Pain management in laparoscopic donor nephrectomy: a review

A Comparison of Analgesic and Recovery Profiles of Ketamine, Lignocaine, and Dexmedetomidine (KeLiDex) Versus Fentanyl-Based Anesthesia in Laparoscopic Nephrectomies: A Randomized, Single-Blind, Pilot Study

BACKGROUND

In the search for opioid-free anesthesia, notable numbers of drugs, singly or in combinations, have been tested with variable results. However, most of the drugs used are not as strong as opioids. Even if some non-opioid drugs are potent enough, they cause significant untoward effects, necessitating the use of lower effective dosages of multiple drugs as a substitute. The present pilot study evaluated low-dose combinations of ketamine, lignocaine, and dexmedetomidine (KeLiDex) against fentanyl-based anesthesia for analgesia and recovery profiles in laparoscopic nephrectomies.

METHODS

Twenty patients (10 in each group) randomly received KeLiDex or fentanyl infusion as an analgesic component for balanced general anesthesia. Entire patients also received paracetamol and quadratus lumborum block-2. Anesthesia depth, neuromuscular blockade, and reversal were standardized. Intraoperative hemodynamic variation, time to extubation after reversal (T-tEAR) administration, postanesthesia care unit (PACU) discharge readiness assessed using modified Aldrete score, sedations using Richmond Agitation Sedation Scale, postoperative pain, and rescue analgesia consumptions were compared using different validated scales. P-value <0.05 was considered significant.

RESULTS

The KeLiDex group had a significantly lower heart rate (HR) between 45-90 minutes and at the time of reversal. Mean arterial pressure (MAP) (mean ± standard deviation (SD)) differed significantly at only a 60-minute interval (KeLiDex group 80.90 ± 9.50 versus fentanyl group 92.60 ± 16.13 mmHg, p-value 0.041). The Friedman test for change in HR and MAP over time within each group was also insignificant. The mean ± SD of T-tEAR was 6.37 ± 2.13 in KeLiDex, and 8.18 ± 2.92 minutes in the fentanyl group, p-value 0.27. Sedation scores, Modified Alderette scores, pain scores, and rescue analgesic requirements were also comparable.

CONCLUSION

KeLiDex could effectively control hemodynamics and pain both at rest and in movements in line with fentanyl-based anesthesia for laparoscopic nephrectomies. Further, recovery from the anesthesia, sedation, and PACU discharge readiness were similar.

Kidney Donor Perspectives on Acute Postoperative Pain Management

This study employed a qualitative descriptive approach to examine living kidney donor's experience of postoperative pain. Thirteen living kidney donors aged 46.5 (±14.4) years participated in this study. Semi-structured interviews were conducted and transcribed. Transcripts were inductively coded and reviewed for trends, patterns, and insights into donor's experience of postoperative pain. Donors experienced postoperative pain from a variety of sources that hindered recovery and created anxiety and fear in some. Donors managed pain with opioid and non-opioid medications, social support, and ambulation. Donor's past experiences with and expectations about pain, relationships with intended recipients, social support, as well as motivations for and meaning of donation informed their experience of postoperative pain. Prompt pharmacologic intervention for pain, as well as further coaching and education about pain management should be emphasized for nurses caring for living kidney donors. Further study of how donor's motivation might mediate their pain experience is needed.

Efficacy Of Quadratus Lumborum Blocks (QLBs) in Robotic Nephrectomy: A Retrospective Study

INTRODUCTION

Abdominal blocks such as quadratus lumborum block (QLB) have been used as an effective analgesic in abdominal surgeries. However, their efficacy in kidney surgery remains unknown. To the best of our knowledge, there are no clinical studies exploring the relationship between QLBs and post-operative opioid consumption in robotic laparoscopic nephrectomy.

OBJECTIVES

To assess the analgesic efficacy of QLB and its impact on perioperative opioid consumption in robotic laparoscopic nephrectomy.

MATERIALS AND METHODS

A retrospective chart review was conducted by querying the electronic medical record system of a 2,200-bed tertiary academic hospital center in New York City. The primary measured outcome was postoperative morphine milligram equivalents (MME) consumption for the first 24 hours. Secondary outcomes include intra-operative MME as well as postoperative pain scores measured on a visual analogue scale (VAS) scale at 2, 6, 12, 18, and 24 hours postoperatively.

