BRIGHAM AND WOMEN'S HOSPITAL PLASTIC SURGERY FIRST DOUBLE HAND TRANSPLANT

Inside the OR, anesthesiologist Lauren Gavin (at left), OR nurse Kate Manning and anesthesiology resident Raymond Malapero (at right) prepare a double arm transplant recipient for surgery last year.

Ever since surgeon Joseph E. Murray, MD, and his team performed the world’s first successful organ transplant at Peter Bent Brigham Hospital in 1954, BWH has been expanding the boundaries of what is possible in transplantation.

An integral part of all transplant surgeries—from kidney, heart and lung to more recent face, hand and arm transplants—has been the role of anesthesiologists, who are involved from the very start through all critical stages of a transplant candidate’s journey at BWH.

The guardians of vital signs

Along with surgeons, immunologists and transplant medicine physicians, anesthesiologists evaluate if candidates would be able to survive surgery and the extended postoperative period, and prepare patients medically and mentally for these complex procedures. The specific organ being transplanted determines many aspects—from the long-planned course of care to the potential risks and recovery process. Underlying medical conditions, including coexisting organ failures, dictate the rest.

During surgery, anesthesiologists closely monitor patients’ vital functions—heart beat, breath, blood pressure and oxygenation levels, brain activity—in order to provide optimal surgical conditions, avoid sudden changes and prevent complications. Organ transplantations are associated with significant blood loss and other extreme stress to the body, such as precipitous chemical imbalances, fluid and heat loss, which are assessed and corrected continually by the anesthesiologists. Their involvement continues after surgery, with intensivists taking the baton.

Nowadays, transplant surgery involves specialized teams that are system-specific; for example, heart transplantations are performed by cardiac surgery teams, including cardiac surgeons, cardiac anesthesiologists, perfusionists, nurses, the cardiac ICU team and many others.

The latest such team, formed at BWH with the advent of face and upper extremity transplants, includes a group of anesthesiologists who bring collective subspecialty expertise in intensive care, cardiac, thoracic and regional anesthesia.

“While these patients are not as critically ill before the operations as heart or lung failure patients, they present unique challenges,” said anesthesiologist and group coordinator Kamen Vlassakov, MD. “As we move to larger organs, the risks and complexity increase. We’re constantly treading a fine line, closely monitoring patient responses throughout the procedure and assessing the delicate limits of life.”

Vlassakov’s passion and area of expertise is regional anesthesia—the injection of numbing medication near nerves to render insensitive and immobile only the area of a patient’s body that requires surgery. Regional anesthesia includes spinal, epidural and peripheral nerve blocks, which all require injections delivered with great precision in the immediate vicinity of sensitive nerve structures, often guided by real-time ultrasound imaging.

“We’re lucky to have one of the largest and strongest regional anesthesia teams in one place: 18 subspecialty-trained expert-regionalists on our main campus alone,” said Vlassakov, who says it’s an incredible honor to lead the dedicated team. “Regional anesthesia is unique; drastic interventions can be performed without pain, and with minimal stress and discomfort. In addition, regional anesthesia may assure superior blood circulation in the transplanted organ.”

Interestingly, during the first transplant at the Brigham in 1954, the patient remained awake under spinal anesthesia administered by Leroy Vandam, MD, the founding chairman of BWH’s Anesthesiology Department—a department recognized as a national and world leader.

Unique surgeries, unique challenges

With face, hand and arm transplants, distinct challenges arise. A non-amputee patient would usually have an IV placed in his or her hand prior to surgery, for example, but if the patient doesn’t have hands, an alternative must be designed. The same flexibility and creativity is needed for a face transplant patient who needs a breathing tube but no longer has a mouth or a nose.

Communication not only with patients, but also among the members of the multidisciplinary care team is pivotal. Each patient’s case is unique, often requiring innovative solutions and mandating utmost coordination, collaboration, respect and understanding.

“It is most rewarding to see a great outcome, to know that we have made a difference,” said Vlassakov. “Nothing beats having a patient wake up and recover clear-minded, with no complications, pain or side effects, and in these cases, with the ultimate miracle of restored anatomy and function.”