General Medical Support in Face Transplantation

Abstract

Postoperative care of composite tissue allotransplantation patients has significant differences when compared to other solid organ transplantation procedures. In general terms, the management of these types of patients is less complex than solid organ transplantation; however, some specific issues complicate it, including immunological barriers, antigen load of composite tissues, surgical stress, and bleeding and fluid management.

Appendix 8.1: Postoperative Orders

• 1. Diagnosis.

• 2. Check vital signs according to ICU protocol.

• 3. Check fluid balance every hour.

• 4. Tracheotomy care as per ICU protocol.

• 5. Central line management as per ICU protocol.

• 6. Nihil by mouth (exception, oral medications).

• 7. NG tube to gravity.

• 8. Urinary catheter and control of hourly urine output.

• 9. Check drains every 2 h.

• 10. Chest X-ray on admission to ICU.

• 11. Control of anastomosis with hand-held Doppler every hour for the first 24 h and then every 2 h for 6 days.

• 12. Blood test on admission to ICU:

  • (a) Blood gas analysis with lactate and calcium (ion)

  • (b) Complete blood cell count, platelets, prothrombin and partial thromboplastin ratios, fibrinogen, AST, ALT, bilirubin, GGTP, calcium/magnesium/phosphate, sodium/potassium/chlorine, total proteins, BUN, creatinine and glucose

• 13. Daily blood test:

  • (a) Complete blood cell count, platelets, prothrombin and partial thromboplastin ratios, fibrinogen, AST, ALT, bilirubin, GGTP, calcium/magnesium/phosphate, sodium/potassium/chlorine, total proteins, albumin, BUN, creatinine, glucose and tacrolimus level

• 14. Cross-match on first day post transplant.

• 15. IV fluids as per protocol ICU and patient response.

• 16. IV broad-spectrum antibiotics according to institution guidelines (cover Gram+ cocci and Gram– bacteria):

  • (a) Continue 3–5 days.

  • (b) Change to appropriate antibiotics when surveillance microbiological results from donor and recipients are available (or PCRs).

• 17. Antifungal prophylaxis (liposome amphotericin 1 mg/kg IV).

• 18. Trimethoprim/sulfamethoxazole IV every 24 h until good oral tolerance; start then 80 mg PO 3 times per week.

• 19. Ganciclovir 5 mg/kg bid until good oral tolerance (if recipient– and donor+)

• 20. Tacrolimus 0.15 mg/kg/24 h IV in perfusion 24 h; switch to PO when good oral intake and correct IV levels

• 21. Thymoglobulin 2 mg/kg IV in IV perfusion (over 12 h). Premedicate patients 30 min before administration with prednisone 2 mg/kg, Benadryl 1 mg/kg, and acetaminophen 10 mg/kg.

• 22. Prednisone 2 mg/kg/day.

• 23. Topical tacrolimus 0.1 % 2 times per day for 2 months (start 10 days postoperative).

• 24. Mycostatin oral rinses every 8 h.

• 25. Omeprazole 40 mg/24 h.

• 26. AAS 100 mg PO every 24 h (3 weeks).

• 27. Low molecular heparin s.c. when platelet count >100,000.

• 28. Check capillary glucose every 6 h.

• 29. Insulin in sliding scale.

• 30. In case of rejection, start protocol (boluses of methylprednisolone) followed by daily quick taper:

  • (a) First day, 5 mg/kg/day = _______ mg IV Q 6 h (divided in 4 doses)

  • (b) Second day, 4 mg/kg/day = _______ mg IV Q 6 h (divided in 4 doses)

  • (c) Third day, 3 mg/kg/day = _______ mg IV Q 6 h (divided in 4 doses)

  • (d) Fourth day, 2 mg/kg/day = _______ mg IV Q 6 h (divided in 4 doses)

  • (e) Fifth day, 2 mg/kg/day = _______ mg IV Q 12 h (divided in 2 doses); continued overtime mandated by clinical course