RESULTS

The mean total postoperative MME in the posterior QLB (pQLB) group was 11 in the QLB group (interquartile range (IQR) 4, 18) and 15 in the control group (IQR 5.6, 28) . There was a significant reduction in intraoperative MME in the QLB group in comparison to the control group. This reduction was not seen in postoperative MME. There was no significant difference in pain scores at any of the measured time points up to 24 hours postoperatively.

CONCLUSION

Our study provides compelling support that ultrasound guided QLB significantly decreased intraoperative opioid requirements but did not have the same effect on postoperative opioid requirements following robotic kidney surgeries in the context of an enhanced recovery after surgery (ERAS) pathway.

Quadratus Lumborum Blocks in Nephrectomy: A Narrative Review

The quadratus lumborum block is a novel truncal block where local anaesthetic is injected adjacent to the quadratus lumborum muscle. It is used for caesarean sections, hip arthroplasty, gynecologic surgery, colectomy, and recently nephrectomy. To date, there are no reviews that outline the efficacy and performance of the quadratus lumborum blocks in patients receiving laparoscopic nephrectomy. The objective of this project was to outline the current available data from both clinical trials along with case series and reports regarding the methods and utility of quadratus lumborum blocks for analgesia in patients receiving nephrectomy. For this literature review, we searched Pubmed, Embase, and Web of Science from their inception until 5/31/2020. Our search terms were as follows: “(nephrectomy OR laparoscopic nephrectomy) AND (QL block OR Quadratus Lumborum block OR QL OR TQL OR Thoracolumbar fascia block).” We analyzed all relevant clinical trials for quality using the Jadad scale. Our search yielded a total of 30 articles, 23 of which we ultimately reviewed for this manuscript. The qualitative sum of these data show that patients receiving quadratus lumborum block for nephrectomies have reduced opioid requirements, reduced pain scores, and improved side-effects relative to other analgesic modalities like epidurals. Based on these findings, we conclude that the quadratus lumborum block is a useful analgesic for patients undergoing nephrectomy.

Transmuscular quadratus lumborum block reduces opioid consumption and prolongs time to first opioid demand after laparoscopic nephrectomy

BACKGROUND

Robotic and hand-assisted laparoscopic nephrectomies are often associated with moderate to severe postoperative pain. The aim of the current study was to investigate the analgesic efficacy of the transmuscular quadratus lumborum (TQL) block for patients undergoing robotic or hand-assisted laparoscopic nephrectomy.

METHODS

Fifty patients were included in this single-center study. All patients were scheduled for elective hand-assisted or robotic laparoscopic nephrectomy under general anesthesia. Preoperatively, patients were randomly allocated to TQL block bilaterally with ropivacaine 60 mL 0.375% or 60 mL saline and all patients received standard multimodal analgesia and intravenous patient-controlled analgesia. Primary outcome was postoperative oral morphine equivalent (OME) consumption 0-12 hours. Secondary outcomes were postoperative OME consumption up to 24 hours, pain scores, time to first opioid, nausea/vomiting, time to first ambulation and hospital length of stay (LOS).

RESULTS

Mean (95% CI) OME consumption was significantly lower in the intervention group at 12 hours after surgery 50 (28.5 to 71.5) mg versus control 87.5 (62.7 to 112.3) mg, p=0.02. At 24 hours, 69.4 (43.2 to 95.5) mg versus 127 (96.7 to 158.6) mg, p<0.01. Time to first opioid was significantly prolonged in the intervention group median (IQR) 4.4 (2.8-17.6) hours compared with 0.3 (0.1-1.0) hours in the control group, p<0.001. No significant intergroup differences were recorded for time to first ambulation, pain scores, nausea/vomiting nor for LOS.

CONCLUSION

Preoperative bilateral TQL block significantly reduced postoperative opioid consumption by 43% and significantly prolonged time to first opioid.

TRIAL REGISTRATION NUMBER

NCT03571490.

