Lower rate of delayed graft function is observed when epidural analgesia for living donor nephrectomy is administered

Impact of spinal or epidural anaesthesia on perioperative outcomes in adult noncardiac surgery: a narrative review of recent evidence

Spinal and epidural anaesthesia and analgesia are important anaesthetic techniques, familiar to all anaesthetists and applied to patients undergoing a range of surgical procedures. Although the immediate effects of a well-conducted neuraxial technique on nociceptive and sympathetic pathways are readily observable in clinical practice, the impact of such techniques on patient-centred perioperative outcomes remains an area of uncertainty and active research. The aim of this review is to present a narrative synthesis of contemporary clinical science on this topic from the most recent 5-year period and summarise the foundational scholarship upon which this research was based. We searched electronic databases for primary research, secondary research, opinion pieces, and guidelines reporting the relationship between neuraxial procedures and standardised perioperative outcomes over the period 2018-2023. Returned citation lists were examined seeking additional studies to contextualise our narrative synthesis of results. Articles were retrieved encompassing the following outcome domains: patient comfort, renal, sepsis and infection, postoperative cancer, cardiovascular, and pulmonary and mortality outcomes. Convincing evidence of the beneficial effect of epidural analgesia on patient comfort after major open thoracoabdominal surgery outcomes was identified. Recent evidence of benefit in the prevention of pulmonary complications and mortality was identified. Despite mechanistic plausibility and supportive observational evidence, there is less certain experimental evidence to support a role for neuraxial techniques impacting on other outcome domains. Evidence of positive impact of neuraxial techniques is best established for the domains of patient comfort, pulmonary complications, and mortality, particularly in the setting of major open thoracoabdominal surgery. Recent evidence does not strongly support a significant impact of neuraxial techniques on cancer, renal, infection, or cardiovascular outcomes after noncardiac surgery in most patient groups.

Continuous Erector Spinae Plane Analgesia in Kidney Transplant Recipients: A Quality Improvement Project

Introduction Pain management in patients with chronic kidney disease is challenging. Due to impaired kidney function, analgesic options are limited. Postoperative analgesia in transplant recipients is further complicated by their vulnerability to infections, titrated fluid management and optimal haemodynamics to maintain graft function. Erector spinae plane (ESP) blocks have been used successfully in a variety of surgeries. This study is a quality improvement project aiming to assess the efficacy of continuous erector spinae plane catheter analgesia in the postoperative management of kidney transplant recipients. Methods We conducted an initial audit over a period of three months. All patients who underwent kidney transplantation under general anaesthesia with erector spinae plane catheters were included. Erector spinae plane catheters were secured prior to induction, and continuous local anaesthetic infusion was maintained postoperatively. Pain scores using the numerical rating scale (NRS) were recorded at intervals in the first 24 hours postoperatively, and supplementary analgesics given were noted. Following satisfactory results from the initial audit, we implemented erector spinae plane catheters as part of multimodal analgesia in transplant patients in our centre. We re-audited all transplants done over the next year to reassess the quality of postoperative analgesia. Results Five patients were audited during the initial audit. The average NRS score ranged from 0 at rest to a maximum of 5 during mobilisation. All patients were given only paracetamol to supplement analgesia, and none required opioids. During the re-audit, data was collected on postoperative pain management in 13 subsequent transplants conducted over the next year. The NRS scores ranged from 0 at rest to 6 on mobilisation. Two patients required boluses of fentanyl 25 mcg via the catheter, and the rest reported satisfactory analgesia with paracetamol as needed. Conclusion This quality improvement project changed our centre's practice in managing postoperative pain in kidney transplantations. We switched from securing epidural catheters to erector spinae plane catheters due to better safety profile, minimal use of opioids and lesser adverse effects. We shall continue to re-audit our practices for the best outcomes.

