Replantation of Extremities

Abstract

Summary Successful replantation requires a physiologically oriented team, including skilled surgeons with available relief and a skilled anesthesiologist with relief. Regional centers provide the most efficient management, having more frequent exposure to major injuries and increased experience with replant procedures. A management protocol (Table 3) outlines the major steps in the care of such patients. This author prefers regional anesthesia for most cases. Supplemental intravenous sedation reduces anxiety and its effects on the microvasculature. For axillary and interscalene brachial plexus blocks of the upper extremity, bupivacaine is most suitable. Management of lower extremity replantations usually entails a femoral sciatic, epidural block or a general anesthetic. The anesthesia team must remember the importance of vascular physiology and rheology on outcome. Also, they must pay attention to (1) concomitant risks of emergency procedures (coexisting injury, intoxication, a full stomach, and so forth); (2) expeditious management, which reduces warm ischemia time; (3) patient comfort in the operating theater; and (4) a cooperative and informed team approach. Given these factors and proper patient sedation, a reasonable success rate can be expected. In the future, advances in anesthesia care will involve better management of fluids and methods to prolong sensory and sympathetic blockade.