Prescription patterns of opioids and non-steroidal anti-inflammatory drugs in the first year after living kidney donation: An analysis of U.S. Registry and Pharmacy fill records

We examined a novel database linking national donor registry identifiers to records from a US pharmaceutical claims warehouse (2007-2015) to describe opioid and NSAID prescription patterns among LKDs during the first year postdonation, divided into three periods: 0-14 days, 15-182 days, and 183-365 days. Associations of opioid and NSAID prescription fills with baseline factors were examined by logistic regression (adjusted odds ratio, LCL aORUCL ). Among 23,565 donors, opioid prescriptions were highest during days 0-14 (36.6%), but 12.6% of donors filled opioids during days 183-365. NSAID prescriptions rose from 0.5% during days 0-14 to 3.3% during days 183-365. Women filled opioids more commonly than men, and black donors filled both opioids and NSAIDs more commonly than white donors. After covariate adjustment, significant correlates of opioid prescription fills during days 183-365 included obesity (aOR,1.24 1.381.53 ), less than college education (aOR,1.19 1.311.43 ), smoking (aOR,1.33 1.451.58 ), and nephrectomy complications (aOR,1.11 1.291.49 ). NSAID prescription fills in year 1 were not associated with differences in estimated glomerular filtration rate, incidence of proteinuria or new-onset hypertension at the first and second year postdonation. Prescription fills for opioids and NSAIDs for LKDs varied with demographic and clinic traits. Future work should examine longer-term outcome implications to help inform safe analgesic regimen choices after donation.

Comparison of transversus abdominis plane block and intrathecal morphine for laparoscopic donor nephrectomy: Randomised controlled trial

Background and Aims:

Postoperative pain following laparoscopic donor nephrectomy (LDN) is significant and no suitable analgesic technique is described. Opioid analgesia in standard doses is often suboptimal and associated with numerous adverse effects. Transversus abdominis plane (TAP) block has been evaluated in various laparoscopic procedures. Intrathecal morphine (ITM) has been seen to provide long-lasting analgesia of superior quality in laparoscopic colorectal procedures.

Methods:

The present study was undertaken to evaluate the analgesic efficacy of single-dose ITM 5 μg/kg for LDN. After ethics approval, 60 adult patients scheduled for LDN were randomised to receive intravenous fentanyl, ultrasound-guided TAP block or ITM for postoperative analgesia. Postoperative 24-h patient-controlled analgesia (PCA) fentanyl consumption, visual analogue scale (VAS) score and intraoperative fentanyl and muscle relaxant requirements were compared. Statistical analysis was performed using appropriate statistical tests by using Stata 11.1 software.

Results:

Haemodynamic stability at pneumoperitoneum and in the post anaesthesia care unit was significantly better in patients receiving ITM. Intraoperative rescue fentanyl requirement (P = 0.01) and postoperative fentanyl requirement until 24 h (P = 0.000) were significantly lower in the morphine group. Postoperative VAS at rest and on movement was significantly lower in the morphine group at all points of assessment (P = 0.000).

Conclusion:

ITM 5 μg/kg provides better intraoperative and postoperative analgesia and reduces postoperative PCA fentanyl requirement in laparoscopic donor nephrectomy compared to TAP block or intravenous fentanyl.

Anesthetic considerations for urologic surgeries

Urologic surgeries are widely performed, and the cases have increased owing to the fact that the elderly population is growing. The narrow and limited surgical space is a challenge in performing most urologic surgeries. Additionally, the elderly population is exposed to the risk of perioperative complications; therefore, a comprehensive understanding and approach are required to provide optimized anesthesia during surgery. We have searched the literature on anesthesia for urologic surgeries and summarized the anesthetic considerations for urologic surgeries.

Chronic pain after hand-assisted laparoscopic donor nephrectomy

BACKGROUND

Data on chronic pain after kidney donation are sparse. The aim of this study was to assess the incidence of chronic pain after hand-assisted laparoscopic nephrectomy.

METHODS

Living kidney donors who donated between 2011 and 2017 at the University Medical Centre Groningen were included. All patients underwent hand-assisted laparoscopic donor nephrectomy. Postdonation pain and movement disabilities were assessed using the Carolinas Comfort Scale (CCS) and a visual analogue scale (VAS). The prevalence, severity of pain and the need for analgesics were reported.

RESULTS

Some 333 living kidney donors with a mean age of 56 years were included. At a median of 19 (i.q.r. 10-33) months after donation, 82 donors (24·6 per cent) had a CCS score above 0, of which 58 (71 per cent) had a CCS score of at least 2 and 57 (70 per cent) reported movement limitations. Some 110 donors (33·0 per cent) had a VAS score of more than 0. Complaints mainly occurred during bending over (12·3 per cent) and exercising (12·4 per cent). Thirty-two donors (9·7 per cent) required analgesics during follow-up between donation and the time of measurement, and six of 82 (7 per cent) reported chronic inguinal pain. In multivariable analysis, donor age (odds ratio (OR) 0·97, 95 per cent c.i. 0·95 to 0·99; P = 0·020) and length of hospital stay (OR 1·21, 1·01 to 1·51; P = 0·041) were independently associated with chronic pain.

