Postoperative analgesia following renal transplantation - current practice in the UK

Postoperative pain management after abdominal transplantations

PURPOSE OF REVIEW

The aim of this review article is to present current recommendations as well as knowledge gaps and controversies pertaining to commonly utilized postoperative pain management after solid organ transplantation in the abdominal cavity.

RECENT FINDINGS

Postsurgical pain has been identified as one of the major challenges in recovery and treatment after solid organ transplants. Many perioperative interventions and management strategies are available for reducing and managing postoperative pain. Management should be tailored to the individual needs, taking an interdisciplinary and holistic approach and following enhanced recovery after surgery guidelines. Many centers currently utilize peripheral and neuraxial blocks during transplantation surgery, but these techniques are far from standardized practices. The utilization of these procedures is often dependent on transplantation centers' historical methods and perioperative cultures.

SUMMARY

The optimal pain management regimen has not yet been definitively established, and current scientific evidence does not yet support the endorsement of a certain analgesic approach. This objective necessitates the need for high-quality randomized controlled trials.

Anterior quadratus lumborum block for analgesia after living-donor renal transplantation: a double-blinded randomized controlled trial

INTRODUCTION

Limited non-opioid analgesic options are available for managing postoperative pain after renal transplantation. We aimed to investigate whether the unilateral anterior quadratus lumborum (QL) block would reduce postoperative opioid consumption after living-donor renal transplantation in the context of multimodal analgesia.

METHODS

Eighty-eight adult patients undergoing living-donor renal transplantation were randomly allocated to receive the unilateral anterior QL block (30 mL of ropivacaine 0.375%) or sham block (normal saline) on the operated side before emergence from anesthesia. All patients received standard multimodal analgesia, including the scheduled administration of acetaminophen and fentanyl via intravenous patient-controlled analgesia. The primary outcome was the total opioid consumption during the first 24 hours after transplantation. The secondary outcomes included pain scores, time to first opioid administration, cutaneous distribution of sensory blockade, motor weakness, nausea/vomiting, quality of recovery scores, time to first ambulation, and length of hospital stay.

RESULTS

The total opioid consumption in the first 24 hours after transplantation did not differ significantly between the intervention and control groups (median (IQR), 160.5 (78-249.8) vs 187.5 (93-309) oral morphine milligram equivalent; median difference (95% CI), -27 (-78 to 24), p=0.29). No differences were observed in the secondary outcomes.

CONCLUSIONS

The anterior QL block did not reduce opioid consumption in patients receiving multimodal analgesia after living-donor renal transplantation. Our findings do not support the routine administration of the anterior QL block in this surgical population.

TRIAL REGISTRATION NUMBER

NCT04908761.

A national survey on enhanced recovery for renal transplant recipients: current practices and trends in the UK

INTRODUCTION

Enhanced recovery after surgery (ERAS) is well established in many specialties but has not been widely adopted in renal transplantation. The aim of this survey was to understand current national practices and sentiment concerning ERAS for renal transplant recipients in the UK.

METHODOLOGY

A national web-based survey was sent to consultant surgeons at all 23 UK adult renal transplant units. Completed questionnaires were collected between May and July 2020. Data were analysed according to individual responses and grouped according to the existence of formal ERAS pathways within units.

RESULTS

All transplant units were represented in this survey. Three units had a formal ERAS pathway for all recipients. Of the remaining units, 65.9% considered implementing an ERAS pathway in the near future. The most commonly perceived barrier to ERAS implementation was 'embedded culture within transplant units' (54.8% of respondents). A fifth of respondents insert surgical drains selectively and 11.7% routinely discontinue patient-controlled analgesia on postoperative day 1. Most respondents routinely remove urinary catheters on day 5 (70%) and ureteric stents 4-6 weeks post-transplantation (81.7%). Median length of stay for deceased donor kidney transplant recipients was lower in units with ERAS programmes (5-7 days versus 8-10 days, respectively). The main cited barriers for discharge were 'suboptimal fluid balance' and 'requirement of treatment for rejection'.

