Anesthetic management of the first pediatric bilateral hand transplant

Purpose: The purpose of this case report is to describe the anesthetic and case management of the first vascularized composite allograft pediatric bilateral hand transplant. Clinical details: Our patient was an eight-year-old male with a medical history of Staphylococcus aureus sepsis at one year of age that resulted in end-stage renal disease as well as bilateral upper and lower extremity amputations. After referral for bilateral hand transplantation, the transplantation team, with expertise in all aspects of perioperative care (surgery, anesthesiology, nephrology, renal transplantation, pediatric intensive care, and therapeutic pharmacy), was consulted to help develop anesthetic and other perioperative protocols for surgery. Prior to activation of the transplantation team, the lead surgeon evaluated potential donors by comparing a three-dimensional printed model of the recipient’s forearm with the donor’s upper extremities to ensure an adequate match. The anesthesia team inserted bilateral ultrasound-guided infraclavicular catheters to provide a sympathetic block to facilitate blood flow to the upper extremities and to provide both intraoperative and postoperative pain control. The patient remained in the operating room for 13 hr 37 min for a surgical time of ten hours 39 min. He remained in the hospital for 34 days after the procedure and was then transferred to an inpatient rehabilitation facility for a further 15 days. The patient is currently doing well in a postoperative rehabilitation program. He has demonstrated motor power to the hands using the forearm muscles but is not expected to reach his maximum sensory function for at least one to two years. Conclusion: This report describes the anesthetic management of the first pediatric bilateral hand transplant. This procedure required considerable preoperative planning and communication between various teams to ensure all resources needed to deliver the care for this complex and novel transplant surgery were readily available.