Epidural for Post-op Analgesia for Renal Transplantation

[twoliter]

I'm preparing a Grand Rounds for next week on Anesthetic Management of Renal Transplantation and trying to focus on areas in which we could improve. After speaking with our transplant nephrologist, one of his biggest issues is the frequency of post-op ileus these patients have due to opioid-based PCAs. A transplant surgeon that left here about a year ago always requested epidurals for his planned transplant patients, but neither of our current surgeons think it's worth it. I personally like the idea, though, and think it would be beneficial.
What is the current practice at your place? If no epidural (e.g., patient is not a candidate for whatever reason), what are your thoughts on TAP blocks for these patients. There's not a whole lot of literature on epidurals or TAPs for renal transplanation.


Sidenote: I also plan to push for using LR instead of (ab)NS for these cases, too. I'm pretty sure that has been discussed on here, as well. Surprisingly, the surgeons said they'd take a look at the articles and consider changing their practice on this.

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[Ignatius J]

I'm preparing a Grand Rounds for next week on Anesthetic Management of Renal Transplantation and trying to focus on areas in which we could improve. After speaking with our transplant nephrologist, one of his biggest issues is the frequency of post-op ileus these patients have due to opioid-based PCAs. A transplant surgeon that left here about a year ago always requested epidurals for his planned transplant patients, but neither of our current surgeons think it's worth it. I personally like the idea, though, and think it would be beneficial.
What is the current practice at your place? If no epidural (e.g., patient is not a candidate for whatever reason), what are your thoughts on TAP blocks for these patients. There's not a whole lot of literature on epidurals or TAPs for renal transplanation.


Sidenote: I also plan to push for using LR instead of (ab)NS for these cases, too. I'm pretty sure that has been discussed on here, as well. Surprisingly, the surgeons said they'd take a look at the articles and consider changing their practice on this.

Great endeavor. I would think TAPs could be good for these. I like TAPs for simple reasons. Although Epidurals can handle visceral pain and Taps won't, a lot of our transplants are sick as hell and may come in on all sorts of blood thinners, or need to be on them post-op. Also, I go to different hospitals every day so following Epidurals is not the most practical thing for my practice.

 

[IlDestriero]

We don't place them for kidney transplants. TAP blocks might be nice at the end, but how long will they really last? They will still need significant opiates.

 

[Noyac]

Isn't there some new medication out just for this purpose, post op ileus? An agonist antagonist?

I can't recall the name.

 

[Freak]

Alvimopan

 

[Hoya11]

I'm preparing a Grand Rounds for next week on Anesthetic Management of Renal Transplantation and trying to focus on areas in which we could improve. After speaking with our transplant nephrologist, one of his biggest issues is the frequency of post-op ileus these patients have due to opioid-based PCAs. A transplant surgeon that left here about a year ago always requested epidurals for his planned transplant patients, but neither of our current surgeons think it's worth it. I personally like the idea, though, and think it would be beneficial.
What is the current practice at your place? If no epidural (e.g., patient is not a candidate for whatever reason), what are your thoughts on TAP blocks for these patients. There's not a whole lot of literature on epidurals or TAPs for renal transplanation.


Sidenote: I also plan to push for using LR instead of (ab)NS for these cases, too. I'm pretty sure that has been discussed on here, as well. Surprisingly, the surgeons said they'd take a look at the articles and consider changing their practice on this.

I think the incision is too high for a TAP block to be effective.
Epidural is a good idea if post-op management allows it (no anticoagulation/lots of pain, continuous high lumbar/low thoracic catheter OK on floor)

IV or PO tylenol.

I think "Relistor" or methylnaltrexone was referred to above. Its IM opiate antagonist that doesnt get into systemtic circulation. Works great in my experience and you can keep them on the PCA.

There are a lot of reasons for post-op ileus in these patients and opiates may not be the only source. So I think adding tylenol and relistor is a way to start before putting epidurals in everyone, unless incisions are large and painful then go for it.

 

[Consigliere]

http://www.entereg.com/

 

[Arch Guillotti]

I'm preparing a Grand Rounds for next week on Anesthetic Management of Renal Transplantation and trying to focus on areas in which we could improve. After speaking with our transplant nephrologist, one of his biggest issues is the frequency of post-op ileus these patients have due to opioid-based PCAs. A transplant surgeon that left here about a year ago always requested epidurals for his planned transplant patients, but neither of our current surgeons think it's worth it. I personally like the idea, though, and think it would be beneficial.
What is the current practice at your place? If no epidural (e.g., patient is not a candidate for whatever reason), what are your thoughts on TAP blocks for these patients. There's not a whole lot of literature on epidurals or TAPs for renal transplanation.


Sidenote: I also plan to push for using LR instead of (ab)NS for these cases, too. I'm pretty sure that has been discussed on here, as well. Surprisingly, the surgeons said they'd take a look at the articles and consider changing their practice on this.

I would be very wary of placing an epidural in these patients. We did a lot of these in residency and it wasn't infrequent that the patients were "oozy", presumably because of platelet dysfunction.

 

[dhb]

TAPs work fine

 

[BLADEMDA]

TAPs work fine

It Depends on the surgical incision area. Some surgeons make a very lateral incision and the TAP block won't cover the pain. I know from personal experience that incisions for open kidney/hand assisted kidney surgery vary from surgeon to surgeon.