CONCLUSIONS

Despite slow uptake of ERAS in kidney transplantation, appetite appears to be increasing, particularly in the post-COVID-19 era. The current practice and opinions of transplant specialists highlighted in this survey may help to establish nationally agreed ERAS guidelines in this field.

Anaesthetic Approach to Enhanced Recovery after Surgery for Kidney Transplantation: A Narrative Review

Enhanced recovery after surgery (ERAS) protocols are designed to reduce medical complications, the length of hospital stays (LoS), and healthcare costs. ERAS is considered safe and effective for kidney transplant (KTx) surgery. KTx recipients are often frail with multiple comorbidities. As these patients follow an extensive diagnostic pathway preoperatively, the ERAS protocol can ideally be implemented at this stage. Small singular changes in a long perioperative pathway can result in significant positive outcomes. We have investigated the current evidence for an ERAS pathway related to anaesthetic considerations in renal transplant surgery for adult recipients.

Implementing nursing round to deal with unresolved nursing problem on patient with acute pain: A case report

Background: The determining factors for improvement of health services quality includes nursing services. Furthermore, a method for providing this quality nursing services is professional nursing care model, and comprises nursing round. However, fewer hospitals implement this due to several barriers including lack of knowledge and practices. This study is, therefore, aimed at identifying improvements in quality of nursing care and solving of patient’s problem by frequent nursing rounds.

Design and Method: This study employed a single case report design using exploratory and descriptive methods. A 27-year-old male underwent nephrectomy surgery to treat hydronephrosis. The person still revealed persistent pain in the surgery area even though it has been treated for 3 days. The staff nurses administered nursing round to discuss and solve this problem. The study participation was voluntary, while the involved patient gave the informed consent. The steps of nursing round procedure including preround, round, and post-round were used to solve the problem.

Results: The results indicated that nurses discovered blood clots in the patient’s drain during nursing round. The cause of the persistent pain was revealed and used to determine the intervention modification needed. It was recommended to evacuate the blood clot and followed by appropriate pain management. Furthermore, the problem in the patient with acute pain was resolved.

Results: The results indicated that nurses discovered blood clots in the patient’s drain during nursing round. The cause of the persistent pain was revealed and used to determine the intervention modification needed. It was recommended to evacuate the blood clot and followed by appropriate pain management. Furthermore, the problem in the patient with acute pain was resolved.

Utilizing multimodal analgesia to evaluate postoperative analgesic requirements in kidney transplant recipients

The use of non-opioid analgesics following surgery has proven beneficial in managing pain and decreasing adverse outcomes following surgery. Data assessing outcomes related to opioid use is limited in kidney transplant recipients (KTRs). We evaluated the effectiveness of implementing a reduced to no opioid use protocol in KTRs. This retrospective cohort study included adult KTRs between January 2017 and July 2019 with a multimodal analgesic protocol (MAP), focused on limiting opioids, implemented in August 2018. We compared analgesic requirements in morphine milligram equivalents (MME) during transplant admissions between the MAP cohort and traditional cohort. There were 217 KTRs who met the criteria. Inpatient opioid use was significantly reduced in the MAP cohort (16.5 ± 19.2 MME/day vs 24.7 ± 19.7 MME/day; P <.05) with no significant difference in pain scores. No use of opioids within six months of discharge was significantly increased in the MAP cohort (50% vs 7%; P <.001), and there were no reported deaths at six months in either cohort. The use of multimodal analgesia is beneficial in KTRs to provide adequate pain control with limited to no exposure of opioids during admission or at discharge.

