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Saks J, Yoon U, Neiswinter N, Schwenk ES, Goldberg S, Nguyen L, Torjman MC, Elia E, Shah A. Randomized Controlled Trial of Enhanced Recovery After Surgery Protocols in Live Kidney Donors: ERASKT Study. Transplant Direct 2024; 10:e1663. [PMID: 38953038 PMCID: PMC11216682 DOI: 10.1097/txd.0000000000001663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Revised: 04/25/2024] [Accepted: 05/06/2024] [Indexed: 07/03/2024] Open
Abstract
Background Enhanced recovery after surgery (ERAS) pathways represent a comprehensive approach to optimizing perioperative management and reducing hospital stay and cost. In living donor kidney transplantation, key impediments to postoperative discharge include pain, and opioid associated complications such as nausea, vomiting, and the return of gastrointestinal function. Methods In this randomized controlled trial, living kidney transplantation donors were assigned to either the ERAS or control group. The ERAS group patients received 15 preoperative, 17 intraoperative, 19 postoperative element intervention. The control group received standard care. The ERAS group received a multimodal opioid sparing pain management including an intraoperative transverse abdominis plane block. Our primary outcome measure was postoperative opioid consumption. The secondary outcome measures were postoperative pain scores, first oral intake, and hospital length of stay. Results There were no significant differences in demographics between the 2 groups. The ERAS group had a statistically significant reduction in total postoperative opioid consumption calculated in intravenous morphine equivalents (24.2 ± 20.2 versus 71 ± 39.5 mg, P < 0.01). Postoperative pain scores were significantly lower (P < 0.001) from 1 h postoperatively to 48 h. Surgical time was 45 min shorter (P = 0.037). Intraoperative PlasmaLyte administration was lower (PlasmaLyte: 1444 ± 907 versus 2168 ± 1347 mL, P = 0.049). Time to tolerating regular diet was shorter by 2 h (P < 0.008), and length of hospital stay was decreased by 10.1 h. Conclusions The ERAS group experienced superior postoperative analgesia and a shorter length of hospital stay compared with controls.
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Affiliation(s)
- Jacob Saks
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Uzung Yoon
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Natalie Neiswinter
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Eric S. Schwenk
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Stephen Goldberg
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Linh Nguyen
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Marc C. Torjman
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Elia Elia
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Ashesh Shah
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA
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Kiani AZ, Progar K, Hill AL, Vachharajani N, Olumba F, Yu J, Chapman WC, Doyle MB, Wellen JR, Khan AS. Robotic living donor nephrectomy is associated with reduced post-operative opioid use compared to hand-assisted laparoscopic approach. Surg Endosc 2024; 38:3654-3660. [PMID: 38777895 DOI: 10.1007/s00464-024-10925-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 05/05/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Robotic donor nephrectomy (RDN) has emerged as a safe alternative to laparoscopic donor nephrectomy (LDN). Having previously demonstrated comparable efficacy, this study aims to examine postoperative analgesia use (opioid and non-opioid) in the two groups. METHODS We conducted a retrospective review of 300 living donor nephrectomies performed at our center, comparing 150 RDN's with a contemporary cohort of 150 hand-assisted LDN's. In addition to clinical and demographic information, data on postoperative inpatient opioid and non-opioid analgesia (from patient's arrival to the surgical floor after surgery till the time of discharge) was collected. Opioid dosages were standardized by conversion to morphine milligram equivalents (MME). All patients were managed post-operatively under a standardized ERAS pathway for living donor nephrectomy patients. RESULTS There were no significant differences in donor age, gender, and BMI between RDN and LDN groups. Total post-operative opioid use (MME's) was significantly lower in RDN patients (RDN 27.1 vs. LDN 46.3; P < 0.0001). Breakdown of opioid use with post-operative (POD) day demonstrated significantly lower use in RDN group on POD1 (RDN 8.6 vs. LDN 17.0; P < 0.05), and POD2 (RDN 3.9 vs LDN 10; P < 0.05). RDN patients had a shorter post-operative length of stay (LOS) (RDN 1.69 days vs. LDN 1.98; P = 0.0003). There were no differences between groups in non-opioid medication use, complications, and readmission rates. CONCLUSION RDN has comparable safety to hand-assist LDN and offers additional benefits of lower postoperative opioid requirement and a shorter hospital LOS.
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Affiliation(s)
- Amen Z Kiani
- Section of Abdominal Transplant, Department of General Surgery, Washington University in St. Louis, St. Louis, MO, 63110, USA.
