Altered hematologic profiles following donor right hepatectomy and implications for perioperative analgesic management

Abstract

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 ...

Efficacy and Safety of a Continuous Wound Catheter in Open Abdominal Partial Hepatectomy

“…[14][15] However, unwanted complications and the possibility of a labor-intensive and non-functioning epidural catheter make epidural analgesia not an ideal analgesic method for hepatectomy. Large hepatectomy can lead to postoperative coagulopathy, 16 which was confirmed in our study. Recently, epidural analgesia has been suggested to be an independent risk factor for AKI after hepatectomy.…”

Epidural Analgesia for Pancreatoduodenectomy: A Critical Appraisal

“…10,14,[33][34] Others have raised concern about the safety of this analgesic modality, particularly when employed for liver resections, which harbor an inherent risk of coagulopathy and hepatotoxicity. [35][36][37] These uncertainties are further compounded by a paucity of randomized trials examining the efficacy of epidural analgesia in upper abdominal operations specifically, particularly in terms of pancreatic operations. Although a frequently cited study-reported by Rigg et al in 2002 16 -did include 35 pancreatic operations (of 915 total), no pancreatic morbidity endpoints were evaluated.…”

The analgesic efficacy of continuous wound instillation with ropivacaine after open hepatic surgery

“…However, administration of morphine is associated with various side-effects [15]. In addition, unexpected sensitivity to systemic opioid has been observed after hepatic resection, perhaps as a result of altered drug metabolism [16]. The plasma concentration of morphine and sedation score were higher in patients after liver resection compared with colonic resection, and this was correlated with the amount of liver resected [17].…”