Opioid Preconditioning Modulates Repair Responses to Prevent Renal Ischemia-Reperfusion Injury

Progression to renal damage by ischemia-reperfusion injury (IRI) is the result of the dysregulation of various tissue damage repair mechanisms. Anesthetic preconditioning with opioids has been shown to be beneficial in myocardial IRI models. Our main objective was to analyze the influence of pharmacological preconditioning with opioids in renal function and expression of molecules involved in tissue repair and angiogenesis. Experimental protocol includes male rats with 45 min ischemia occluding the left renal hilum followed by 24 h of reperfusion with or without 60 min preconditioning with morphine/fentanyl. We analyzed serum creatinine and renal KIM-1 expression. We measured circulating and intrarenal VEGF. Immunohistochemistry for HIF-1 and Cathepsin D (CTD) and real-time PCR for angiogenic genes HIF-1α, VEGF, VEGF Receptor 2 (VEGF-R2), CTD, CD31 and IL-6 were performed. These molecules are considered important effectors of tissue repair responses mediated by the development of new blood vessels. We observed a decrease in acute renal injury mediated by pharmacological preconditioning with opioids. Renal function in opioid preconditioning groups was like in the sham control group. Both anesthetics modulated the expression of HIF-1, VEGF, VEGF-R2 and CD31. Preconditioning negatively regulated CTD. Opioid preconditioning decreased injury through modulation of angiogenic molecule expression. These are factors to consider when establishing strategies in pathophysiological and surgical processes.

A Better Journey for Patients, a Better Deal for the NHS: The Successful Implementation of an Enhanced Recovery Program After Renal Transplant Surgery

OBJECTIVES

Our aim was to apply the principles of enhanced recovery in renal transplant recipients and to assess the changes in the quality of patient care and patient satisfaction.

MATERIALS AND METHODS

Our study included 286 consecutive renal transplant patients. Of these, 135 patients went through the enhanced recovery program and 151 patients had traditional recovery. Patient education and discharge planning were commenced on admission. For enhanced recovery, prolonged preoperative fasting was avoided by carbohydrate loading. Goal-directed fluid management was aided by transesophageal Doppler to avoid central line insertion. Intrathecal diamorphine and ultrasonography-guided transversus abdominis plane blocks were used to achieve adequate analgesia. Patients started oral intake a few hours postoperatively. The urinary catheter was removed 2 to 4 days after transplant.

RESULTS

The postoperative patient-controlled analgesia requirement for morphine was significantly reduced in the enhanced recovery versus traditional recovery group (median of 9.5 vs 47 mg; P < 0.001). The length of stay was significantly reduced for living-donor (median 5 vs 7 days; P < .001) and for deceased-donor transplant recipients (median 5 vs 8.5 days; P < 0.001) with enhanced recovery versus recipients who had traditional recovery. Implementing enhanced recovery saves £2160 per living-donor transplant and £3078 per deceased-donor transplant. In the enhanced recovery group, readmission within 10 days after transplant was 5%.

CONCLUSIONS

Our service evaluation demonstrated that enhanced recovery benefits both types of renal transplant (living and deceased grafts) procedures, with excellent patient satisfaction and reduction of hospital length of stay.

Comparison of intrathecal morphine and surgical-site infusion of ropivacaine as adjuncts to intravenous patient-controlled analgesia in living-donor kidney transplant recipients

INTRODUCTION

This prospective observational study compared the postoperative analgesic effectiveness of intrathecal morphine (ITM) and surgical-site infusion (SSI) of ropivacaine as adjuncts to intravenous (IV) patient-controlled analgesia (PCA) (fentanyl) in living-donor kidney transplant recipients.

METHODS

Patients undergoing living-donor kidney transplantation who received ITM or SSI in addition to IV PCA were included. Rescue analgesia was achieved with IV meperidine as required. The primary outcome, measured using the Numeric Pain Rating Scale (NRS), was pain at rest and when coughing. Patients were assessed for 48 hours after surgery.

RESULTS

A total of 53 patients (32 ITM, 21 SSI) were included in the study. The ITM group showed significantly lower NRS scores, at rest and when coughing, for up to 12 and eight hours. NRS scores were comparable between the groups at other times. The ITM group had significantly less postoperative systemic opioid requirement in the first 24 hours, but there was no significant difference between the systemic opioid consumption of the groups on postoperative Day 2. In the ITM group, 3 (9.4%) patients presented with bradypnoea and 1 (3.1%) with excessive sedation in the first 12 postoperative hours. More patients in the ITM group developed pruritus requiring treatment during the first 24 hours. There were no differences between the groups in other outcomes (e.g. nausea/vomiting, change in pulmonary or kidney functions).

