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systemic vasopressors. Nevertheless, of the 13 anesthesiologists who responded to the survey, 6 chose continuous infusion and 7 chose intermittent boluses of catecholamines as temporizing measures. Postoperative follow-up reporting the results of these approaches would have been useful in highlighting any detrimental effect on flap outcome.One of the frustrating issues that the anesthesiologists faced was the poor visibility of the surgical field (away by 180 degrees) and hence the difficulty in identifying blood loss in timely fashion. We suggest overhead cameras integrated into the light handle over the operating room table to ameliorate this problem. We welcome the suggestion of using specialized drapes for sterile blood collection from the operative field and the use of cell savers.In a procedure as rare and extensive as facial transplantation, careful planning must be undertaken by both the surgical and anesthetic teams, and many challenges must be addressed. This review describes several of the anticipated issues that may be encountered by the anesthetic team. Long-term outcomes for these patients need to be reviewed before being able to establish specific guidelines to provide optimal care for these complicated procedures.R econstructive surgery, that which combines the principles of plastic and transplantation surgeries, is a growing multidisciplinary specialty. Upper-extremity transplantation is now performed at 7 centers in the United States. Although much information has been published on the immunologic and surgical aspects of upper-extremity transplantation, no studies on anesthetic management of this technology have been reported. This article discusses the challenges and considerations in upperextremity transplant anesthesia based on experience at the authors' institutions. The Pittsburgh Upper Extremity Transplant Anesthesiology Protocol (PUETAP) provides guidelines and recommendations for management of the transplant recipients.The protocol focuses on fluid management, intraoperative monitoring, and regional anesthesia strategies. For fluid management, the recommendation is to use an intravenous access via the internal jugular route with a large-bore catheter, a single-lumen infusion catheter inserted through the diaphragm of the introducer to monitor central venous pressure for a unilateral transplant, and a 7-gauge double-lumen central venous catheter in the jugular vein for bilateral hand transplantation. The trauma resuscitation protocol is followed with a ratio of 1 unit of packed red blood cells to 1 unit of fresh frozen plasma to 250 mL normal saline. This provides a hematocrit value of 26% to 28% in the rapid infusion system (RIS) reservoir. Every procedure must have at least 10 units of packed red blood cells and 10 units of fresh frozen plasma on hand along with adequate platelets. Any >-agonists should be avoided because they may affect graft perfusion. Dopamine is used when hypotension cannot be corrected by intravenous fluid or blood product infusions. Arterial blood gases, electroly...

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