Decreased patient analgesic requirements after liver transplantation and associated neuropeptide levels

The Practice of Fast-Track Liver Transplant Anesthesia

Prior to the 1990s, prolonged postoperative intubation and admission to the intensive care unit was considered the standard of care following liver transplantation. Advocates of this practice speculated that this time allowed patients to recover from the stress of major surgery and allowed their clinicians to optimize the recipients' hemodynamics. As evidence in the cardiac surgical literature on the feasibility of early extubation grew, clinicians began applying these principles to liver transplant recipients. Further, some centers also began challenging the dogma that patients need to be cared for in the intensive care unit following liver transplantation and instead transferred patients to the floor or stepdown units immediately following surgery, a technique known as "fast-track" liver transplantation. This article aims to provide a history of early extubation for liver transplant recipients and offer practical advice on how to select patients that may be able to bypass the intensive care unit and be recovered in a non-traditional manner.

Nonopioid Modalities for Acute Postoperative Pain in Abdominal Transplant Recipients

The field of abdominal organ transplantation is multifaceted, with the clinician balancing recipient comorbidities, risks of the surgical procedure, and the pathophysiology of immunosuppression to ensure optimal outcomes. An underappreciated element throughout this process is acute pain management related to the surgical procedure. As the opioid epidemic continues to grow with increasing numbers of transplant candidates on opioids as well the increase in the development of enhanced recovery after surgery protocols, there is a need for greater focus on optimal postoperative pain control to minimize opioid use and improve outcomes. This review will summarize the physiology of acute pain in transplant recipients, assess the impact of opioid use on post-transplant outcomes, present evidence supporting nonopioid analgesia in transplant surgery, and briefly address the perioperative approach to the pretransplant recipient on opioids.

Decreased analgesic requirement in recipient of liver transplantation from monozygotic twin - A case report

Background

There have been many reports about decreased analgesic requirements in liver transplant recipients compared with patients undergoing other abdominal surgery.

Case

Herein we describe a case in which a 42-year-old man underwent living donor liver transplantation from his monozygotic twin. Because innate pain thresholds may be similar in monozygotic twins, we could effectively investigate postoperative pain in the donor and the recipient. Concordant with previous reports, the recipient used less analgesic than the donor in the present study.

Conclusions

Physicians caring for patients who have received liver transplantation should consider their comparatively low requirement for analgesic, to prevent delayed recovery due to excessive use of analgesic.

Comparison of bispectral index targeted end-tidal concentration of desflurane during three phases of orthotopic liver transplantation

Background and Aims:

Reduced inhalational anaesthetic requirement in end-stage liver disease during living donor orthotopic liver transplantation (LD-OLT) is due to increased endogenous opioids. This study evaluated the changes in bi-spectral index (BIS) monitored end-tidal desflurane (ET_Des) requirements during ‘dissection’, ‘anhepatic’, and ‘neohepatic’ phases of LD-OLT.

Methods:

This prospective, cohort study included 40 adults undergoing LD-OLT under general anaesthesia (GA). All patients received BIS-guided desflurane GA. ET_Des requirements in three phases of LD-OLT (primary objective); relationship between inhalational anaesthetic requirements and severity of liver disease; and effect of changes in mean arterial pressure (MAP) and body temperature on ET_Des concentration for all three phases were also evaluated.

Results:

ET_Des during the ‘dissection’ phase (2.92 ± 0.65%) was > ‘anhepatic’ (2.68 ± 0.85%, P = 0.049) and ‘neohepatic’ phases (2.58 ± 0.71%, P = 0.005). Patients with model of end-stage liver disease (MELD) score < 20 returned significantly greater ET_Des than those with MELD score ≥20 during the ‘dissection’ (MELD <20: 3.11 ± 0.49%; MELD ≥20: 2.58 ± 0.77%, P = 0.01) and ‘anhepatic’(MELD <20: 2.96 ± 0.76%; MELD ≥20: 2.17 ± 0.79%, P = 0.003) phases. A positive correlation was observed between ET_Des(r = 0.584, P = 0.001) and temperature in the ‘dissection’ phase only.

Conclusion:

In patients undergoing LD-OLT, BIS monitoring guidance of depth of desflurane GA suggests lower desflurane requirements during ‘anhepatic’ and the ‘neohepatic’ phase of surgery. Also, the desflurane requirement is greater in patients with lesser severity of liver disease.

Pain control after liver transplantation surgery

BACKGROUND

Although post-liver transplantation pain is not as severe as expected from the size of the surgical incision, optimal pain control becomes crucial to aid compliance with the ventilator, improve respiratory function, and facilitate an early weaning from mechanical ventilation.