 

[BLADEMDA]

Anesth Analg. 2012 Oct;115(4):953-7. Epub 2012 Jul 4.
Transversus abdominis plane block for analgesia in renal transplantation: a randomized controlled trial.
Freir NM1, Murphy C, Mugawar M, Linnane A, Cunningham AJ.
Author information

Abstract
BACKGROUND:
The transversus abdominis plane (TAP) block has proven effective in reducing opioid requirements and pain scores for some procedures involving the lower abdominal wall. In this study we assessed its efficacy in patients with end-stage renal failure undergoing cadaveric renal transplantation.

METHODS:
Sixty-five adult renal transplant recipients were prospectively randomized to receive a standard general anesthetic technique supplemented with levobupivacaine 0.375% 20 mL TAP block or sham block with 20 mL 0.9% saline. Both groups received patient-controlled morphine analgesia and acetaminophen. Patient assessment occurred in the postanesthetic care unit and at 2, 4, 6, 12, and 24 hours. The primary outcome was total morphine consumption in the first 24 hours after renal transplantation. Other outcomes assessed included pain scores, presence of nausea or vomiting, excessive sedation, and respiratory depression.

RESULTS:
Morphine requirements did not differ between the 2 groups, 31.6 ± 5.6 mg in the TAP group and 32.6 ± 5.5 mg in the control group (95% confidence interval [CI], -8.96 to 7.09, P = 0.817). Pain scores also did not differ significantly at any time point after surgery. Nausea was reported in 53% of the TAP group and 24% of the control group. The relative risk of nausea associated with treatment was 2.2 (95% CI, 1.1 to 4.3, P = 0.017). No patient exhibited excessive sedation or respiratory depression.

CONCLUSIONS:
The addition of a TAP block to the analgesia regimen for renal transplantation did not reduce morphine requirements.

 

[BLADEMDA]

The use of epidural for renal transplant surgery is rare and controversial; the main reason is that uraemic patients tend to have a tendency to develop coagulopathy. Few recent studies have shown that it is a safe technique to use as long as prothrombin time (PT) is normal and the patient should have heparin-free dialysis sessions before epidural placement. Epidural can be used as the sole anaesthetic technique or in combination with GA. Both techniques were found to have similar encouraging results with respect to early graft function. The level of insertion is usually low thoracic to high lumbar (T12 – L1 or L1 – L2). Local anaesthetic infusion of Levo-Bupivacaine or Ropivacaine can be used safely. (13) Facilities to continuously monitor the neurological status of the patient, and to pick early signs of epidural haematoma should be readily available.


http://cdn.intechopen.com/pdfs-wm/19051.pdf

 

[BLADEMDA]

ransplant Proc. 2012 Dec;44(10):2949-54. doi: 10.1016/j.transproceed.2012.08.004.
Combination of epidural anesthesia and general anesthesia attenuates stress response to renal transplantation surgery.
Hadimioglu N1, Ulugol H, Akbas H, Coskunfirat N, Ertug Z, Dinckan A.
Author information

Abstract
Choice of the anesthestic technique can reduce or even eliminate stress responses to surgery and decrease the incidence of complications. Our aim was to compare a combination of epidural anesthesia+general anesthesia with general anesthesia alone as regards perioperative insulin resistance and inflammatory activation among renal transplant recipients. Forty-six nondiabetic patients undergoing renal transplantation were prospectively randomized to the epidural anesthesia + general anesthesia group (n = 21), or general anesthesia alone group (n = 25). Plasma levels of glucose, insulin, interleukin (IL)-6, tumour necrosis factor (TNF)-α, resistin, and adiponectin were measured at baseline (T1), end of surgery (T2), postoperative first hour (T3), postoperative second hour (T4) and postoperative 24th hour (T5). Homeostasis model assessment-estimated insulin resistance (HOMA-IR) scores were calculated at every time point that the blood samples were collected. Glucose levels (P < .001) and insulin levels at the end of surgery (P = .048) and at postoperative first hour (P = .005) and HOMA-IR levels at the end of surgery (P = .012) and at postoperative first hour (P = .010) showed significantly higher values among the general anesthesia alone group when compared with the epidural+general anesthesia group. TNF-α levels at postoperative 2nd and at 24th hour (P = .005 and P = .004, respectively) and IL-6 levels at postoperative 1st and 2nd hours (P = .002 and P = .045, respectively) were significantly higher in the general anesthesia alone group when compared with the epidural+general anesthesia group. The TNF-α levels were significantly less at all time points when compared with baseline only in the epidural+general anesthesia group (T1, 33.36 vs 37.25; T2, 18.45 vs 76.52; T3, 15.18 vs 78.27; T4, 10.75 vs 66.64; T5, 2.98 vs 36.32) Hospital stays were significantly shorter among the epidural+general anesthesia group (P = .022). We showed partly attenuated surgical stress responses among patients undergoing renal transplantation using general anesthesia combined with epidural anesthesia compared with general anesthesia alone.

 

[Ventil8]

As a transplant anesthesiologist these questions have gone through the ringer here.

If you're giving a steroid bolus to the recipient, its unlikely regional will decrease pain scores or PCA use in the first 24h. We looked at these endpoints for TAP vs Epidural internally and found similar results as those papers above. We DO TAP in donors, and they certainly benefit.

For fluids, look at O'Malley paper: NS vs LR in kidney Txp. Higher intra and postop [K+] in the (ab)Normal Saline group. Balanced salt solution is best for almost everything except a few heads. If you're looking for good fluid referenes, in general, look at the 2008 paper by Daniel Chappel: A Rational Approach to Fluid Management. My favorite paper on the topic. Same authors are revising it and will publish this year titled something like "Fluid Theory", with Bloomstone as primary author.