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Transplante de cara. Retos anestésicos
Face transplantation: Anesthetic challenges.
Abstract
Face transplantation is a complex vascular composite allotransplantation (VCA) surgery. It involves multiple types of tissue, such as bone, muscles, blood vessels, nerves to be transferred from the donor to the recipient as one unit. VCAs were added to the definition of organs covered by the Organ Procurement and Transplantation Network Final Rule and National Organ Transplant Act. Prior to harvest of the face from the donor, a tracheostomy is usually performed. The osteotomies and dissection of the midface bony skeleton may involve severe hemorrhagic blood loss often requiring transfusion of blood products. A silicon face mask created from the facial impression is used to reconstruct the face and preserve the donor's dignity. The recipient airway management most commonly used is primary intubation of an existing tracheostoma with a flexometallic endotracheal tube. The recipient surgery usually averages to 19-20 h. Since the face is a very vascular organ, there is usually massive bleeding, both in the dissection phase as well as in the reperfusion phase. Prior to reperfusion, often, after one sided anastomosis of the graft, the contralateral side is allowed to bleed to get rid of the preservation solution and other additives. Intraoperative product replacement should be guided by laboratory values and point of care testing for coagulation and hemostasis. In face transplantation, bolus doses of pressors or pressor infusions have been used intraoperatively in several patients to manage hypotension. This article reviews the anesthetic considerations for management for face transplantation, and some of the perioperative challenges faced.
KEYWORDS: Face transplantation; Facial reconstruction; Organ harvest; Vascular composite allotransplantation
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Algoritmo para la procuración de la cara y mútiples órganos de un donador con muerte cerebral
Algorithm for total face and multiorgan procurement from a brain-dead donor.
Am J Transplant. 2013 Oct;13(10):2743-9. doi: 10.1111/ajt.12382. Epub 2013 Aug 5.
Abstract
Procurement of a facial vascularized composite allograft (VCA) should allow concurrent procurement of all solid organs and ensure their integrity. Because full facial procurement is time-intensive, "simultaneous-start" procurement could entail VCA ischemia over 12 h. We procured a total face osteomyocutaneous VCA from a brain-dead donor. Bedside tracheostomy and facial mask impression were performed preoperative day 1. Solid organ recovery included heart, lungs, liver, kidneys, and pancreas. Facial dissection time was 12 h over 15 h to diminish ischemia while awaiting recipient preparation. Solid organ recovery began at 13.5 h, during midfacial osteotomies, and concluded immediately after facial explantation. Facial thoracic and abdominal teams worked concurrently. Estimated blood loss was 1300 mL, requiring five units of pRBC and two units FFP. Urine output, MAP, pH and PaO2 remained normal. All organs had good postoperative function. We propose an algorithm that allows "face first, concurrent completion" recovery of a complex facial VCA by planning multiple pathways to expedient recovery of vital organs in the event of clinical instability. Beginning the recipient operation earlier may reduce waiting time due to extensive recipient scarring causing difficult dissection.
KEYWORDS: Composite tissue transplantation; face transplantation; multiorgan donor; organ and tissue procurement; organ protection and preservation; organ sharing
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5to Curso Internacional de Anestesiología cardiotorácica, vascular, ecocardiografía y circulación extracorpórea. SMACT
Mayo 4-6, 2017, Ciudad de México
Informes Dr. Hugo Martínez Espinoza bajamed@hotmail.com
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Regional Anesthesiology and Acute Pain Medicine Meeting
April 6-8, 2017, San Francisco, California, USA
ASRA American Society of Regional Anesthesia and Pain Medicine
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California Society of Anesthesiologists
Annual Meeting April 27-30, 2017
San Francisco California
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