Continuous Infusion of Local Anesthesia After Living Donor Nephrectomy: A Comparative Analysis

Peri-Incisional Infiltration and Intraperitoneal Instillation of Local Anesthetic for Reducing Pain After Laparoscopic Donor Nephrectomy: A Prospective, Randomized, Double-Blind Control Trial

BACKGROUND

The analgesic efficacy of peri-incisional infiltration and intraperitoneal instillation of ropivacaine in laparoscopic donor nephrectomy has not been clearly established.

METHODS

This randomized, controlled, double-blind trial allocated living donors undergoing left-sided laparoscopic donor nephrectomy to one of the following 4 groups: peri-incisional normal saline (NS) and intraperitoneal NS (group A, n = 30), peri-incisional 0.375% ropivacaine and intraperitoneal NS (group B, n = 31), peri-incisional NS and intraperitoneal 0.15% ropivacaine (group C, n = 31), and peri-incisional 0.375% and intraperitoneal 0.15% ropivacaine (group D, n = 32). Pain status was assessed using the visual analog scale at rest and during coughing at 2, 12, 24, and 48 hours postoperatively. Patient-controlled analgesia and additional rescue analgesic consumption were calculated by conversion to an equivalent dosage of morphine. This study did not include prisoners or those individuals who were coerced or paid as study participants.

RESULTS

The patient demographics and perioperative outcomes, including operative time, blood loss, and incision length, were comparable between the groups. The pain scores and number of patients who experienced shoulder pain at all postoperative time points did not differ significantly among the 4 groups. Postoperative analgesic consumption was similar in all groups, and there was no difference in the length of hospital stay.

CONCLUSION

Peri-incisional infiltration and intraperitoneal instillation of ropivacaine did not reduce postoperative pain or analgetic consumption.

An Evaluation of the Effect of Catheter-Directed Continuous Infusion of Local Anesthetic by Elastomeric Pump on Opioid Usage Following Donor Kidney Nephrectomy

BACKGROUND

Postoperative pain management following donor nephrectomy can prove challenging for immediate discharge on postoperative day 1 or 2. Although the standard for pain control is utilization of opioids, this increases the risk of postoperative ileus and, if continued inappropriately, increases excess opioids circulating in the community. One strategy that proposes to limit postoperative opioids in kidney donors is the continuous infusion of local anesthetics (CILA), though the effect on patient outcomes is unclear.

OBJECTIVE

The purpose of this study was to evaluate the effectiveness of postoperative CILA to decrease opioid usage in kidney donors who undergo laparoscopic nephrectomy.

METHODS

A retrospective analysis was conducted of kidney donors who underwent laparoscopic nephrectomy and received CILA (CILA group) compared with kidney donors who received standard-of-care (SOC) postoperative analgesia. The primary outcome was the mean total oral morphine equivalents (OMEs) administered following surgery.

RESULTS

A total of 176 kidney donors were evaluated, 88 in each group. The mean OME administered in the CILA group was significantly higher than in the SOC group: 194.8 versus 133.5 mg (P = 0.003). Mean total postoperative administration of acetaminophen was also increased in the CILA group: 3736.9 versus 2611.6 mg (P = 0.0041). Mean length of stay following surgery was higher in the kidney donors who received CILA, whereas return to bowel function, time to ambulation, and pain scores were not significantly different.

CONCLUSION AND RELEVANCE

This report demonstrated that CILA is not an effective modality to reduce opioid utilization or improve recovery in kidney donors following laparoscopic nephrectomy.

