Spinal Anesthesia for Enhanced Recovery After Liver Surgery
Description:
Hepatic resection surgery (hepatectomy) for primary or metastatic malignancy is a major
operation involving large, painful upper abdominal incisions, as well as considerable
postoperative physiological derangements.
Uncontrolled postoperative incisional pain results in significant respiratory impairment,
delayed mobilization, and augmentation of the surgically-induced stress response, placing
patients at increased risk of postoperative complications and chronic post-surgical pain.
Acute pain management with high-dose parenteral opioids further compounds this risk.
Multimodal opioid-sparing therapy, and regional anesthesia in particular, is therefore an
essential component of enhanced recovery after surgery (ERAS) pathways and patient-centred
care.
Regional anesthesia using neuraxial block (intraoperative spinal anesthesia or thoracic
epidural anesthesia) followed by postoperative continuous thoracic epidural analgesia (CTEA;
postoperative administration of epidural local anesthetic and/or opioid) is the best method
for treating pain following large abdominal surgeries, including liver resection, and has
been shown to improve postoperative respiratory function and decrease respiratory
complications in other surgeries.
However, the effects of intraoperative neuraxial block and postoperative CTEA on fluid
balance, systemic hemodynamics, and functional recovery after hepatic resection surgery
remain controversial. CTEA is frequently associated with postoperative hypotension, resulting
in increased perioperative intravenous (IV) fluid administration, red blood cell transfusion,
and vasopressor use in liver resection patients. For major hepatectomies, CTEA may also be an
independent risk factor for postoperative acute kidney injury (AKI), presumably due to
impairment of renal autoregulation. Excessive IV fluid administration in the postoperative
period is associated with significant weight gain, often necessitating diuretic therapy;
delayed return of gastrointestinal function; increased need for packed red blood cell (pRBC)
transfusion due to hemodilution; increased infective complications due to this increased pRBC
transfusion rate; and increased length of hospital stay.
In addition, concerns remain about the use of CTEA following liver resection surgery due to
the potentially increased risk of epidural hematoma formation in the setting of postoperative
coagulopathy. This concern has resulted in unplanned delays in epidural catheter removal
postoperatively, due to persistent coagulation abnormalities, prolonging hospitalization by
1-3 d in up to 15% of patients.
These concerns about the consequences of excess fluid administration and the safety of CTEA
for liver resection surgery have prompted the use of alternative and/or ancillary analgesic
techniques, particularly for major resections and in patients with preoperative liver
dysfunction, for whom a prolonged period of postoperative coagulopathy is anticipated.
Intraoperative spinal anesthesia (SA) using local anesthetic (LA) and/or opioid (most
commonly intrathecal morphine [ITM]) for neuraxial block without CTEA is frequently used as
postoperative analgesia for various surgeries. Spinal anesthesia using ITM without LA has
been reported in four randomized and three non-randomized studies of patients undergoing
liver resections. ITM has provided superior analgesia to IV patient-controlled analgesia
(IV-PCA) with opioids, and equivalent analgesia to epidural infusions. Compared with CTEA
and/or IV-PCA, ITM was associated with reduced IV fluid administration; earlier mobilization,
and resumption of normal dietary intake; decreased incidence of respiratory complications;
and decreased hospital length of stay.
Spinal anesthesia using both LA and ITM may provide an additional benefit by providing a
degree of preemptive analgesia, as well as by decreasing the stress and inflammatory
response, thereby possibly decreasing the incidence of surgical stress-related complications
such as postoperative delirium. High-spinal anesthesia (HSA) uses larger doses of LA to
achieve a "high" block for this purpose. HSA combined with ITM has been used in cardiac
surgery, and decreases the stress and inflammatory response to surgery; facilitates early
extubation; improves postoperative analgesia; decreases the incidence of postoperative
delirium; and decreases intensive care unit (ICU) readmissions. Neither the use of HSA (with
or without ITM) for analgesia following non-cardiac surgical procedures, nor the
effectiveness of SA with ITM versus CTEA following hepatic resection surgery has been
investigated to date.
Condition:
Hepatectomy
Treatment:
Continuous thoracic epidural analgesia
Start Date:
October 4, 2018
Sponsor:
University of Manitoba
For More Information:
https://clinicaltrials.gov/show/NCT03715517