- Department of Surgery, Division of Abdominal Transplant Surgery, Washington University School of Medicine, 660 Euclid Ave St., Louis, MO, 63110, USA.
| | - Kristin Progar
- Department of Pharmacy, Barnes-Jewish Hospital, Barnes-Jewish Hospital Plaza, Saint Louis, MO, 63130, USA
| | - Angela L Hill
- Section of Abdominal Transplant, Department of General Surgery, Washington University in St. Louis, St. Louis, MO, 63110, USA
| | - Neeta Vachharajani
- Section of Abdominal Transplant, Department of General Surgery, Washington University in St. Louis, St. Louis, MO, 63110, USA
| | - Franklin Olumba
- Section of Abdominal Transplant, Department of General Surgery, Washington University in St. Louis, St. Louis, MO, 63110, USA
| | - Jennifer Yu
- Section of Abdominal Transplant, Department of General Surgery, Washington University in St. Louis, St. Louis, MO, 63110, USA
| | - William C Chapman
- Section of Abdominal Transplant, Department of General Surgery, Washington University in St. Louis, St. Louis, MO, 63110, USA
| | - Majella B Doyle
- Section of Abdominal Transplant, Department of General Surgery, Washington University in St. Louis, St. Louis, MO, 63110, USA
| | - Jason R Wellen
- Section of Abdominal Transplant, Department of General Surgery, Washington University in St. Louis, St. Louis, MO, 63110, USA
| | - Adeel S Khan
- Section of Abdominal Transplant, Department of General Surgery, Washington University in St. Louis, St. Louis, MO, 63110, USA
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De Leon F, Alghannam K, Gul HL, Goussous N, Mineyev N, Than PA, Perez RV, Sageshima J. Effectiveness of Postoperative Single-shot and Continuous Transverse Abdominis Plane Block Compared to Conventional Analgesia in Hand-assisted Laparoscopic Live-donor Nephrectomy. Transplant Direct 2024; 10:e1581. [PMID: 38380346 PMCID: PMC10876253 DOI: 10.1097/txd.0000000000001581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 12/02/2023] [Accepted: 12/08/2023] [Indexed: 02/22/2024] Open
Abstract
Background Few studies have evaluated the efficacy of transverse abdominis plane (TAP) block in patients undergoing hand-assisted laparoscopic live-donor nephrectomy (HALN). We aimed to evaluate the analgesic effectiveness of TAP block as part of a multimodal pain management regimen in patients undergoing HALN. Methods We retrospectively reviewed the medical records of living kidney donors at our center between June 2016 and February 2020. HALNs were performed via a transperitoneal approach through a suprapubic incision. Additional laparoscopic ports were used in the upper midabdomen. In consenting donors, TAP block was performed postoperatively under ultrasound guidance with either a single-shot or continuous infusion of long-acting local anesthetic (0.2%-0.5% ropivacaine). All the patients received postoperative around-the-clock ketorolac and acetaminophen. Results Overall, 72 donors received the block (block group, 38 single-shot, 34 continuous), whereas 86 donors did not receive the block (control group). Baseline characteristics were comparable between the groups except for body weight (control: 71.8 ± 13.3 versus block: 77.8 ± 17.3 kg; P = 0.01) and intraoperative opioid dose (32.1 ± 9.6 versus 26.6 ± 10.7 morphine milligram equivalents; P < 0.001). After adjusting for baseline differences, postoperative opioid requirements were similar between the groups. When the baseline pain scale was adjusted for, there was no difference in the overall pain scale scores between the groups (P = 0.242). Subgroup analyses comparing single-shot or continuous TAP versus control did not show any differences. Conclusions With the caveat of the retrospective nature of the study, the adjunctive effect of TAP block after transabdominal HALN was limited when other multimodal analgesia was used.
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Affiliation(s)
- Fransia De Leon
- School of Medicine, University of California Davis, Sacramento, CA
| | - Karima Alghannam
- Department of Surgery, University of California Davis, Sacramento, CA
| | - Hadia Lala Gul
- Department of Internal Medicine, University of California Davis, Sacramento, CA
| | - Naeem Goussous
- Department of Surgery, University of California Davis, Sacramento, CA
| | - Neal Mineyev
- Department of Surgery, University of California Davis, Sacramento, CA
| | - Peter A Than
- Department of Surgery, University of California Davis, Sacramento, CA
| | - Richard V Perez
- Department of Surgery, University of California Davis, Sacramento, CA
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Lee JE, Kim HY, Lee KW, Kim GS. Second-generation supraglottic airway in laparoscopic donor nephrectomy. Sci Rep 2023; 13:8406. [PMID: 37225750 DOI: 10.1038/s41598-023-34691-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 05/05/2023] [Indexed: 05/26/2023] Open
Abstract
Supraglottic airway (SGA) may have advantages over endotracheal tube (ETT) regarding laryngospasm, coughing, sore throat, and hemodynamic changes; however, studies on the use of SGA in laparoscopic donor nephrectomy (LDN) are lacking. Here, we aimed to confirm the safety and feasibility of second-generation SGA in LDN and compare them with those of ETT. Enrolled adult donors (aged > 18 years) who underwent LDN between August 2018 and November 2021 were divided into two groups-ETT vs. SGA. Airway pressure, lung compliance, desaturation, and hypercapnia were recorded during surgery. After propensity score matching for baseline characteristics and surgical duration, 82 and 152 donors were included in the ETT and SGA groups, respectively, and their outcomes were compared. The peak airway pressure was lower in the SGA group than in the ETT group 5 min after pneumoperitoneum. Dynamic lung compliance was higher in the SGA group than in the ETT group during surgery. There were no cases of intraoperative desaturation, hypercapnia, or postoperative aspiration pneumonitis. The use of second-generation SGA, a safe alternative to ETT for LDN, resulted in reduced airway resistance and increased lung compliance, which suggests its benefits for airway management in kidney donors.