METHODS

Because the majority of analgesics are primarily metabolized and excreted by the hepatobiliary system, a poor recovery of graft function will result in a decrease in clearance and reduced elimination of the drug. On the other hand, if the liver is working well, the metabolism of analgesics improves significantly with minimal accumulation. Morphine-based analgesia has been associated with a higher risk of sedation and respiratory depression compared with major abdominal surgical procedures. Fentanyl and sufentanil in continuous intravenous infusion may be preferred in the presence of hemodynamic instability or bronchospasm. Sufentanil produces shorter-lasting respiratory depression and long-lasting analgesia than does fentanyl.

RESULTS

The provision of potent continuous analgesia, independent of the duration of infusion, and the unique pharmacokinetics, not significantly affected by the functional status of the graft, make remifentanil appropriate for the majority of liver-transplanted patients. Unlike for patients with very severe pain after major abdominal surgery, liver transplant recipients usually benefit from tramadol, either in repeated intravenous boluses or continuous intravenous infusion. Paracetamol has been included as adjuvant (or sole agent, rarely) in the analgesic treatment of mild to moderate postoperative pain. The combination treatment (paracetamol plus tramadol) is a reasonable, safe option with improved analgesia and concurrent reduction in the incidence of some opioid-related side effects.

CONCLUSIONS

Frequent review of the patient's response is mandatory when potent opioids are used because dose-dependent respiratory depression is a serious and potentially life-threatening adverse effect. The benefits provided by epidural analgesia in this particular setting should be weighed against the risks because in the presence of markedly deranged perioperative blood clotting, the development of epidural hematoma represents a disastrous complication.

Entropy-guided end-tidal desflurane concentration during living donor liver transplantation

Background:

The three phases of living donor liver transplantation (LDLT) represent different liver conditions. The aim is to study the required end-tidal desflurane concentration (ET-Des) guided with entropy monitoring for the depth of anesthesia.

Methods:

After the Ethics and Research Committee approval, 40 patients were included in this prospective study. Anesthesia was maintained with Desflurane-O2-air. State entropy (SE) and Response entropy (RE) were kept between 40 and 60.

Results:

Age and Model for End-stage Liver Disease (MELD) score were 45±10 years and 15.43±3.92, respectively. ET-Des were significantly lower in the anhepatic phase (2.8±0.4%) than in the pre-anhepatic and neohepatic phases (3.3±0.3%, 3.47±0.3%, respectively, P<0.001). The SE and RE for pre-anhepatic, anhepatic, and neohepatic phases were (45.6±3.7, 47.4±3.2), (44.7±2.1, 46.4±2.04), and (46.1±3.3, 47.9±3.3), respectively, with no significant changes between the phases, P > 0.05. Total operative time was 651±88 minutes, and for each phase it was 276±11, 195±55, and 191±24 minutes, respectively. Significant changes were found in hemoglobin g/dl and hematocrit % between the three phases (10.28±1.5, 30.48±4.3), (9.45±1.34, 28.36±4.1), and (8.88±1.1, 26.63±3.5), P<0.05. The heart rate and mean blood pressures were stable despite the cardiac index demonstrated a significant reduction during the anhepatic phase (2.99±0.22) when compared to the pre-anhepatic and neohepatic phases (3.60±0.29) and (4.72±0.32), respectively, (P<0.05). There was a significant correlation between CI and ET-Des% (r=0.604, P<0.05).

Conclusion:

Inhalational anesthetic requirements differed from one phase to another during LDLT, with requirements being the least during the anhepatic phase. Monitoring of the anesthesia depth was required, to avoid excess administration, which could compromise the hemodynamics before the critical time of reperfusion.

Clinical practice of early extubation after liver transplantation

BACKGROUND

Anesthetic practices such as early tracheal extubation facilitate postoperative recovery. Early extubation after liver transplantation has been adopted by some centers in the recent two decades. No universal clinical guidelines are used and questions remain. This review aimed to address the current status of early extubation after liver transplantation.

DATA SOURCES

A literature search of MEDLINE and ISI Web of Knowledge databases was performed using terms such as liver transplantation, early extubation, immediate tracheal extubation, fast tracking or fast track anesthesia and postoperative tracheal extubation. Additional papers were identified by a manual search of the references in the key articles.

RESULTS

Review of the available literature provided an insight into the definition, evolution, advantages and risks of early extubation, and anesthetic techniques that prompt early extubation in liver transplant patients. Early extubation has proved to be feasible and safe in these patients, but the outcomes are still uncertain.

