|Year : 2020 | Volume
| Issue : 3 | Page : 235-239
Reducing opioid consumption in postoperative renal transplant patients: A retrospective analysis
Marian Sherman1, Geoffrey Ho1, Everett Chu1, Ivy Benjenk1, Sam Gumbert1, Connie Lin2, Richard Amdur3, Jason Podolnick1, Joshua Slocum1, Eric Heinz1
1 Department of Anesthesiology and Critical Care Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
2 Department of Anesthesiology, Pain and Perioperative Medicine, Children's National Hospital, Washington, DC, USA
3 Department of Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
|Date of Submission||13-May-2020|
|Date of Acceptance||31-May-2020|
|Date of Web Publication||30-Sep-2020|
Dr. Marian Sherman
900 23rd Street, NW Suite G-2092, Washington, DC
Source of Support: None, Conflict of Interest: None
Background: Opioid use is high in renal transplant patients, both before and after surgery, in part due to the chronic pain associated with end-stage renal disease. Recent studies have shown patients with high opioid consumption post-transplant have higher incidences of graft loss and mortality. Despite this, opioids remain the mainstay of postoperative analgesia. Aims and Objectives: We wanted to see if known analgesic adjuncts, namely regional anesthesia via a continuous transversus abdominis plane (TAP) catheter block or systemic intravenous lidocaine, could reduce the postoperative opioid requirement in this patient group. Materials and Methods: We conducted a retrospective analysis of renal transplant patients over a 2-year period, comparing patients who had an opioid patient-controlled analgesia pump as their main treatment modality, against patients who had either a TAP block or systemic lidocaine as an adjunct. As a primary outcome measure, we calculated their oral morphine equivalents for the 72 hours post-transplant. We excluded patients who had surgical complications, or were on chronic opioid therapy for other conditions. Results: We identified 86 patients over this study period. We found that regional anesthesia was associated with a 34.4% reduction (P < 0.01) and systemic lidocaine with a 36.5% reduction (P = 0.134) in cumulative opioid consumption without adversely affecting the quality of pain control. No significant complications were noted. Conclusion: Both regional anesthesia and systemic lidocaine are viable opioid sparing adjuncts for postoperative acute pain in this patient population.
Keywords: Acute pain, reducing opioid consumption, regional anesthesia, renal transplant
|How to cite this article:|
Sherman M, Ho G, Chu E, Benjenk I, Gumbert S, Lin C, Amdur R, Podolnick J, Slocum J, Heinz E. Reducing opioid consumption in postoperative renal transplant patients: A retrospective analysis. Indian J Transplant 2020;14:235-9
|How to cite this URL:|
Sherman M, Ho G, Chu E, Benjenk I, Gumbert S, Lin C, Amdur R, Podolnick J, Slocum J, Heinz E. Reducing opioid consumption in postoperative renal transplant patients: A retrospective analysis. Indian J Transplant [serial online] 2020 [cited 2021 May 18];14:235-9. Available from: https://www.ijtonline.in/text.asp?2020/14/3/235/296895
| Introduction|| |
Renal transplant patients have been found to have high rates of opioid use both before and after surgery, which is attributed to pain associated with the underlying causes and complications of end-stage renal disease that plagues patients even after transplantation. In addition to the risks of addiction and misuse, patients with high-level opioid use after renal transplantation have been found to be at increased risk for death and graft loss., Despite this, opioid-based patient-controlled analgesia (PCA) modalities remain the international gold standard for treating acute pain in the immediate postoperative period.,
Our institution began its transplant program in 2015, and opioid-based PCAs were the predominant modality for postoperative pain management. In response to the U.S. Department of Health and Human Services declaring the opioid crisis a public health emergency in 2017, our anesthesiology providers increased our efforts of employing multimodal approaches to postoperative analgesia using regional anesthesia and nonopioid adjuncts to minimize patient exposure to opioids.,,
Ultrasound-guided transversus abdominis plane (TAP) blocks are a common regional anesthetic technique that provides analgesia for abdominal surgery. They are performed either as a single injection or a continuous infusion via catheter of local anesthetic into the fascial plane superficial to the transversus abdominis muscle in the anterior abdominal wall, which contains somatic afferents to the intercostal, subcostal, and L1 segmental nerves. TAP blocks after intra-abdominal surgery have been found to yield consistent improvement of pain scores and an overall decrease in opioid consumption in the first 24–48 h.,,,, These benefits have been validated in procedures including hernia repair, hysterectomy, cesarean delivery, and suprapubic prostatectomy.,,
Systemic lidocaine, administered intravenously as a continuous infusion, is a nonopioid analgesic adjunct that possesses significant analgesic, anti-hyperalgesic, and anti-inflammatory properties via mechanisms that are not fully understood., Unlike the TAP block, it does not require special training to administer, but instead requires enhanced postadministration monitoring to look for signs of local anesthetic toxicity (LAST). The efficacy of perioperative intravenous (IV) lidocaine is known to vary between surgical procedures. Although data are promising, there is little established evidence of perioperative lidocaine infusions in renal transplant populations.
