Thoracic epidural analgesia in donor hepatectomy: An analysis

Abstract

The purpose of this study is to analyze whether supplementation of general anesthesia (GA) with thoracic epidural analgesia (TEA) for right lobe donor hepatectomy is a safe modality of pain relief in terms of changes in postoperative coagulation profile, incidence of epidural catheter-related complications, and timing of removal of epidural catheter. Retrospective analysis of the record of 104 patients who received TEA for right lobe donor hepatectomy was done. Platelet count, international normalized ratio, alanine aminotransferase, and aspartate aminotransferase were recorded postoperatively until the removal of the epidural catheter. The day of removal of the epidural catheter and visual analogue scale (VAS) scores were also recorded. Any complication encountered was documented. Intraoperatively, central venous pressure (CVP), hemodynamic variables, and volume of intravenous fluids infused were also noted. Statistical analysis was performed by using SPSS statistical package, version 17.0 (SPSS Inc. Chicago, IL). Continuous variables were presented as mean ± standard deviation. A total of 90% of patients had mean VAS scores between 1 and 4 in the postoperative period between days 1 and 5. None of the patients had a VAS score above 5. Although changes in coagulation status were encountered in all patients in the postoperative period, these changes were transient and did not persist beyond postoperative day (POD) 5. There was no delay in removal of the epidural catheter, and the majority of patients had the catheter removed by POD 4. There was no incidence of epidural hematoma. Aside from good intraoperative and postoperative analgesia, TEA in combination with balanced GA and fluid restriction enabled maintenance of low CVP and prevention of hepatic congestion. In conclusion, vigilant use of TEA appears to be safe during donor hepatectomy. Living liver donors should not be denied efficient analgesia for the fear of complications. Liver Transplantation 24 214-221 2018 AASLD.

Anaesthesia for liver transplantation at King Hussein medical centre: an overview of 70 cases

“…6 It also has positive effects on postoperative pulmonary function and provides excellent postoperative pain relief. 7 Such benefits for epidural anaesthesia in donors for LDLT have also been demonstrated in many studies. [8][9][10] On the other hand the use of TEA in LT recipients is a debatable issue due to coagulation profile derangements and bleeding tendency in patients with liver failure.…”

Erector Spinae Block with Opioid Free Anesthesia in Cirrhotic Patients Undergoing Hepatic Resection: A Randomized Controlled Trial

“…Hepatic resection in cirrhotic patients is a major abdominal surgery with challenging pain management due to extended subcostal incision, rib retraction, as well as diaphragmatic and peritoneal irritation which have both visceral and somatic components 14 with risk of coagulopathy. The role of epidural has been questioned due to the risk of epidural hematoma caused by the possible prolonged prothrombin time after liver surgery.…”

Safe and Effective Use of Bilateral Erector Spinae Block in Patient Suffering from Post-operative Coagulopathy following Hepatectomy

“…The transverse process is then identified by moving the ultrasound probe laterally and changing the probe orientation by 90°. At T5, the needle is inserted in the plane through the skin, subcutaneous tissue, trapezius, rhomboid major, and erector spinae, followed by hydrodissection with saline, and a single shot injection of bupivacaine or ropivicaine and catheter placement if needed for continuous infusion [11,16].…”

“…Optimal volume, concentration, and type of local anesthetic to reach the target dermatomes and enter the paravertebral space, while avoiding systemic toxicity are under active investigation [15]. Patients undergoing extensive liver surgery experience dramatic somatic and visceral pain due to extended subcostal incision, rib retraction, as well as diaphragmatic and peritoneal irritation [16]. Despite the absence of a pre-operative contraindication for epidural placement, patients undergoing hepatic surgery are prone to the development of post-operative coagulopathy which could potentially pose a bleeding risk and delay removal of an epidural catheter [8,17].…”

“…Despite the absence of a pre-operative contraindication for epidural placement, patients undergoing hepatic surgery are prone to the development of post-operative coagulopathy which could potentially pose a bleeding risk and delay removal of an epidural catheter [8,17]. Risk factors for the development of post-operative elevations in international normalized ratios following hepatic resection include small remnant liver volumes, decreased body mass index, and long duration of procedure [16]. In such clinical scenarios, the erector spinae block may serve as a safe new and effective method to achieve control of pain related to hepatic surgery [8].…”