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multivisceral transplantation
Pain Management After Small Bowel/Multivisceral Transplantation A. Siniscalchi, B. Begliomini, L. De Pietri, S. Ivagnes Petracca, V. Braglia, M. Girardis, A. Pasetto, M. Masetti, N. Cautero, E. Jovine, and A.D. Pinna
T
HE POSTOPERATIVE pain management in patients who received a small bowel transplant is made difficult due to the extensive surgical trauma and the preoperative treatment of these patients with drugs, such as analgesics, tranquilizers, and antidepressants due to the anxiety associated with chronic disease. For the reasons the maintenance of these drugs during the postoperative period is even more relevant in these patients. Another important consideration is their administration to patients who did not use them before the procedure. So, postoperative acute pain therapy should use medicines in association with agents that have anxiolytic and antidepressive activities. The purpose of the study was to identify guidelines for pain management in intestinal transplant recipients.
RESULTS
During the first three postoperative days, patients in Group 1 had a VAS of 70 to 80 mm during the first 72 hours (Fig 1) and required additional doses of morphine (average total dose ⫽ 35 mg/72 h) for pain management. Patients in Group 2 had a satisfactory pain control during the first 72 hours after transplantation, with a VAS of 40 to 50 mm and required a smaller additional amount of morphine a (averaged total dose 4 mg/72 h). After the third postoperative day the management of pain was similar and satisfactory in both group. Ten days after small bowel transplantation, two patients required amitriptiline (25 mg/d) because of depression. One patient who was treated with morphine before transplantation received the same drug until the 14th postoperative day when morphine was successfully tapered thereafter.
METHODS This report includes six patients, age 21 to 38 years, who underwent either isolated small bowel transplantation (four patients) or multivisceral transplantation (two patients). Pain management during small bowel transplantation was achieved in group 1 (three patients) with IV fentanyl (2 to 3 mcg/kg) for induction of anesthesia followed by maintenance therapy by continuous infusion at a rate of 0.06 to 0.08 mcg/kg during the procedure. Before the skin closure morphine (0.1 mg/kg IV) was administered. Postoperative pain control was obtained by continuous IV infusion of 0.012 mg/kg/h until the fifth postoperative day when the dosage was decreased to 0.006 mg/kg/h and continued until the seventh postoperative day. Thereafter morphine was replaced with clonidine (0.075 mg IV b.i.d) and lorazepam (2 mg IV at night). In group 2 (three patients) an epidural catheter was placed at the D10-D11 level before induction of anesthesia. Ropivacaine (0.2%; 5 mL) and morphine (5 mg) were infused through the catheter after induction of anesthesia. Morphine (5 mg) was given again through the epidural catheter at the end of the procedure. In the postoperative period analgesia was achieved by administration of ropivacaina (0.2%, 5 mL/h) and morphine (0.003 mg/kg/h) via an epidural elastomeric pump until the removal of the epidural catheter on the third postoperative day. Thereafter, pain treatment was similar to group 1 patients. A pain evaluation was performed 1 hour after emergence from anesthesia (T0) and then at times T1, T2, T3, T4, T5, T6 corresponding to 6, 12, 18, 24, 48, 72 hours after the end of surgery. The Visual Analog Scale (VAS) was used to determine the intensity of pain (no pain ⫽ 0, maximum pain ⫽ 100). © 2002 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010 Transplantation Proceedings, 34, 969 –970 (2002)
DISCUSSION
Pain control in the patients from Group 2 was better than that in Group 1 patients. However, from the third day pain management in both groups was not completely satisfactory. The combination of a local anesthetic with morphine in the epidural during the first 3 days yielded better pain control in the second group. This was not only confirmed by the vas behavior, but also by a reduced consumption of analgesic medicines in the second group. This issue confirms previous reports, which show that postoperative pain in patients treated by administration of an anesthetic and morphine in an epidural catheter is inferior to that in patients treated by systemic administration of opioids.1,2 Anyway it is necessary to use opioids with the local anesthetic because the surgical trauma includes different levels, which are hardly reached by the administration of the local anesthetic.3 The causes of this suboptimal result may be the major extension of surgical abdominal incision and the modified perception of pain due to the psychologic effects From the Anesthesiology and Critical Care Unit (A.S., B.B., L.D.P., S.I.P., V.B., M.G., A.P.). Liver and Multivisceral Transplant Center (M.M., N.C., E.J., A.D.P.), University of Modena, Modena, Italy. Address reprint requests to Antonio Siniscalchi, Policlinico of Modena, Via del Pozzo 71, 41100 Modena, Italy. E-mail: [email protected] 0041-1345/02/$–see front matter PII S0041-1345(02)02721-5 969
970
SINISCALLCHI, BEGLIOMINI, DE PIETR, ET AL
Figure.