The objective of this study was to determine if our multimodal analgesia strategies following renal transplantation would lead to less opioid consumption. Our hypothesis was that either TAP blocks or systemic lidocaine would reduce postoperative opioid use in this population.
| Materials and Methods|| |
This was a retrospective analysis of patients who had a renal transplantation between October 2017 and October 2019 at our institution, a 431-bedded, urban, quaternary care, academic teaching hospital.
We included renal transplant patients aged 18–80 years and excluded patients with a history of substance abuse or narcotic use, intraoperative surgical complication, postoperative complication requiring return to the operating room, or need for postoperative respiratory support from our analysis.
Three groups of interest were identified: a PCA-only group, TAP group, and lidocaine group. All patients received an opioid PCA with IV boluses of 0.2 mg hydromorphone available every 10 min. Patients with TAP catheters in situ received a continuous infusion of 0.2% ropivacaine at 8–12 ml/h for up to 5 days postoperatively in addition to a PCA. Patients receiving systemic lidocaine had IV infusions run at 1.0–1.5 mg/kg/h for 48 h postoperatively in addition to a PCA. Additional opioids were available for breakthrough pain across all groups.
Medical records were reviewed for demographics, complications, and both postoperative cumulative opioid consumption and quality of pain control (via visual analog scale scores) at 12, 24, 48, and 72 h after arrival in the postanesthesia care unit. Opioid consumption was converted into oral morphine equivalents (OME), and the primary outcome measured was cumulative OME intake at 72-h postoperation. Complications noted were sepsis, LAST, opioid toxicity requiring naloxone, hyperacute transplant rejection, and need for postoperative hemodiafiltration.
We used Welch unequal variance t-tests for continuous variables. All analyses were conducted in STATA v15.1 (StataCorp LLC, College Station, TX, USA), and we considered all P < 0.05 to be statistically significant.
Declaration of Patient consent
The patient consent has been taken for participation in the study and for publication of clinical details and images. Patients understand that the names, initials would not be published, andl their identity. all standard protocols will be followed to concea
This study was determined exempt by the Institutional Review Board at the George Washington University of Human Research (IRB: NCR191485). The study was conducted as per the Guidelines of Declaration of Helsinki.
| Results|| |
A total of 115 patients were identified and 29 were excluded from the analysis [Figure 1]. Of the 86 patients studied, 43 had PCA only for postoperative pain control, 34 had TAP blocks, and 9 had systemic lidocaine for postoperative pain control. There were no significant demographic differences between our three treatment groups [Table 1].
In comparison to the PCA-only group [Table 2] and [Figure 2], OME was significantly lower for the TAP group at all the four time points (12, 24, 48, and 72 h). At 72 h, TAP blocks provided a 34.4% cumulative reduction in opioid consumption (168.2 mg vs. 256.2 mg; P < 0.01) compared to the PCA-only group. Similarly, OME was lower in the lidocaine group compared to the PCA-only group across all time points, but only significantly so at the 12-h mark. At 72 h, patients on systemic lidocaine had a 36.5% cumulative reduction in opioid consumption, although statistically nonsignificant (162.8 mg vs. 256.2 mg; P = 0.134). The quality of pain control in the TAP and lidocaine groups was better than that of PCA-only across all time points, although not significantly so.
|Table 2: Comparison of patient-controlled analgesia to transversus abdominis plane and lidocaine across the four measured time points|
Click here to view
|Figure 2: Cumulative oral morphine equivalent consumption over 72-h time period after arrival in the postanesthetic care unit|
Click here to view
Three patients in the PCA-only group and one patient in the TAP group required hemodiafiltration postoperatively. There were no other complications noted.
| Discussion|| |
Our study shows that both continuous TAP catheters and systemic lidocaine can substantially reduce opioid consumption in postrenal transplantation patients without pretransplant chronic opioid use while maintaining effective pain control. Further, we did not find additional significant complications as a result of these adjuncts.