CONCLUSION

Compared with SSI, ITM reduced immediate postoperative pain and IV opioid consumption on postoperative Day 1 after living-donor kidney transplantation, but at the cost of increased pruritus and respiratory depression.

Can intraperitoneal bupivacaine decreases pain in patients undergoing laparoscopic live donor nephrectomy? A randomized control trial

PURPOSE

To evaluate effect of intraperitoneal bupivacaine on postoperative pain in patients undergoing laparoscopic live donor nephrectomy.

METHODS

Hundred patients undergoing laparoscopic live donor nephrectomy were included in the study and were divided randomly into two groups based on computer-generated randomization chart of fifty each. Patients were made familiar with VAS chart preoperatively. Group A received 20 mL of 0.5 % bupivacaine, while group B patients received 20 mL of 0.9 % normal saline intraperitoneally Postoperatively, patients were assessed based on VAS and requirement of rescue analgesic, hemodynamic parameters and presence of any adverse effects. Student's t test was used for statistical analysis.

RESULTS

At all-time interval, mean pain scores were higher in group B than group A. The difference between the mean pain scores was statistically significant (p < 0.05) at 0, 2 and 4 h. The mean dose of rescue analgesia (pentazocin, 30 mg in one vial) in group A was 33 ± 26 mg which was significantly less as compared to group B where it was 62 ± 28 mg. There was statistically insignificant difference between all cardiorespiratory factories at all-time intervals except for heart rate and mean blood pressure at 0 h in group A as compared to group B.

CONCLUSIONS

Intraperitoneal bupivacaine is a simple, safe, inexpensive method for control of postoperative pain in patients undergoing laparoscopic live donor nephrectomy. Use of the correct dose and concentration of the drug are essential for effective pain control.

Comparison of Postoperative Analgesic Requirements in Living Donors and Patients Undergoing Similar Surgical Procedures

BACKGROUND

More factors affect pain perception of donors than patients. We prospectively evaluated postoperative pain intensity and analgesic requirements in living kidney donors and patients with renal cell carcinoma undergoing laparoscopic nephrectomy with similar surgical procedures.

MATERIAL AND METHODS

The study included 30 living kidney donors and 30 patients with renal cell carcinoma undergoing laparoscopic nephrectomy from March 2013 to August 2014. All of the participants underwent similar surgical procedures under general anesthesia. Data including participants' demographics, surgical data, postoperative analgesic requirements, visual analog scale scores at rest and during coughing at postoperative 0.5, 2, 4, 8, 12, 24, and 48 hours, side effects, and overall satisfaction degree were compared between the 2 groups.

RESULTS

Time to the first tramadol request was significantly shorter in the donors. The donors received more intravenous doses of tramadol than the patients. Visual analog scale scores at 2 and 4 hours at rest and at 2, 4, and 8 hours during coughing after extubation were significantly higher in the donors. There were no significant differences between the groups according to the number of participants given pethidine, time to pethidine rescue, and adverse effects. The overall satisfaction degree was comparable between the 2 groups.

CONCLUSIONS

There were significant differences with respect to postoperative pain intensity and analgesic requirements in living kidney donors and patients undergoing retroperitoneal laparoscopic nephrectomy with similar surgical procedures.

Nefopam as an adjunct to intravenous patient-controlled analgesia after renal transplantation: a randomised trial

BACKGROUND

Nefopam has been used as an adjuvant to opioid analgesia after operation. We investigated the efficacy of nefopam as an adjunct to fentanyl-based intravenous patient-controlled analgesia (IV PCA) on post-operative pain relief in patients undergoing renal transplantation.

