Background & Aims

Background:
Living donor hepatectomy is a major surgery requiring a long upper abdominal incision and extensive dissection. Post operative incision site pain is a major cause of morbidity.
The objectives of this study were to evaluate the efficacy and feasibility of subcostal Transverse Abdominis Plane (TAP) block and bilateral rectus sheath blocks as an adjunct to Patient controlled Analgesia (PCA) using Morphine for postoperative analgesia by comparing the consumption of Morphine in patients receiving the regional blocks with ropivacaine and those receiving blocks with placebo.

Aims and Objectives:
1. Addressing crucial issue of perioperative pain management in living healthy liver donors.
2.Finding a safe and effective tool for acceptable analgesia in liver donors.
3.Reducing complications and increasing satisfaction among patients and healthcare providers involved in postoperative pain management in these otherwise healthy patient subgroup.

Methods

50 ASA I liver donors belonging to age group 18-50 years were randomized into two groups of 25 each. Patients in both the groups received a standard general anaesthetic with Fentanyl, Propofol, Atracurium and Isoflurane.
A single bolus of Morphine 0.1 mg/Kg was given before incision. A further Morphine bolus of 0.05 mg/Kg was repeated if the surgery lasted longer than 6 hours but at least 1 hour prior to expected finishing time. All patients also received intravenous Diclofenac 75 mg towards the end of surgery. Group I patients received the blocks with 50 ml of 0.2% Ropivacaine; with 10 ml each for rectus sheath blocks and 30ml for subcostal TAP block using a 10 cm long 20G nerve block sonoplex needle, under ultrasound guidance. Group II patients received the same blocks with 50 ml of Normal Saline (placebo) at the end of surgery.
Patients in both the groups had access to an intravenous PCA device dispensing 1 mg Morphine per request for 36 hours.

Results

Morphine consumption was found to be significantly less (p<0.05) in Group I patients (28 mg in Group Ropivacaine versus 43 mg in the placebo group). The Numerical Rating Scores (NRS) were comparable in both the groups. Pain assessment was carried out at regular intervals by the acute pain service nurses for the first three post-operative days. Static pain was assessed by manually compressing the surgical wound, whereas dynamic pain assessment was assessed by ability to take a deep breath and attempting to sit upright from the supine position. 68% patients in the ropivacaine group were satisfied with their pain management compared to just 52% in the placebo group. No major technique related complications, in the form of subcutaneous hematoma, infection, serous discharge from wound, etc, were noted in any of the patients. We found subcostal TAP block in combination with bilateral rectus sheath blocks a safe and effective adjunct for pain management in these patients.

Conclusions

Living donor hepatectomy is a complex surgery, which evokes somatic and visceral components of pain. An effective strategy for pain management utilizes a multi-model technique for the use of analgesics. Prolonged duration of surgery that involves dissection and removal of a significant portion of liver, limits the metabolism of opioids and also leads to metabolic and lactic acidosis. This sometimes causes delayed awakening in the patients post-surgery.
In addition the use of opioids in post-anaesthesia care unit (PACU) further adds to respiratory depression.
Hence, we presented our hypothesis for the use of peripheral regional anaesthesia in the form of Transverse Abdominis Plane block and Rectus Sheath Block, to effectively take care of somatic or nociceptive pain and hence reduce the requirement of post-operative opioids. This enhances the recovery profile and early mobility of patients after a complex abdominal surgery.

References

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Presenting Author

Chetan Mehra

Poster Authors

Chetan Mehra

MBBS, DA, DNB, FIPM, EDRA

Indraprastha Apollo Hospital, New Delhi

Lead Author

E-mail

Topics

  • Pain in Special Populations: Adolescents