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Inside the OR, anesthesiologist Lauren Gavin (at left) and anesthesiology resident Raymond Malapero (at right) prepare a double arm transplant recipient for surgery last year.
Over the years, we've brought you stories about innovation in transplantation at BWH. This article delves into one specialty involved in these complex surgeries-anesthesiology-as the American Society of Anesthesiologists' inaugural Physician Anesthesiologists Week comes to a close.
Ever since surgeon Joseph 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 start through all critical stages of a transplant candidate's journey at BWH.
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-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 chemical imbalances, fluid and heat loss, which are assessed and corrected continually by anesthesiologists.
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 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 response throughout the procedure and assessing the delicate limits of life."
Vlassakov's 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 is honored to lead the team. "Regional anesthesia is unique; drastic interventions can be performed without pain and with minimal stress and discomfort. In addition, regional anesthesia may provide superior blood circulation in the transplanted organ."
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.
With face, hand and arm transplants, distinct challenges can 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 are 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 across the multidisciplinary care team is pivotal. Each patient's case is unique, requiring innovative solutions, and coordination, collaboration, respect and understanding. "It is most rewarding to see a great outcome, to know we have made a difference," said Vlassakov. "Nothing beats a patient waking up and recovering clear-minded, with no complications or pain, and in these cases, with the miracle of restored anatomy and function."