Management of massive transfusion and coagulation during bilateral hand transplantation surgery

Abstract

Dear Editor, Massive transfusion (MT) aims to limit hypoperfusion till surgical hemostasis could be attained and takes into account volume status, tissue oxygenation, management of bleeding, and coagulation abnormalities.[1] However, it may not be possible to follow recommended protocols of MT strictly during hand transplant surgeries as, in addition to restoring blood volume, ensuring good perfusion and avoidance of thrombus formation in transplanted hands is critical. A 46 year-old-female, bilateral hand amputee, was posted for bilateral upper extremity allotransplantation (supracondylar level on the right side and mid-arm level on the left side). The donor was a 45 year-old-female who was declared brain dead following trauma. The recipient received standardized general anesthesia and immunosuppressants as per protocol. Femoral arterial, internal jugular, femoral venous, and two 16G saphenous catheters were placed. Her initial hemoglobin was 13.2 g/dL. Reperfusion of transplanted hands was done around 6 h intraoperatively following which there was major surgical bleeding and hemoglobin dropped <5 g/dL multiple times despite aggressive fluid replacements. The surgery lasted 15 h, and she received 12 units of packed red blood cells (PRBCs), 4 units of fresh frozen plasma (FFP), 2 L of hydroxyethyl starch, 600 mL albumin, 15 L of Kabilyte (acetated intravenous fluid), and 40 mL of 10% calcium gluconate. Intraoperative fluid management was guided by continuous arterial and central venous pressure monitoring, frequent arterial blood gas analysis including electrolyte levels, platelet count, prothrombin time, and thromboelastography (TEG). She required noradrenaline infusion up to 0.2 mcg/kg to maintain mean arterial pressure >65 mmHg, and urine output was >1 mL/kg/h. Intraoperatively, perfusion of transplanted hands was impeded by arterial and venous thrombi which required multiple thrombectomy and reanastomoses and fasciotomies for decompression. Therefore, a certain degree of coagulopathy was accepted to prevent further thrombus formation and hence MT protocols were not strictly followed. The aim was to maintain good perfusion of hands with target hemoglobin of 10 g/dL with hemodilution to facilitate perfusion across anastomoses. In 48 h, she had received a total of 21 units of PRBC and 9 units of FFP. Coagulation parameters were maintained at safe acceptable levels [Table 1]. Other than hypothermia, she did not develop any major complications such as renal or lung injury secondary to MT.Table 1: Laboratory investigation results and interventionsMT is defined as replacement of one entire blood volume within 24 h, transfusion of >10 units of PRBCs in 24 h, transfusion of >4 units of PRBCs in 1 h, or replacement of 50% of total blood volume within 3 h.[2] Consumption of coagulation factors during massive bleeding and dilution of remaining factors due to volume expanders add to coagulopathy and altered hemostasis.[3] Coagulation tests are usually time-consuming and may not greatly help in guiding therapy during ongoing massive bleeding. TEG tests the entire hemostatic system including platelet function and fibrinolytic system. Therefore it is useful in managing complicated coagulopathies with timely intervention.[2] Ideally, MT protocols are to be activated after transfusion of 4–10 units which have a predefined ratio of RBCs, FFP/cryoprecipitate, and platelet units (1:1:1 or 2:1:1 ratio).[4,5] It is concluded that during bilateral hand transplantation surgeries, management of MT should be individualized taking into account hemoglobin levels, coagulation profile, and perfusion of transplanted hands. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.