E. M. Betka1, J. Ortiz2, M. Rees2, S. Spetz1, P. Samenuk1, L. Eitniear1 1University Of Toledo Medical Center,Pharmacy,Toledo, OH, USA 2University Of Toledo Medical Center,Transplant Surgery,Toledo, OH, USA
Introduction: The management of post-operative pain is critical for improving patient satisfaction, recovery time, and reducing hospital length of stay. In 2016, the American Pain Society (APS) and the American Society of Anesthesiologist (ASA) teamed up to provide the first evidenced based guidelines for the management of post-operative pain. The APS/ASA strongly recommend utilizing a multimodal approach for the management of post-operative pain as this approach is supported by a high quality of evidence. This approach for post-operative pain management has proven to be efficacious for procedures involving the abdominal wall. However, data are controversial in regards to this approach for kidney transplant recipients.
Methods: This retrospective cohort study was approved by the Institutional Review Board at The University of Toledo Medical Center (UTMC). Patients 18 years and older admitted to UTMC from July 1, 2006 through July 30, 2016 who underwent kidney transplantation were included. Patients received one of the following post-operative pain management regimens: the standard of care (SOC) consisting of intravenous (IV) and/or oral (PO) opioids, with or without the addition a local anesthetic pain ball (LAPB). The primary outcome was the cumulative opioid requirements in IV morphine equivalents at 48 hours following transplantation. Secondary outcomes included post-operative pain scores at 24 and 48 hours following transplantation, and hospital length of stay.
Results: Information on baseline characteristics and study endpoints were collected for 102 patients. Propensity scores were utilized to match the patients based on the following confounders: age, sex, race, body mass index, baseline opiate use, previous abdominal procedure, repeat transplantation, type of transplant, and intra-operative morphine requirements. After matching, 38 subjects remain in each group. The median (IQR) IV morphine equivalent dose at 48 hours was 19.85 mg (14.85, 42.18) in the SOC group and 17.65 mg (4.95, 30.56) in the LAPB group (p= 0.120). There was no significant difference in median pain scores at 24 hours (p= 0.059) or 48 hours (p-value=0.139) in those receiving the LAPB versus those receiving the SOC. Also, there was no significant effect on hospital length of stay in those receiving the LAPB versus the SOC (3 days versus 4 days, respectively; p=0.449).
Conclusion: This study demonstrates that the use of a LAPB as a alternative to IV/PO opioids did not reduce the post-operative opioid requirements in kidney transplant recipients following transplantation. The current literature regarding the use of LAPB for abdominal procedures outside of kidney transplantation remains positive. However, the literature supporting the use in kidney transplant recipients remains controversial. The data obtained from this trial supports the need for further randomized control trials that heavily control for confounding factors that are likely to affect post-operative opioid utilization.