Living liver donors for adult liver transplant recipients undergo extensive liver resection. Partial donor hepatectomies may alter postoperative drug metabolism and hemostasis; thus, the risks and the benefits of pain management for this unique patient population may need to be reassessed. The safety and efficacy of combined epidural analgesia and field infiltration in our initial living liver donor group are presented. A thoracic epidural catheter was placed before general anesthesia in 2 female and 6 male donors (44.2 ؎ 11.3 years old, mean ؎ standard deviation [SD], range 26 -56). At the end of surgery, incisions were infiltrated (bupivacaine 0.25%), and an epidural infusion was used (bupivacaine 0.1% ؉ hydromorphone hydrochloride 0.02%). Clinical outcomes were followed for 5 days. The time sequence of pain intensity on a 0 -10 visual analog scale clustered into 3 phases, the intensity of which differed significantly from each other (2.2 ؎ 0.6, 0.69 ؎ 0.2, and 2.37 ؎ 0.3 respectively, P ؍ 0.028). Right shoulder pain was observed in 75% of the donors. Sedation, pruritus, and nausea were minimal. Consistently maximal international normalized ratio elevation occurred at 17.6 ؎ 7 hours postoperatively, then slowly declined. Platelet counts were lowest on day 3. No neurologic injury or local anesthetic toxicity was observed. This 2-site approach provided effective, safe, postoperative analgesia for our donors. Universally, coagulopathy ensued, indicating a potentially increased risk for epidural hemorrhage at epidural catheter removal and mandating close postoperative neurologic and laboratory monitoring. Research is needed to advance the understanding of postoperative coagulopathy and hepatic dysfunction in these donors to further optimize their perioperative management, including that of analgesia. (Liver Transpl 2004;10:363-368.) M inimization of perioperative pain enhances many surgical outcomes, 1 and safe, effective postoperative pain management is a clinical goal, an ethical mandate, and a standard of the Joint Commission on Accreditation of Healthcare Organizations. 2 Large liver resections may result in transient metabolic impairment [3][4][5][6] and temporary disturbances in hemostasis. 3,4,[7][8][9][10][11] Hence, development of an optimal perioperative pain management strategy for donors is a complex clinical challenge. Although epidural pain management has been recommended, 12 and used successfully in living liver donor surgery, 8,9,12 a systematic assessment of its efficacy and safety in living donors for adult liver transplantation, who typically donate approximately 60% of their liver, 13,14 is not available.Reports in operations other than liver donation suggest that epidural pain management, in combination with local anesthetic field infiltration, offers effective, opioid-sparing analgesia [15][16][17] as an alternative to systemic opioids with their potential hepatotoxicity 18,19 and risk of sedation. In the current case series, we evaluated the efficacy and safety of this 2-site approach and ...