METHODS

Ninety-eight patients undergoing elective renal transplantation were randomised into two groups: nefopam or control groups. The former received nefopam (160 mg in 200 ml at a rate of 4 ml/h) whereas the latter received normal saline during the first 48 h after reperfusion of grafted kidney. Pain intensity scores, cumulative dose of fentanyl, and the incidence of adverse events were assessed at 1, 6, 12, 24, and 48 h post-operatively. Serum creatinine and estimated glomerular filtration rate were evaluated on post-operative days 1, 2, 4, and 7.

RESULTS

The cumulative fentanyl consumption during the first 48 h after operation was 19% less in the nefopam group than that in the control group (1005 ± 344 μg vs. 1246 ± 486 μg, mean ± SD; P = 0.006). Pain intensity scores at rest and on coughing were significantly lower in the nefopam group throughout the first 12 and 48 h after operation, respectively. Adverse events and early graft function were comparable between the groups, except a significantly lower incidence of drowsiness observed in the nefopam group (4% vs. 21%, P = 0.027).

CONCLUSION

In combination with fentanyl PCA, nefopam reduced post-operative fentanyl consumption with superior analgesia after renal transplantation.

Continuous transversus abdominis plane block catheter analgesia for postoperative pain control in renal transplant

PURPOSE

Continuous transversus abdominis plane (TAP) block using a catheter has proven its usefulness in reducing opioid requirements and pain scores after lower abdominal surgery. However, there are no reports of its successful use after renal transplant. We tested the hypothesis that continuous TAP block would retrospectively reduce opioid requirement, nausea score and hospital stay after renal transplant surgery.

METHODS

In a retrospective study, we reviewed the data from 63 adult renal transplant recipients-31 with patient-controlled TAP analgesia with standing orders for intravenous as well as oral opioids as needed and 32 with intravenous patient-controlled analgesia. The TAP catheter was inserted preoperatively using an ultrasound-guided technique. Infusion of ropivacaine 0.2 % at 8 ml basal, 12 ml bolus and a lockout interval of 60 min were maintained for 48 h postoperatively. The primary outcome was total morphine-equivalent dose during the 48-h postoperative period. Secondary outcomes were pain and nausea scores for the 48-h postoperative period.

RESULTS

The mean 48-h postoperative morphine-equivalent doses [95 % confidence interval] for patient-controlled intravenous analgesia and TAP catheter were 197 [111, 349] and 50 [28, 90], respectively, which were significantly different (P = 0.002). The mean 48-h average verbal response pain scores were 2.94 [2.39, 3.50] and 2.49 [1.93, 3.06], respectively, which were not significantly different (P = 0.26). The mean nausea scores were 0.66 [0.46, 0.87] and 0.60 [0.40, 0.81], respectively, which were not significantly different (P = 0.69). There was no difference regarding hospital stay.

CONCLUSION

The use of continuous TAP analgesia for postoperative analgesia after renal transplant was effective in reducing the morphine-equivalent requirements.

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.

Transversus abdominis plane block for analgesia in renal transplantation: a randomized controlled trial

BACKGROUND

The transversus abdominis plane (TAP) block has proven effective in reducing opioid requirements and pain scores for some procedures involving the lower abdominal wall. In this study we assessed its efficacy in patients with end-stage renal failure undergoing cadaveric renal transplantation.

METHODS

Sixty-five adult renal transplant recipients were prospectively randomized to receive a standard general anesthetic technique supplemented with levobupivacaine 0.375% 20 mL TAP block or sham block with 20 mL 0.9% saline. Both groups received patient-controlled morphine analgesia and acetaminophen. Patient assessment occurred in the postanesthetic care unit and at 2, 4, 6, 12, and 24 hours. The primary outcome was total morphine consumption in the first 24 hours after renal transplantation. Other outcomes assessed included pain scores, presence of nausea or vomiting, excessive sedation, and respiratory depression.