CONCLUSION

One-quarter of donors experienced chronic postdonation pain or discomfort, most of which was bothersome. Younger donors and those with a longer postoperative hospital stay had more symptoms.

Comparison of early postoperative pain after partial tumour nephrectomy by flank, transabdominal or laparoscopic access

Aim

To explore whether the total pain experience differs after (partial) kidney tumour nephrectomies via flank, transabdominal or laparoscopic access.

Materials and methods

We analyzed retrospectively 107 patients with flank, 12 with transabdominal and 21 with laparoscopic interventions. For pain treatment, conventional analgesics (A) or intravenous patient-controlled analgesia (PCIA) or thoracic peridural analgesia (tPDA) were used. Self-reported pain was measured with a Visual Analogue Scale three times daily. The area under the curve (AUC) at rest (R) and during a standardized body movement (M) were calculated from the intervention till the end of the second T(0-2) and seventh postoperative day T(0-7), respectively.

Results

The median AUC for T(0-2) at R was more intense for laparoscopy (13) than for flank incision (A, 9) and approximately the same during M. For flank incisions (A), the median AUC at R rises from 9 for T(0-2) to 22 for T(0-7) and at M the median AUC increases from 18 to 37. In contrast, laparoscopy did not cause further pain after the second postoperative day. Furthermore, with flank incision for T(0-2), at R, tPDA was superior to A (median AUC: 5 versus 9, p = 0.02) and at M again tPDA (median AUC: 12) had a better pain-control as A (18) or even as PCIA (19, p = 0.005).

Conclusion

Laparoscopic nephrectomies cause a relatively intense mean cumulative pain for T(0-2) and a subsequent absence of pain. However, flank incisions went on to increased pain levels until the seventh postoperative day with tPDA as most effective therapy.

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.

Gender differences in use of prescription narcotic medications among living kidney donors

Prescription narcotic use among living kidney donors is not well described. Using a unique database that integrates national registry identifiers for living kidney donors (1987-2007) in the United States with billing claims from a private health insurer (2000-2007), we identified pharmacy fills for prescription narcotic medications in periods 1-4 and >4 yr post-donation and estimated relative likelihoods of post-donation narcotic use by Cox regression. We also compared narcotic fill rates and medication possession ratios (MPRs, defined as (days of medication supplied)/(days observed)), between donors and age- and sex-matched non-donors. Overall, rates of narcotic medication fills were 32.3 and 32.4 per 100 person-years in periods 1-4 and >4 yr post-donation. After age and race adjustment, women were approximately twice as likely as men to fill a narcotic prescription in years 1-4 (adjusted hazard ratio, aHR, 2.28; 95% confidence interval, CI, 1.86-2.79) and >4 yr (aHR 1.70; 95% CI 1.50-1.93). MPRs in donors were low (<2.5% days exposed), and lower than among age- and sex-matched non-donors. Prescription narcotic medication use is more common among women than men in the intermediate term after live kidney donation. Overall, total narcotic exposure is low, and lower than among non-donors from the general population.

The Effective Synthesis of N-(Arylalkyl)-1-R-4-hydroxy-2,2-dioxo- 1H-2λ(6),1-benzothiazine-3-carboxamides as Promising Analgesics of a New Chemical Class

A new, effective preparative method has been proposed and the synthesis of a series of N-(arylalkyl)-1-R-4-hydroxy-2,2-dioxo-1H-2λ(6),1-benzothiazine-3-car-boxamides has been carried out. It has been shown that amidation of alkyl 1-R-4-hydroxy-2,2-dioxo-1H-2λ(6),1-benzothiazine-3-carboxylates with arylalkyl-amines in boiling xylene proceeds with good yield and purity to the corresponding N-(arylalkyl)-amides. However, the presence of water in the reaction mixture has been shown to cause the formation of specific impurities: N-(arylalkyl)-1-R-2,2-dioxo-1H-2λ(6),1-benzothiazin-4-amines. According to the results of the pharmacological studies, powerful analgesics have been found among the substances synthesized.