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Affiliation(s)
- Ja Eun Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ha Yeon Kim
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Kyo Won Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Gaab Soo Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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Raeder JC, White PF. Enhanced recovery after surgery (ERAS): Guidelines are important but proper implementation is essential. J Clin Anesth 2022; 80:110882. [PMID: 35597004 DOI: 10.1016/j.jclinane.2022.110882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 05/09/2022] [Accepted: 05/10/2022] [Indexed: 10/18/2022]
Affiliation(s)
- Johan C Raeder
- Department of Anaesthesia and Intensive Care, Oslo University Hospital, Oslo, Norway Gulleraasveien 30 B, 0779 Oslo, Norway; Department of Clinical Medicine, University of Oslo Gulleraasveien 30 B, 0779 Oslo, Norway.
| | - Paul F White
- White Mountain Institute, 41299 Tallgrass, The Sea Ranch, CA 95497, USA.
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Dong X, Burton BN, Little C, Woodhouse L, Grogan T, Blumberg JM, Gritsch HA, Rahman S. Intraoperative opioid and analgesic adjuvant administration practice patterns following implementation of an enhanced recovery after surgery protocol for laparoscopic donor nephrectomy. J Clin Anesth 2022; 79:110751. [PMID: 35334291 DOI: 10.1016/j.jclinane.2022.110751] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 03/04/2022] [Accepted: 03/09/2022] [Indexed: 01/19/2023]
Abstract
STUDY OBJECTIVE The primary aim of this study is to understand how intraoperative medication administration patterns change in response to ERAS® protocol implementation for patients who underwent laparoscopic donor nephrectomy. DESIGN Single-center, retrospective analysis of laparoscopic donor nephrectomy patients. SETTING Large tertiary academic medical center. PATIENTS We divided all cases of laparoscopic donor nephrectomies (n = 929) over seven years into three approximately equal time periods: Pre-ERAS 1 (n = 317), Pre-ERAS 2 (n = 297) and Post-ERAS (n = 315). MEASUREMENTS We examined patient demographics, intraoperative opioid and non-opioid pain adjuvant administration, Post Anesthesia Recovery Unit (PACU) pain scores and opioid use as well as PACU and hospital lengths of stay (LOS). MAIN RESULTS Segmented regression analysis of interrupted time series was utilized to evaluate the association of ERAS protocol implementation with the amount of intraoperative opioid and non-opioid pain adjuvant use. In adherence to our institutional ERAS protocol, there was a significant reduction in intraoperative fentanyl use after ERAS protocol of -70.2μg (95% CI -106.0, -34.2, p < 0.001) and a significant increase in intraoperative hydromorphone use of 0.47 mg (95% CI 0.284, 0.655, p < 0.001). However, in contrary to our ERAS protocol, we found no significant change in odds of receiving IV acetaminophen OR 1.31 (95% CI 0.450, 3.76, p = 0.613) or IV ketorolac OR 1.65 (95% CI 0.804, 3.41, p = 0.172) after ERAS protocol implementation. We found a significant reduction in PACU opioid use of -9.68 Morphine Milligram Equivalents (MME) (95% CI -17.1, -2.31, p = 0.010) but no significant change in PACU initial pain score, PACU LOS and hospital LOS. CONCLUSIONS We examined intraoperative practice pattern changes by anesthesiologists in response to ERAS protocol implementation for laparoscopic donor nephrectomies. Our results suggest that there was a variable uptake of recommendations from ERAS protocol. While ERAS protocols are often studied as a bundle of best practice recommendations, understanding the variability of provider adherence represents an important future research direction for the ERAS initiative.
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Affiliation(s)
- Xuezhi Dong
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, Suite 3325, Los Angeles, CA 90095, USA; Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA.
| | - Brittany N Burton
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, Suite 3325, Los Angeles, CA 90095, USA.
| | - Christopher Little
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, Suite 3325, Los Angeles, CA 90095, USA.
| | - Logan Woodhouse
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, Suite 3325, Los Angeles, CA 90095, USA.
| | - Tristan Grogan
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, Suite 3325, Los Angeles, CA 90095, USA.
| | - Jeremy M Blumberg
- Department of Urology, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue Box 951738, Los Angeles, CA 90095, USA.
| | - Hans A Gritsch
- Department of Urology, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue Box 951738, Los Angeles, CA 90095, USA.
| | - Siamak Rahman
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, Suite 3325, Los Angeles, CA 90095, USA.
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