CONCLUSIONS

Early extubation after liver transplantation is feasible, safe and cost-effective in the majority of patients and has been increasingly accepted as an option for conventional postoperative ventilation. Comprehensive and individualized evaluation of the patient's condition before extubation by an experienced anesthesiologist is the cornerstone of success. Understanding of its effect on the outcome remains incomplete. In the future, additional trials are required to establish universal early extubation guidelines and to determine its benefits for patients and practitioners.

The relationship between postoperative intravenous patient-controlled fentanyl analgesic requirements and severity of liver disease

PURPOSE

Decreased inhalational anesthetic requirements during orthotopic liver transplantation (OLT) have been reported according to the severity of the pre-existent disease as well as decreased opioid requirements thereafter. The aim of the present study was to determine the relationship between postoperative opioid requirements and severity of liver disease among OLT patients.

METHODS

We retrospectively reviewed 44 recipients who used intravenous fentanyl-based patient-controlled analgesia (PCA) after OLT from November 2009 to May 2010. The severity of liver disease was assessed using the model for end-stage liver disease (MELD) score. Recipients were divided into a low-MELD group (<20; n=30) and a high-MELD group (≥20; n=14). The amounts of PCA infusion and rescue opioid up to 3 postoperative days (POD) were compared between the 2 groups. The intensity of pain at rest and when coughing was assessed using visual analog scale (VAS) scores.

RESULTS

The cumulative opioid requirements via PCA on POD 1, 2, and 3 were significantly lower in the high-MELD than the low-MELD group. The amounts of rescue opioid were similar between the 2 groups. However, the intensity of pain at both rest and when coughing on POD 1, 2, and 3 were significantly less severe in the high-MELD than the low-MELD group.

CONCLUSIONS

OLT patients with high MELD scores required less postoperative opioids and experienced less pain than those with low scores. Therefore, postoperative pain control after OLT should be carefully titrated according to the severity of the liver disease.

Minimum alveolar concentration of sevoflurane in rabbits with liver fibrosis

BACKGROUND

Sevoflurane is widely used in patients undergoing surgical procedures, which could affect both the liver function and hepatic blood flow. However, the effects of liver fibrosis on minimum alveolar concentration (MAC) of sevoflurane are still unclear. Therefore, we designed this study to determine the MAC of sevoflurane in rabbits with liver fibrosis.

METHODS

Thirty male New Zealand white rabbits weighing approximately 2.5 kg were divided randomly into 2 groups: fibrosis (n = 20) and normal control group (n = 10). The rabbits in the fibrosis group were treated with 50% carbon tetrachloride for 12 weeks to induce liver fibrosis. The serum concentration of total protein, albumin, globulin, total bile acids, alanine aminotransferase, aspartame aminotransferase, alkaline phosphatase, γ-glutamyl transpeptidase, total bilirubin, direct bilirubin, and indirect bilirubin were measured before anesthesia. The anesthesia for animals that survived in both groups was induced and maintained with sevoflurane. A standard tail-clamp technique was used to determine the MAC of sevoflurane in spontaneously breathing rabbits. After anesthesia, animals were killed for liver pathologic examination.

RESULTS

Twelve weeks after 50% carbon tetrachloride administration, 14 of 20 rabbits survived in the fibrosis group, and 9 of 10 survived in the control group. All surviving animals in the fibrosis group had developed moderate to severe liver fibrosis. Three rabbits that survived after the fibrosis challenge were excluded for other diseases or no response to pain stimulation. The levels of globulin, aspartame aminotransferase, and γ-glutamyl transpeptidase significantly increased in fibrosis animals compared with controls. However, the albumin and alkaline phosphatase levels were significantly lower in the fibrosis group than in the control group. Mean arterial blood pressure, heart rate, end-tidal CO(2), and temperature were stable in both groups during sevoflurane anesthesia. The MAC of sevoflurane was significantly less in the fibrosis group than in the control group (3.52% vs 4.10%, P = 0.018).

CONCLUSION

The MAC of sevoflurane decreased significantly in rabbits with liver fibrosis.

The relationship between inhalational anesthetic requirements and the severity of liver disease in liver transplant recipients according to three phases of liver transplantation

PURPOSE

Orthotopic liver transplantation (OLT) patients are known to show decreased intraoperative anesthetic requirements compared with patients undergoing other liver surgeries. The aim of this study was to determine the relationship between inhalational anesthetic requirements and the severity of liver disease among OLT patients.