Evaluation of a multimodal analgesic regimen on outcomes following laparoscopic living donor nephrectomy

Postoperative pain is a significant source of morbidity in patients undergoing living donor nephrectomy (LDN) and a deterrent for candidates. We implemented a standardized multimodal analgesic regimen, which consists of pharmacist-led pre-procedure pain management education, a combination transversus abdominis plane and rectus sheath block performed by the regional anesthesia team, scheduled acetaminophen and gabapentin, and as-needed opioids. This single-center retrospective study evaluated outcomes between patients undergoing LDN who received a multimodal analgesic regimen and a historical cohort. The multimodal cohort had a significantly shorter length of stay (LOS) (days, mean ± SD: 1.8 ± 0.7 vs. 2.6 ± 0.8; p < .001) and a greater proportion who were discharged on postoperative day (POD) 1 (38.6% vs. 1.5%; p < .001). The total morphine milligram equivalents (MME) that patients received during hospitalization were significantly less in the multimodal cohort on POD 0-2. The outpatient MME prescribed through POD 60 was also significantly less in the multimodal cohort (median [IQR]; 180 [150-188] vs. 225 [150-300]; p < .001). The mean patient-reported pain score (PRPS) was significantly lower in the multimodal cohort on POD 0-2. The maximum PRPS was significantly lower on POD 0 (mean ± SD: 7 ± 2 vs. 8 ± 1, respectively; p = .02). This study suggests that our multimodal regimen significantly reduces LOS, PRPS, and opioid requirements and has the potential to improve the donation experience.

Feasibility, Safety and Efficacy of Enhanced Recovery After Living Donor Nephrectomy: Systematic Review and Meta-Analysis of Randomized Controlled Trials

This meta-analysis aims to compare enhanced recovery after surgery (ERAS) vs. standard perioperative practice in the management of living kidney donors. Primary endpoints included mortality, complications, length of stay (LOS) and quality of life after living donor nephrectomy. Medline, Embase, Scopus, Cochrane and Web of Science databases were searched. In total, 3029 records were identified. We then screened 114 full texts. Finally, 11 studies were included in the systematic review corresponding to 813 living donors. Of these, four randomized controlled trials were included in the meta-analysis. ERAS resulted in shorter LOS (95CI: −1.144, −0.078, I² = 87.622%) and lower incidence of post-operative complications (95CI: 0.158, 0.582, I² = 0%). This referred to Clavien–Dindo I-II complications (95CI: 0.158, 0.582, I² = 0%). There was no difference in Clavien–Dindo III-V complications (95CI: 0.061,16.173, I² = 0%). ERAS donors consumed decreased amounts of narcotics during their hospital stay (95CI: −27.694, −8.605, I² = 0%). They had less bodily pain (95CI: 6.735, 17.07, I² = 0%) and improved emotional status (95CI: 6.593,13.319, I² = 75.682%) one month postoperatively. ERAS protocols incorporating multimodal pain control interventions resulted in a mean reduction of 1 day in donors’ LOS (95CI: −1.374, −0.763, I2 = 0%). Our results suggest that ERAS protocols result in reduced perioperative morbidity, shorter length of hospital stay and improved quality of life after living donor nephrectomy.

Introduction of an enhanced recovery protocol into a laparoscopic living donor nephrectomy programme

INTRODUCTION

Living-donor renal transplantation is the optimal treatment for patients with end-stage renal disease. The rate of living donation in the UK is sub-optimal, and potential donor concerns regarding postoperative recovery may be contributory. Enhanced recovery programmes are well described for a number of surgical procedures, but experience in living-donor surgery is sparse. This study reports the impact of introducing an enhanced recovery protocol into a living-donor renal transplant programme.

MATERIALS AND METHODS

All consecutive patients undergoing laparoscopic living-donor nephrectomy over a 25-month period were included. The principles of enhanced recovery were fluid restriction, morphine sparing and expectation management. Outcome measures were postoperative pain scores and complications for donor and recipients.

RESULTS

Standard care was provided for 24 (30%) patients and 57 (70%) followed an enhanced recovery pathway. The latter group received significantly less preoperative intravenous fluid (0ml vs 841ml p < 000.1) and opiate medication (14.83mg vs 23.85mg p = 0.001). Pain scores, postoperative complications and recipient transplant outcomes were comparable in both groups.

CONCLUSIONS

Enhanced recovery for living-donor nephrectomy is a safe approach for donors and recipients. Application of these techniques and further refinement should be pursued to enhance the experience of living donors.

