Donor Hepatectomy Surgery using Ketamine to Compliment Analgesia and Reduce Morbidity - a Retrospective Chart Review Investigation

Abstract

Objective: Inferior and limited analgesic options/techniques during living donor hepatectomy surgery can result in pain and risks of morbidity, opioid-related adverse events (AEs), predisposition to the development of chronic pain and concerns of potential narcotic abuse. Traditional analgesia uses unimodal intravenous opioids that can cause significant side effects. Ketamine provides analgesia and may be opioid sparing, but use in living-donor hepatectomy has not been studied. Methods: Following human investigation committee approval and informed written consent, 47 liver donor patients over a 5-year period scheduled for surgery were categorized into one of three groups: 24 patients received no ketamine (Group 1), 9 received only intraoperative ketamine (Group 2) and 14 patients received intraoperative plus postoperative ketamine (Group 3). Subjects had access to opioid patient-controlled analgesia (PCA). Chart reviews (including operating room and intensive care unit) were collected and analysed for morphine consumption, pain-intensity scores, opioid-sparing effects, AEs of analgesics and for evidence of ketamine side effects on donor hepatectomy patients. Results: There were no differences in patient demographics. Living donor hepatectomy patients receiving intraoperative ketamine that was continued postoperatively consumed fewer morphine-equivalents and had lower median pain scores than subjects from the other two groups. Ileus occurred in those not receiving ketamine, pruritus was lowest in Group 3, and there was no evidence or reports of ketamine-associated AEs. Conclusion: Perioperative ketamine for donor hepatectomy patients could safely provide improved analgesia and be opioid sparing when compared to PCA opioids alone, and there is no evidence of ketamine-related AEs at the dose and delivery methods described here during partial liver donation surgery. Keywords: Living-donor liver transplantation, ketamine, perioperative analgesia Amaç: Canlı donörlü hepatektomi ameliyatı sırasında uygulanan inferior ve sınırlı analjezi seçenekleri/teknikleri ağrıya ve morbidite riskine, opioide bağlı yan etkilere, kronik ağrı gelişimi eğilimine ve potansiyel narkotik bağımlılığına neden olabilirler. Geleneksel analjezi uygulamasında, önemli yan etkilere neden olabilen unimodal intravenöz opioidler kullanılmaktadır. Ketamin analjezi sağlar ve opioid tüketimini azaltabilir. Ancak canlı donörlü hepatektomide kullanımı hakkında henüz çalışma yapılmamıştır. Yöntemler: İnsan araştırmaları etik kurulu onayı ve yazılı bilgilendirilmiş hasta onam formu alındıktan sonra, 5 yıllık bir süreçte ameliyat olması planlanan 47 canlı donör hastası 3 gruba ayrıldı. 24 hastaya hiç ketamin verilmedi (Grup 1); 9 hastaya sadece intraoperatif ketamin verildi (Grup 2); ve 14 hastaya intraoperatif ve postoperatif ketamine uygulandı (Grup 3). Denekler hasta kontrollü opioid analjezisi kullandılar. Hastaların tıbbi kayıtları toplandı (ameliyathane ve yoğun bakım ünitesinden) ve morfin kullanımı, ağrı-yoğunluk skorları, opioid tüketiminin azaltıc...

Does multimodal perioperative pain management enhance immediate and short‐term outcomes after living donor partial hepatectomy? A systematic review of the literature and expert panel recommendations

“…There were no reported technical difficulties or complications of regional or neuroaxial techniques in these cohorts. Adjuvant pharmacological therapies investigated were: Dexmedetomidine, a potent alpha‐2 agonist with hypnotic, sedative, and analgesic properties; ketamine, a NMDA receptor antagonist with sedating, analgesic, and hypnotic actions; intravenous lidocaine, a sodium channel blocker with analgesic properties; ketorolac, a non‐steroidal anti‐inflammatory drug; and parecoxib, a cyclo‐oxygenase‐2 inhibitor 9,11–15 . A single feasibility study investigated the role of acupuncture in this setting and concluded that the delivery of acupuncture was possible in this cohort of patients 8 .…”

“…Post‐operative pain scores were reported in eight studies (Table 2 and Supplementary Table S1). Four out of five studies included a control group and showed a significantly lower pain score at 24 h 9,11–13 . The multi‐modal approach by Hardman et al.…”

“…Post-operative pain scores were reported in eight studies (Table 2 and Supplementary Table S1). Four out of five studies included a control group and showed a significantly lower pain score at 24 h. 9,[11][12][13] The multi-modal approach by Hardman et al did not report a significant difference in pain scores when compared to controls. 14 The study by Kang et al showed a significantly higher pain score at 24 h with ESB when compared to intrathecal morphine, but this was not apparent at 48 or 72 h. There was no significant difference in pain scores in a comparison of ketorolac v. parecoxib.…”

Perioperative management of living donor liver transplantation: Part 2 – Donors

“…A non‐opioid analgesic is an essential tool for LDLT donors. Perioperative ketamine, lidocaine, gabapentin, and magnesium have been reported as useful adjuncts with opioid‐sparing effects in LDLT donors 46,50,51 . Non‐steroidal anti‐inflammatory drugs and acetaminophen have theoretical concerns for postoperative liver dysfunction and coagulation derangements but can be used judiciously.…”

Decrease in Incidence of PONV by using Ondansetron as Preemptive Antiemetic Agent in Liver Donors

“…1,3 Patients undergoing general abdominal surgery are already prone for prolonged bed rest and delayed mobilization therefore this PONV among such patients is not that much of a concern as compared to patients undergoing surgery for organ donation which are otherwise healthy and anticipate an uneventful and speedy recovery and discharge. 4,5,6 Therefore prophylaxis and prevention of PONV among such patients becomes much - ------------------------------------------------------------------------ Ondansetron is a 5-hydroxytryptamine 3 (5-HT3) receptor antagonists which have been widely used for the treatment of PONV. 7 However, its preemptive role in the prevention of PONV is under estimated where only few studies evaluated the incidence of PONV after prophylactic ondansetron administration before surgery.…”