Our study adds to the growing body of literature supporting the use of continuous TAP catheters in renal transplant patients. Farag et al. conducted a retrospective comparison of patient-controlled IV analgesia with TAP blocks with catheter placement in the renal transplant population. The mean 48-h postoperative morphine-equivalent dose for TAP blocks was significantly lower compared to that of the PCA cohort. The benefit of TAP blocks with catheter placement in renal transplant patients was further supported by a prospective double-blind study by Parikh et al. that found a significant lower visual analog score, longer time to first rescue, and lower 24 h narcotic consumption.
Concerns exist surrounding the placement of catheters near surgical incision sites in immunocompromised patients, such as postrenal transplant patients. A large prospective study quotes the risk of infection from peripheral catheters at any site as 0.07% in all patients, and another suggests that immunosuppression secondary to transplant is not considered an increased risk. Although this study was not powered to detect complications, we did not record any infections in any group.
Systemic lidocaine has been shown to positively impact pain scores, opioid consumption, time to rehabilitation, length of hospital stay, wound healing, analgesia, coagulation, postoperative cognitive dysfunction, paralytic ileus, and lung protection.,, Lidocaine infusions have a strong record of safety with relatively benign adverse side effects., It is included in enhanced recovery protocols for patients undergoing open and laparoscopic colorectal surgeries, and available evidence suggests minimal risks of neurologic and cardiac side effects.,
Use of this adjunct in renal transplant patients remains fairly novel due to concerns about its renal excretion, and the subsequent increased risk for LAST. However, a pharmacokinetic study suggests that lidocaine infusions remain safe even in patients on chronic hemodialysis. Although at our institution we have a low nurse-to-patient ratio for postoperative transplant patients, lidocaine infusions have been found to be safe to administer on standard nursing wards with minimal adverse events or lidocaine toxicity.,,
The suggestion that IV lidocaine may also be effective in reducing opioid consumption in this cohort is exciting: first, it obviates the need for a peripheral nerve catheter required by the TAP infusion, and therefore eliminates the theoretical risk of infection. Second, it may be initiated as a reasonable alternative to TAP catheters if a regional-trained anesthesiologist is unavailable, as transplant surgery often occurs at unpredictable hours.
There are several limitations to this study. First, this is a retrospective analysis and as such can be affected by multiple bias, lack of control over exposure and outcome assessments, and reliance on accurate recordkeeping. Second, given the relatively small sample size, it is not possible to report on the safety or adverse events associated with these therapies. Third, our study was not sufficiently powered to determine the difference in pain scores and opioid utilization between the TAP block and lidocaine infusion groups.
Our next steps will include performing a prospective analysis with the intent to quantify opioid-sparing effects of IV lidocaine infusion, and potentially establish it as a viable alternative to regional anesthesia in postoperative renal transplant patients.
In the era of the opioid epidemic, it is imperative to search for optimal analgesia for acute postoperative pain. This retrospective analysis finds clear opioid-sparing benefits to using TAP blocks, and suggests that systemic lidocaine might be equally efficacious in treating postoperative pain in renal transplant patients.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Lentine KL, Lam NN, Naik AS, Axelrod DA, Zhang Z, Dharnidharka VR, et al
. Prescription opioid use before and after kidney transplant: Implications for post-transplant outcomes. Am J Transplant 2018;18:2987-99.
Hah JM, Bateman BT, Ratliff J, Curtin C, Sun E. Chronic opioid use after surgery: Implications for perioperative management in the face of the opioid epidemic. Anesth Analg 2017;125:1733-40.
Williams M, Milner QJ. Postoperative analgesia following renal transplantation – Current practice in the UK. Anaesthesia 2003;58:712-3.
Madeira I, Frada R, Marvão J, Cruz F, Casal M, Costa E. Morphine patient controlled analgesia for postoperative analgesia in patients who have transplanted cadaver donor kidneys. Transplant Proc 2011;43:125-30.
Zhao S, Chen F, Feng A, Han W, Zhang Y. Risk factors and prevention strategies for postoperative opioid abuse. Pain Res Manag 2019;2019:7490801.
Koepke EJ, Manning EL, Miller TE, Ganesh A, Williams DGA, Manning MW. The rising tide of opioid use and abuse: the role of the anesthesiologist. Perioperative Medicine. 2018;7:16. doi:10.1186/s13741-018-0097-4. [Last accessed on 2020 Jul 24].
Abdallah FW, Laffey JG, Halpern SH, Brull R. Duration of analgesic effectiveness after the posterior and lateral transversus abdominis plane block techniques for transverse lower abdominal incisions: A meta-analysis. Br J Anaesth 2013;111:721-35.