Continuous Wound Infiltration of Local Anesthetics in Postoperative Pain Management: Safety, Efficacy and Current Perspectives

Local infiltration and continuous infusion of surgical wound with anesthetics are parts of multimodal analgesia for postoperative pain control. The techniques, given the simplicity of execution that does not increase the timing of the intervention and does not require additional technical skills, are applied in several kinds of surgeries. The continuous wound infiltration can be used for days and a variety of continuous delivery methods can be chosen, including patient-controlled analgesia, continuous infusion or intermittent bolus. The purpose of this narrative review is to analyze the literature, in particular by researching the safety, efficacy and current perspectives of continuous wound infiltration for postoperative pain management in different surgical settings. We have identified 203 articles and 95 of these have been taken into consideration: 17 for the lower limb surgery; 7 for the upper limb surgery, 51 for the laparotomy/laparoscopic surgery of the abdominopelvic area, 13 studies regarding breast surgery and 7 for cardiothoracic surgery. The analysis of these studies reveals that the technique has a variable effectiveness based on the type of structure involved: it is better in structures rich in subcutaneous and connective tissue, while the effectiveness is limited in anatomic districts with a greater variability of innervation. However, regardless the heterogeneity of results, a general reduction in pain intensity and in opioid consumption has been observed with continuous wound infiltration: it is an excellent analgesic technique that can be included in the multimodal treatment of postoperative pain or represents a valid alternative when other options are contraindicated.

Intraperitoneal nebulization versus intraperitoneal instillation of ropivacaine for postoperative pain management following laparoscopic donor nephrectomy

BACKGROUND

Laparoscopic donor nephrectomy is considered less painful than open nephrectomy but is still associated with significant postoperative pain. Studies reported that intraperitoneal instillation of local anesthetics provides uncertain pain relief after laparoscopic surgery. This randomized, double-blind study evaluated the effect of intraperitoneal nebulization of ropivacaine on postoperative pain relief after laparoscopic donor nephrectomy.

METHODS

Sixty patients undergoing elective laparoscopic donor nephrectomy were randomly assigned to receive either an instillation of 20 ml 0.5% ropivacaine after the induction of pneumoperitoneum or nebulization of 5 ml 1% ropivacaine before and after surgery. The primary outcome was the degree of pain relief (static and dynamic) after surgery. The secondary outcomes were postoperative fentanyl consumption, incidence of shoulder pain, unassisted walking and postoperative nausea and vomiting (PONV). Data were collected in the postanesthesia care unit (PACU) and at 6, 24, and 48 h after surgery.

RESULTS

Compared to patients in the instillation group, those in the nebulization group showed significant reductions in postoperative pain and fentanyl consumption, and none complained of significant shoulder pain (visual analog scale score ≥ 30 mm). Within 20 h of surgery, 13.3% of patients in the instillation group and 93.3% in the nebulization group started unassisted walking (absolute risk reduction, 38%; P = 0.001). In the nebulization group, PONV was significantly reduced in the PACU and at 6 h.

CONCLUSIONS

Intraperitoneal nebulization of ropivacaine reduced postoperative pain, fentanyl consumption, referred shoulder pain, and PONV while enabling earlier mobility without any difference in the length of hospital stay.

Effectiveness of Epidural Analgesia, Continuous Surgical Site Analgesia, and Patient-Controlled Analgesic Morphine for Postoperative Pain Management and Hyperalgesia, Rehabilitation, and Health-Related Quality of Life After Open Nephrectomy: A Prospective, Randomized, Controlled Study

BACKGROUND

There is no widely recognized effective technique to optimally reduce pain scores and prevent persistent postoperative pain after nephrectomy. We compared continuous surgical site analgesia (CSSA), epidural analgesia (EA), and a control group (patient-controlled analgesic morphine) in patients undergoing open nephrectomy.

METHODS

Sixty consecutive patients were randomized to be part of EA, CSSA, or control groups postoperatively for 72 hours. All patients received patient-controlled analgesic morphine, if needed. Hyperalgesia was assessed on the first, second, and third postoperative days. Chronic pain characteristics and quality of life were analyzed at 1 and 3 months. The primary outcome was the pain score at 24 hours. Secondary outcomes were morphine consumption, postoperative rehabilitation, hyperalgesia, chronic pain incidence, and quality-of-life parameters.