METHODS

Fifty patients undergoing first living donor OLT were divided into 2 groups: model for end-stage liver disease (MELD) score<20 (low-MELD group; n=25) versus, MELD score>or=20 (high-MELD group; n=25). Anesthesia was maintained with desflurane and inspired concentration was titrated to maintain the bispectral index between 40 and 50. Neither intraoperative opioid nor epidural or intrathecal analgesia was used. End-tidal desflurane concentration (ETdes) was measured every 5 minutes and averaged in 30-minute intervals. These values were divided into 3 phases: preanhepatic (P 0.5 hour, P 1 hour, and P 1.5 hours), anhepatic (A 0.5 hour, A 1 hour, A 1.5 hours, and A 2 hours), and postreperfusion (R 0.5 hour, R 1 hour, R 1.5 hours, R 2 hours, R 2.5 hours, and R 3 hours). Results were compared between the 2 groups.

RESULTS

The demographic and intraoperative data were similar between the 2 groups. ETdes to maintain comparable anesthetic depth was significantly lower during the preanhepatic and anhepatic phases in the high-MELD than the low-MELD group, but there was no significant difference during the postreperfusion period.

CONCLUSIONS

OLT patients with high MELD scores showed less inhalational anesthetic requirements during the preanhepatic and the anhepatic periods than those with low MELD scores.

Comparison of postoperative morphine requirements in healthy living liver donors, patients with hepatocellular carcinoma undergoing partial hepatectomy, and liver transplant recipients

OBJECTIVE

To retrospectively evaluate postoperative morphine requirements in healthy living donors undergoing partial hepatectomy and patients with end-stage hepatocellular carcinoma or end-stage liver disease undergoing liver transplantation.

PATIENTS AND METHODS

The study included all patients who received intravenous patient-controlled analgesia after partial hepatectomy or liver transplantation from May 2008 to February 2009. Patients were divided into 3 groups according to type of surgery: group 1, healthy living liver donors undergoing graft procurement; group 2, patients with liver cirrhosis due to chronic hepatitis B virus or hepatitis C virus infection and hepatocellular carcinoma undergoing hepatectomy; and group 3, patients with end-stage liver disease undergoing living-donor liver transplantation. Data including patient age, morphine use, and visual analog scale score on postoperative days (PODs) 1, 2, and 3 were compared between groups using 2-way analysis of variance. P<.05 was considered significant. Values are given as mean (SD).

RESULTS

Morphine requirement was significantly lower only in group 3 on POD 1. No difference in visual analog scale score between groups was observed postoperatively.

CONCLUSION

Although others have reported decreased morphine requirements on PODs 1, 2, and 3, our results indicated that morphine requirements were significantly less only on POD 1.

Postoperative Sedation and Analgesia After Pediatric Liver Transplantation

The goal of sedation in the pediatric intensive care unit (PICU) is to produce a calm and comfortable child, free from pain and discomfort. Children receiving liver transplantation need analgesics to control pain from surgical incisions, drains, vascular access, or endotracheal suctioning. Sedatives are used to facilitate the delivery of nursing care, to prevent self-extubation, and to facilitate mechanical ventilation. Optimal sedation produces a state in which the patient is somnolent, responsive to the environment but untroubled by it, and with no excessive movements. A common problem in the PICU is the fluctuation in the delivery of sedatives and analgesics depending on the health care providers and on a breakdown in communication between physicians and nurses to define end points for pharmacological therapy. This variability more often leads to oversedation rather than undersedation. Oversedation delays extubation, promotes ventilator-associated pneumonia, and increases the risk of reintubation. The use of written sedation policies to guide practice at the bedside reduces the length of time for which patients require mechanical ventilation and the length of PICU stay. Protocols for drug administration practices increase patient safety during mechanical ventilation, promote nursing autonomy, and facilitate communication between nurses and physicians as well as between nurses.

The use of caudal morphine for pediatric liver transplantation

A 3-yr-old female with cryptogenic cirrhosis presented for a liver transplant. After the induction and intubation, we performed a supplemental caudal block with a 22-gauge B-bevel needle in the usual sterile fashion, and 0.6 mg of Duramorph was injected without complications. Initially, the 14.9-kg child received a total of 110 microg of fentanyl in the first 2 h of the 6-h operation and was maintained on air-oxygen-isoflurane. The child was easily tracheally extubated and remained hemodynamically stable. In the pediatric intensive care unit, she was weaned off oxygen, out of bed, and required minimal pain control in the first 18 h.

