immunosuppressed patients.

Face transplantation: Anesthetic challenges

“…The airway management most commonly used in facial transplantations has been via a primary intubation of an existing tracheostoma with a flexometallic endotracheal tube[17,18]. Primary orotracheal intubation may be challenging in cases of restricted mouth opening, with facial skin contractures as commonly seen in burns, chemical trauma, etc .…”

“…Prior to commencement of surgery, a tracheostomy is done and a soft flexometallic endotracheal tube is inserted into the trachea. This is then sutured rather than tied, inorder to prevent compression to venous outflow from the face by pressure exerted by the circumferential tie[17,18]. …”

“…Face transplantation surgery has a very long duration, usually averaging to approximately 19-20 h[17,18]. One case has been reported to have a surgical time of 36 h[19].…”

“…The internal jugular and subclavian veins may be at risk of thrombosis, or maybe inaccessible. Though femoral venous access is associated with a higher degree of infection[20], it has been used in several cases[17,18]. Whenever feasible, a subclavian central venous line is preferable, to reduce risk of infections in this group of patients receiving immunosuppressive therapy postoperatively.…”

Vascularized Composite Allotransplant in the Realm of Regenerative Plastic Surgery

“…Other complications were reported in 7 patients, including severe intraoperative bleeding (requiring transfusion of 66 U of packed red blood cells), acute respiratory distress syndrome, renal insufficiency, and jugular thrombosis. [49][50][51] Opportunistic infections were common in the Boston experience, 51 with cytomegalovirus being the most frequent organism, but were not associated with rejection.…”