RESULTS

At 24 hours, mean ± standard deviation pain values at rest (2.4 ± 1.7, 2.2 ± 1.2, and 4.2 ± 1.2, respectively, in EA, CSSA, and control groups, P <.001) and during coughing was lower in the EA and CSSA groups. Total morphine consumption was higher in the control group. Rehabilitation parameters improved sooner in the EA and CSSA groups. Median values of area of hyperalgesia differed at 48 hours between the EA group and the control group (36.4 cm) and (52 cm) (P = .01) and at 72 hours among the EA group, CSSA group, and the control group (40 cm, 39.5 cm, and 59 cm, respectively; P = .002). CSSA reduced the severity of pain and hyperalgesia at 1 month and optimized quality of life 3 months after surgery (role physical scores, P = .005).

CONCLUSIONS

CSSA and EA significantly improve postoperative analgesia, reduce postoperative morphine consumption, area of wound hyperalgesia, and accelerate patient rehabilitation after open nephrectomy. CSSA significantly reduces the severity of residual pain 1 month after surgery and optimizes quality-of-life parameters 3 months after surgery.

Postoperative pain control using continuous i.m. bupivacaine infusion plus patient-controlled analgesia compared with epidural analgesia after major hepatectomy

OBJECTIVES

There is debate concerning the best mode of delivery of analgesia following liver resection, with continuous i.m. infusion of bupivacaine (CIB) plus patient-controlled i.v. analgesia (PCA) suggested as an alternative to continuous epidural analgesia (CEA). This study compares these two modalities.

METHODS

A total of 498 patients undergoing major hepatectomy between July 2004 and July 2011 were included. Group 1 received CIB + PCA (n = 429) and Group 2 received CEA (n = 69). Groups were analysed on baseline patient and surgical characteristics. Primary endpoints were pain severity scores and total opioid consumption. Secondary endpoints were pain management failures, need for rescue medication, postoperative (opioid-related) morbidity and hospital length of stay (LoS).

RESULTS

In both groups pain was well controlled and >70% of patients had no or minimal pain on PoDs 1 and 2. The numbers of patients experiencing severe pain were similar in both groups: PoD 1 at rest: 0.3% in Group 1 and 0% in Group 2 (P = 1.000); PoD 1 on movement: 8% in Group 1 and 2% in Group 2 (P = 0.338); PoD 2 at rest: 0% in Group 1 and 2% in Group 2 (P = 0.126), and PoD 2 on movement: 5% in Group 1 and 5% in Group 2 (P = 1.000). Although the CIB + PCA group required more opioid rescue medication on PoD 0 (53% versus 22%; P < 0.001), they used less opioids on PoDs 0-3 (P ≤ 0.001), had lower morbidity (26% versus 39%; P = 0.018), and a shorter LoS (7 days versus 8 days; P = 0.005).

CONCLUSIONS

The combination of CIB + PCA provides pain control similar to that provided by CEA, but facilitates lower opioid consumption after major hepatectomy. It has the potential to replace epidural analgesia, thereby avoiding the occurrence of rare but serious complications.

Pain management in laparoscopic donor nephrectomy: a review

The management of postoperative pain is a key to patient early recovery, in particular, where the surgery was performed to benefit another human being. In recent years it has been recognized that multimodal analgesic methods are superior for postoperative pain relief. It is also imperative to remember that inadequately managed acute postoperative pain opens the doorway to possible suffering from chronic postoperative pain later. Although the laparoscopic donor nephrectomy has reduced the disincentives associated with open surgery, still significant percentage of donors suffers from postoperative pain. In the UK, patient-controlled analgesic system (PCAS) using morphine for postoperative pain relief is being used in majority of the transplant centres. Though opioids provide good analgesia, they are far from being an ideal analgesic due to their adverse effects. This paper pragmatically looks in depth on different modalities of pain management in patients undergoing laparoscopic live donor nephrectomy.