Pain management in groups 1 and 2 in the first 72 hours.
of the chronic bowel disease. A global approach to pain treatment, both physical and psychological, is absolutely important to improve the postoperative quality of life among intestinal graft-recipients. The variability of pain perception makes it difficult to predict the tolerability of the postsurgical discomfort, which is even more stressful in these circumstances. Thus the variabilities in the dosage of analgesic drugs is related to this unpredictable behaviour. Morphine is a first-choice drug among the opiates, though its long-term administration can be affected by tolerance and dependence. Therefore, slow weaning from morphine is strongly recommended to be accompanied by an anxiolytic therapy, such as clonidine. The need to add anxiolytic and antidepressant drugs to the postoperative treatment to
achieve a better control of pain illustrates the difficulty of pain management in these patients. Because of the long period of suffering and chronic disease before the transplant, a global and empathetic approach to these patients needs include their physical and psychological background to achieve the required improvement of their health. REFERENCES 1. Chrubasiks S, Senninger N, Chrubasiks J: Chirurg 67:665, 1996 2. George KA, Wright PMC, Chisakuta AM, et al: Acta Anaesthesiol Scand 38:808, 1994 3. Thore´n T, Sundberg A, Wattwil M, et al: Acta Anaesthesiol Scand 33:181, 1989
T
HE POSTOPERATIVE pain management in patients who received a small bowel transplant is made difficult due to the extensive surgical trauma and the preoperative treatment of these patients with drugs, such as analgesics, tranquilizers, and antidepressants due to the anxiety associated with chronic disease. For the reasons the maintenance of these drugs during the postoperative period is even more relevant in these patients. Another important consideration is their administration to patients who did not use them before the procedure. So, postoperative acute pain therapy should use medicines in association with agents that have anxiolytic and antidepressive activities. The purpose of the study was to identify guidelines for pain management in intestinal transplant recipients.
RESULTS
During the first three postoperative days, patients in Group 1 had a VAS of 70 to 80 mm during the first 72 hours (Fig 1) and required additional doses of morphine (average total dose ⫽ 35 mg/72 h) for pain management. Patients in Group 2 had a satisfactory pain control during the first 72 hours after transplantation, with a VAS of 40 to 50 mm and required a smaller additional amount of morphine a (averaged total dose 4 mg/72 h). After the third postoperative day the management of pain was similar and satisfactory in both group. Ten days after small bowel transplantation, two patients required amitriptiline (25 mg/d) because of depression. One patient who was treated with morphine before transplantation received the same drug until the 14th postoperative day when morphine was successfully tapered thereafter.
