Two new studies begin to outline guidelines for the anesthetic management of patients undergoing hand and face transplants. The research appears in the September issue of Anesthesia & Analgesia.

The "Pittsburgh Upper Extremity Transplant Anesthesiology Protocol" (PUETAP) was derived from the authors’ experience with eight hand/forearm/arm transplants in five patients performed from 2008 to 2010.

The PUETAP includes detailed information on management of the patient during surgery including fluid management, intraoperative monitoring and anesthesia. They emphasize the need to meet with the patient before surgery to explain anesthesia plans, and after surgery to evaluate immediate and long-term pain management.

Follow-up also includes monitoring for immune system function and possible rejection of the transplanted tissues. The Pitt team used such immunomodulatory approaches as infusion of bone marrow from the tissue donor to induce long-term immune tolerance of the transplanted tissue. The authors plan a complete review of the "immunologic, functional, and graft survival outcomes" of their hand transplant patients.

A second study looked at issues involved in the anesthetic management of patients undergoing face transplants. Thomas Edrich, MD, of Brigham and Women’s Hospital in Boston and colleagues surveyed facial transplantation centers worldwide regarding their perioperative management. Data on 13 face transplants reported a median 19 hours of surgery and anesthesia. Blood loss was "considerable,” the study showed. This can occur rapidly once blood flow is restored to the transplanted facial tissues, and must be prepared for in advance.