Siddiqui MR, Sajid MS, Uncles DR, Cheek L, Baig MK. A meta-analysis on the clinical effectiveness of transversus abdominis plane block. J Clin Anesth 2011;23:7-14.
Brady RR, Ventham NT, Roberts DM, Graham C, Daniel T. Open transversus abdominis plane block and analgesic requirements in patients following right hemicolectomy. Ann R Coll Surg Engl 2012;94:327-30.
Milan ZB, Duncan B, Rewari V, Kocarev M, Collin R. Subcostal transversus abdominis plane block for postoperative analgesia in liver transplant recipients. Transplant Proc 2011;43:2687-90.
Mrunalini P, Raju NV, Nath VN, Saheb SM. Efficacy of transversus abdominis plane block in patients undergoing emergency laparotomies. Anesth Essays Res 2014;8:377-82. [Full text]
Farag E, Guirguis MN, Helou M, Dalton JE, Ngo F, Ghobrial M, et al
. Continuous transversus abdominis plane block catheter analgesia for postoperative pain control in renal transplant. J Anesth 2015;29:4-8.
McDonnell JG, Curley G, Carney J, Benton A, Costello J, Maharaj CH, et al
. The analgesic efficacy of transversus abdominis plane block after cesarean delivery: A randomized controlled trial. Anesth Analg 2008;106:186-91.
O'Donnell BD, McDonnell JG, McShane AJ. The transversus abdominis plane (TAP) block in open retropubic prostatectomy. Reg Anesth Pain Med 2006;31:91.
Eipe N, Gupta S, Penning J. Intravenous lidocaine for acute pain: An evidence-based clinical update. BJA Educ 2016;16:292-8.
Dunn LK, Durieux ME. Perioperative use of intravenous lidocaine. Anesthesiology 2017;126:729-37.
Parikh BK, Waghmare V, Shah VR, Modi P, Rizvi S, Khemchandani S, et al
. The analgesic efficacy of continuous transversus abdominis plane block in renal transplant recipients. J Anaesthesiol Clin Pharmacol 2015;31:531-4.
] [Full text]
Capdevila X, Pirat P, Bringuier S, Gaertner E, Singelyn F, Bernard N, et al
. Continuous peripheral nerve blocks in hospital wards after orthopedic surgery: A multicenter prospective analysis of the quality of postoperative analgesia and complications in 1,416 patients. Anesthesiology 2005;103:1035-45.
List F, Kessler P, Volk T. Regional anesthesia in patients with pre-existing infections or immunosuppression. Anaesthesist 2013;62:175-82.
McCarthy GC, Megalla SA, Habib AS. Impact of intravenous lidocaine infusion on postoperative analgesia and recovery from surgery: A systematic review of randomized controlled trials. Drugs 2010;70:1149-63.
Hollmann MW, Durieux ME. Local anesthetics and the inflammatory response: A new therapeutic indication? Anesthesiology 2000;93:858-75.
Weibel S, Jelting Y, Pace NL, Helf A, Eberhart LH, Hahnenkamp K, et al
. Continuous intravenous perioperative lidocaine infusion for postoperative pain and recovery in adults. Cochrane Database Syst Rev 2018;6:CD009642.
Lemming K, Fang G, Buck ML. Safety and tolerability of lidocaine infusions as a component of multimodal postoperative analgesia in children. J Pediatr Pharmacol Ther 2019;24:34-8.
Collinsworth KA, Kalman SM, Harrison DC. The clinical pharmacology of lidocaine as an antiarrhythymic drug. Circulation 1974;50:1217-30.
McEvoy MD, Scott MJ, Gordon DB, Grant SA, Thacker JK, Wu CL, et al
. American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) joint consensus statement on optimal analgesia within an enhanced recovery pathway for colorectal surgery: Part 1–from the preoperative period to PACU. Perioper Med (Lond) 2017;6:8.
Greenwood E, Nimmo S, Paterson H, Homer N, Foo I. Intravenous lidocaine infusion as a component of multimodal analgesia for colorectal surgery-measurement of plasma levels. Perioper Med (Lond) 2019;8:1.
Collinsworth KA, Strong JM, Atkinson AJ Jr., Winkle RA, Perlroth F, Harrison DC. Pharmacokinetics and metabolism of lidocaine in patients with renal failure. Clin Pharmacol Ther 1975;18:59-64.
[Figure 1], [Figure 2]
[Table 1], [Table 2]