METHODS This report includes six patients, age 21 to 38 years, who underwent either isolated small bowel transplantation (four patients) or multivisceral transplantation (two patients). Pain management during small bowel transplantation was achieved in group 1 (three patients) with IV fentanyl (2 to 3 mcg/kg) for induction of anesthesia followed by maintenance therapy by continuous infusion at a rate of 0.06 to 0.08 mcg/kg during the procedure. Before the skin closure morphine (0.1 mg/kg IV) was administered. Postoperative pain control was obtained by continuous IV infusion of 0.012 mg/kg/h until the fifth postoperative day when the dosage was decreased to 0.006 mg/kg/h and continued until the seventh postoperative day. Thereafter morphine was replaced with clonidine (0.075 mg IV b.i.d) and lorazepam (2 mg IV at night). In group 2 (three patients) an epidural catheter was placed at the D10-D11 level before induction of anesthesia. Ropivacaine (0.2%; 5 mL) and morphine (5 mg) were infused through the catheter after induction of anesthesia. Morphine (5 mg) was given again through the epidural catheter at the end of the procedure. In the postoperative period analgesia was achieved by administration of ropivacaina (0.2%, 5 mL/h) and morphine (0.003 mg/kg/h) via an epidural elastomeric pump until the removal of the epidural catheter on the third postoperative day. Thereafter, pain treatment was similar to group 1 patients. A pain evaluation was performed 1 hour after emergence from anesthesia (T0) and then at times T1, T2, T3, T4, T5, T6 corresponding to 6, 12, 18, 24, 48, 72 hours after the end of surgery. The Visual Analog Scale (VAS) was used to determine the intensity of pain (no pain ⫽ 0, maximum pain ⫽ 100). © 2002 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010 Transplantation Proceedings, 34, 969 –970 (2002)
DISCUSSION
Pain control in the patients from Group 2 was better than that in Group 1 patients. However, from the third day pain management in both groups was not completely satisfactory. The combination of a local anesthetic with morphine in the epidural during the first 3 days yielded better pain control in the second group. This was not only confirmed by the vas behavior, but also by a reduced consumption of analgesic medicines in the second group. This issue confirms previous reports, which show that postoperative pain in patients treated by administration of an anesthetic and morphine in an epidural catheter is inferior to that in patients treated by systemic administration of opioids.1,2 Anyway it is necessary to use opioids with the local anesthetic because the surgical trauma includes different levels, which are hardly reached by the administration of the local anesthetic.3 The causes of this suboptimal result may be the major extension of surgical abdominal incision and the modified perception of pain due to the psychologic effects From the Anesthesiology and Critical Care Unit (A.S., B.B., L.D.P., S.I.P., V.B., M.G., A.P.). Liver and Multivisceral Transplant Center (M.M., N.C., E.J., A.D.P.), University of Modena, Modena, Italy. Address reprint requests to Antonio Siniscalchi, Policlinico of Modena, Via del Pozzo 71, 41100 Modena, Italy. E-mail: [email protected] 0041-1345/02/$–see front matter PII S0041-1345(02)02721-5 969
970
SINISCALLCHI, BEGLIOMINI, DE PIETR, ET AL
Figure.
Pain management in groups 1 and 2 in the first 72 hours.
of the chronic bowel disease. A global approach to pain treatment, both physical and psychological, is absolutely important to improve the postoperative quality of life among intestinal graft-recipients. The variability of pain perception makes it difficult to predict the tolerability of the postsurgical discomfort, which is even more stressful in these circumstances. Thus the variabilities in the dosage of analgesic drugs is related to this unpredictable behaviour. Morphine is a first-choice drug among the opiates, though its long-term administration can be affected by tolerance and dependence. Therefore, slow weaning from morphine is strongly recommended to be accompanied by an anxiolytic therapy, such as clonidine. The need to add anxiolytic and antidepressant drugs to the postoperative treatment to
achieve a better control of pain illustrates the difficulty of pain management in these patients. Because of the long period of suffering and chronic disease before the transplant, a global and empathetic approach to these patients needs include their physical and psychological background to achieve the required improvement of their health. REFERENCES 1. Chrubasiks S, Senninger N, Chrubasiks J: Chirurg 67:665, 1996 2. George KA, Wright PMC, Chisakuta AM, et al: Acta Anaesthesiol Scand 38:808, 1994 3. Thore´n T, Sundberg A, Wattwil M, et al: Acta Anaesthesiol Scand 33:181, 1989