RESULTS

Morphine requirements did not differ between the 2 groups, 31.6 ± 5.6 mg in the TAP group and 32.6 ± 5.5 mg in the control group (95% confidence interval [CI], -8.96 to 7.09, P = 0.817). Pain scores also did not differ significantly at any time point after surgery. Nausea was reported in 53% of the TAP group and 24% of the control group. The relative risk of nausea associated with treatment was 2.2 (95% CI, 1.1 to 4.3, P = 0.017). No patient exhibited excessive sedation or respiratory depression.

CONCLUSIONS

The addition of a TAP block to the analgesia regimen for renal transplantation did not reduce morphine requirements.

Anesthesia for pediatric renal transplantation with and without epidural analgesia--a review of 7 years experience

BACKGROUND

Few objective data exist describing current anesthesia practice for pediatric renal transplantation. We describe here, the experience from an Australian tertiary pediatric center that has continued an active pediatric renal transplantation program after relocation in 1995. Areas of interest include preoperative status, fluid management, hemodynamic stability, perioperative complications, and the use of epidural analgesia. In particular, the influence of perioperative epidural analgesia on hemodynamic stability is addressed.

METHODS

A retrospective review of anesthesia records of all patients undergoing pediatric renal transplantation performed at the Children's Hospital at Westmead (CHW), from November 1995 to October 2002 was carried out.

RESULTS

Fifty-three pediatric renal transplants were performed in 50 patients. Average age and weight were 10.2 years (range: 1-18 years) and 31.4 kg (range: 9-66 kg), respectively. A total of 14 recipients were less than or equal to 6 years of age. Twenty-four children were recipients of cadaveric transplants, 29 children received kidneys from living related donors. Few children presented with severe anemia (two patients) gross electrolyte abnormalities (three patients) or uncontrolled hypertension. Intraoperatively, all children had central venous pressure monitoring and only four had invasive arterial blood pressure monitoring. Average intraoperative fluid administration was 88 ml x kg(-1) (range: 30-190). Twenty-three children received blood transfusions intraoperatively. Postoperative analgesia was provided using an epidural infusion in 39 patients and an opioid infusion/patient controlled analgesia in the remainder. There was a tendency to greater hemodynamic stability in the group, which received intra-operative epidural analgesia. Half the patients who had epidural analgesia required parenteral opioid supplementation. Five patients had postoperative pulmonary edema. Minor postoperative adverse events included epidural associated motor block (three cases) and opioid related oversedation (one patient). No perioperative mortality or major morbidity was recorded.

CONCLUSIONS

Anesthesia for renal transplantation in pediatric patients at CHW is safe and effective using a selected range of drugs and techniques. Pretransplant medical optimization, careful preoperative assessment, adequate monitoring and precise fluid management together with appropriate postoperative analgesia typify the perioperative care of CHW renal transplant recipients.

Kidney transplantation: recent developments and recommendations for anesthetic management

Kidney transplantation is the treatment of choice for patients with end-stage renal disease. After receiving a transplant, survival rates are higher and comorbidities may resolve. As a consequence, more patients with significant comorbidities such as advanced cardiovascular disease will present for transplantation. This review highlights commonly encountered issues in patients undergoing kidney transplantation and recommendations are made for their anesthetic management.

Anaesthesia for laparoscopic urological surgery

Laparoscopy for urological surgery is a relatively recent surgical innovation. Some centres have substantial experience of single operations, but very few have experience with a comprehensive range. Our programme began with nephrectomy and pyeloplasty, and has expanded to provide for a living related kidney donor programme and for other procedures usually conducted open. Recently, it has included prostate and bladder cancer surgery. The learning curve and implications for anaesthesia are described on the basis of the experience of one anaesthetist with 124 patients. Perioperative care issues, in common with other abdominal laparoscopic procedures, relate to operating positions, the consequences of carbon dioxide under pressure in the abdomen and postoperative analgesia. There is only a small requirement for regional anaesthesia supplementation and invasive analgesia. The corporate laparoscopic cholecystectomy experience was used as the foundation for anaesthesia and to delineate specific organ system issues and any interventions. Significant differences were found in the spectrum of the urological patient population and comorbidity, notably renal function or dysfunction, and complications.