Orthotopic liver transplant patients require less postoperative morphine than do patients undergoing hepatic resection

STUDY OBJECTIVE

To compare postoperative morphine use, analgesic efficacy, and side effect profiles in patients following orthotopic liver transplantation (OLTx) and liver resection (LR).

DESIGN

Retrospective study.

SETTING

Liver transplant and liver resection surgery at a university hospital.

PATIENTS

25 ASA physical status I, II, III, and IV patients undergoing OLTx or liver resection.

MEASUREMENTS AND MAIN RESULTS

Morphine use was significantly decreased in the OLTx patients at 6,12, 24, 48, and 72 hours following commencement of patient-controlled analgesia. After commencement of patient-controlled analgesia, pain scores were significantly reduced in the OLTx group compared with those in the liver resection group at 6 and 12 hours.

CONCLUSIONS

Orthotopic liver transplant patients experienced less pain and used less morphine postoperatively than did liver resection patients.

Induction of antinociception and increased met-enkephalin plasma levels by cyclosporine and morphine in rats: implications of the combined use of cyclosporine and morphine and acute posttransplant neuropsychosis

BACKGROUND

Cyclosporine A (CsA) and morphine have neurotoxic and psychiatric side effects, respectively. Endogenous opiatelike peptides can elicit a number of behavioral responses that mimic the symptoms of psychiatric illness. The purpose of this study was to quantitiate the changes of Met-enkephalin (ME) and beta-endorphin (BE) after administration of CsA and morphine in surgery and to assess the antinociceptive effect.

PATIENTS AND MATERIALS

Pain sensitivity, an antinociceptive indicator in rats, was determined with the hotplate test. Plasma ME and BE levels were measured with radioimmunoassays.

RESULTS

In normal unoperated rats, CsA induced a profound analgesic effect concomitant with an increased plasma ME level on day 1. Morphine produced an analgesic effect on days 1 and 2, with decreased ME levels on days 2 and 3. Coadministration of CsA and morphine prolonged the analgesia from days 1 to 4 and increased the plasma ME level on day 1. No change in plasma BE level was found. In surgically operated rats, CsA induced an analgesic effect and higher ME levels than those in unoperated rats. Interestingly, the combined use of CsA and morphine prolonged the analgesia and increased plasma ME levels from days 1 to 4, with no significant change in plasma BE levels.

CONCLUSIONS

Our results showed that CsA can induce antinociception and increase plasma ME levels. This induction can be potentiated by the addition of morphine. Acute neuropsychiatric manifestations in the early posttransplant period might, therefore, be due to induction of ME after coadministration of CsA and morphine.

Anaesthesia for patients with a transplanted organ

Increasing numbers of individuals leading normal lives have transplanted organs. They may appear in any hospital for treatment of trauma or general diseases. Common anaesthesia methods can be used for these patients, but safe conduct of anaesthesia requires knowledge of the immunosuppression, risk factors, and altered physiology or drug actions. This article reviews the anaesthesia-related literature on patients with transplanted organs.

Epidural analgesia reduces the release of amino acids from peripheral tissues in the ebb phase of the metabolic response to major upper abdominal surgery

The purpose of this prospective cohort study was to compare metabolic effects of epidural or patient controlled analgesia (PCA) in patients undergoing major upper abdominal surgery. Seventeen patients undergoing major upper abdominal surgery were included: 10 received perioperative epidural analgesia (Group I) and the remainder received morphine via a PCA device for postoperative analgesia (Group II). A number of measures compared between one day preoperatively (day 1) and day 2 postoperatively included femoral arterial and venous blood concentrations of glucose, lactate, pyruvate and amino acids. In addition, the relevant flux values were measured from the products of the respective arteriovenous substrate concentration differences and calf blood flow. The efflux of lactate from peripheral tissues was greater in Group II than in Group I (P < 0.01): glucose and pyruvate efflux did not differ between groups. There was no difference between groups in mean individual and total flux of amino acids on day-1. However increased efflux between day-1 and day 2 was found for alanine, valine, isoleucine, leucine, phenylalanine, lysine, arginine in both groups, and for serine, glycine, tyrosine and histidine in Group II (P < 0.05). The efflux of glycine, methionine, amino benzoic acid, alanine, and lysine was less in Group I than Group II on day 2 (P < 0.05). There was a significant difference in the total amino acid flux on day 2 (Group I = -1.2 mumol. (100 ml tissue)-1.min-1 cf Group II = -2.5 mumol. (100 ml tissue)-1.min-1; P = 0.04). In conclusion, perioperative epidural analgesia was associated with a reduced postoperative amino acid efflux two days following major upper abdominal surgery.