Effects of Multimodal Bundle with Remote Ischemic Preconditioning and Intrathecal Analgesia on Early Recovery of Estimated Glomerular Filtration Rate after Robot-Assisted Laparoscopic Partial Nephrectomy for Renal Cell Carcinoma

Simple Summary

This study suggested that robot-assisted laparoscopic partial nephrectomy (RALPN) may have benefits with regard to the preservation of renal function and few complications postoperatively in patients with renal cell carcinoma (RCC). However, a reduction in the estimated glomerular filtration rate may be unavoidable. Our results suggested that the preservation of renal function may be enhanced by combining robot-assisted nephron-sparing surgery with an intraoperative bundle strategy consisting of remote ischemic preconditioning (RIPC) and an intrathecal morphine block (ITMB), to protect against ischemia–reperfusion injury and the pain-related stress induced by renal artery clamping and surgical insults. It is important to adjust modifiable variables related to the progression of renal impairment in a timely and appropriate manner for the recovery of renal function after RALPN. Together with surgical and pharmacological methods to minimize irreversible injury, RIPC and ITMB combined bundle therapy may relieve ischemia–reperfusion- and pain-induced stress and serve as a safe and efficient method for improving renal outcomes of RALPN in patients with RCC.

Abstract

We investigated the effects of multimodal combined bundle therapy, consisting of remote ischemic preconditioning (RIPC) and intrathecal morphine block (ITMB), on the early recovery of kidney function after robot-assisted laparoscopic partial nephrectomy (RALPN) in patients with renal cell carcinoma (RCC). In addition, we compared the surgical and analgesic outcomes between patients with and without bundle treatment. This prospective randomized double-blind controlled trial was performed in a cohort of 80 patients with RCC, who were divided into two groups: a bundle group (n = 40) and non-bundle group (n = 40). The primary outcome was postoperative kidney function, defined as the lowest estimated glomerular filtration rate (eGFR) on postoperative day (POD) 2. Surgical complications, pain, and length of hospital stay were assessed as secondary outcomes. The eGFR immediately after surgery was significantly lower in the bundle group compared to the preoperative baseline, but serial levels on PODs 1 and 2 and at three and six months after surgery were comparable to the preoperative baseline. The eGFR level immediately after surgery was lower in the non-bundle than bundle group, and serial levels on PODs 1 and 2 and at three months after surgery remained below the baseline. The eGFR level immediately after surgery was higher in the bundle group than in the non-bundle group. The eGFR changes immediately after surgery, and on POD 1, were smaller in the bundle than in the non-bundle group. The non-bundle group had longer hospital stays and more severe pain than the bundle group, but there were no severe surgical complications in either group. The combined RIPC and ITMB bundle may relieve ischemia–reperfusion- and pain-induced stress, as a safe and efficient means of improving renal outcomes following RALPN in patients with RCC.

Delayed remnant kidney function recovery is less observed in living donors who receive an analgesic, intrathecal morphine block in laparoscopic nephrectomy for kidney transplantation: a propensity score-matched analysis

BACKGROUND

This study analyzed remnant kidney function recovery in living donors after laparoscopic nephrectomy to establish a risk stratification model for delayed recovery and further investigated clinically modifiable factors.

PATIENTS AND METHODS

This retrospective study included 366 adult living donors who underwent elective donation surgery between January 2017 and November 2019 at our hospital. ITMB was included as an analgesic component in the living donor strategy for early postoperative pain relief from November 2018 to November 2019 (n = 116). Kidney function was quantified based on the estimated glomerular filtration rate (eGFR), and delayed functional recovery of remnant kidney was defined as eGFR < 60 mL/min/1.73 m² on postoperative day (POD) 1 (n = 240).

RESULTS

Multivariable analyses revealed that lower risk for development of eGFR < 60 mL/min/1.73 m² on POD 1 was associated with ITMB, female sex, younger age, and higher amount of hourly fluid infusion (area under the receiver operating characteristic curve = 0.783; 95% confidence interval = 0.734-0.832; p < 0.001). Propensity score (PS)-matching analyses showed that prevalence rates of eGFR < 60 mL/min/1.73 m² on PODs 1 and 7 were higher in the non-ITMB group than in the ITMB group. ITMB adjusted for PS was significantly associated with lower risk for development of eGFR < 60 mL/min/1.73 m² on POD 1 in PS-matched living donors. No living donors exhibited severe remnant kidney dysfunction and/or required renal replacement therapy at POD 7.

CONCLUSIONS

We found an association between the analgesic impact of ITMB and better functional recovery of remnant kidney in living kidney donors. In addition, we propose a stratification model that predicts delayed functional recovery of remnant kidney in living donors: male sex, older age, non-ITMB, and lower hourly fluid infusion rate.