Pain Management in Living Liver Donors
Daniela Ladner1, Robert A. Fisher3, Elizabeth A. Pomfret2, Mary Ann Simpson2, Robert S. Brown4, Amna Daud1, Kathryn Waitzman1, John R. Joseph1, Donna Woods1
1Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, IL; 2Lahey Clinic, Boston, MA; 3Medical College of Virginia Hospital; Virginia Commonwealth University, Richmond, VA; 4Columbia University Medical Center, New York, NY
BACKGROUND: Living Liver Donation is a highly complex, voluntary surgical procedure associated with pain. However, managing pain after donation is difficult. Pain medications in liver donors (LDs) are not metabolized in the same way as patients with full livers. Furthermore, respiratory complications might occur more readily. Respiratory depression and perceived pain in LDs has not been previously reported. METHOD: Retrospective medical record review (years 2008-2010) of 23 LDs from four large transplant centers participating in the A2ALL Patient Safety System Improvements in Living Donor Liver Transplantation Study (R01DK090129) was conducted by a trained RN reviewer. POD#0-7 pain scores (1-10 scale), pain medications, vitals around pain score, and incidence of respiratory depression requiring intervention were assessed. RESULTS: LDs had mean pain scores of 3.86, 4.52, 4.03, 3.74, 4.81, 4.41, 5.91, and 4.75 on POD #0-7 respectively, however pain scores ranged from 0-10 throughout POD#0-7.The highest reported mean pain scores occurred on POD#6 (5.1). Percentage of pain score assessments > 6 increased on POD#4 (34%), and were highest on POD#6 (48%). All LDs received IV opioids after donation, 56% received IV NSAIDS, 26% received an epidural. PO medications increased from 13% to 100% at discharge. Vitals recorded around the pain scores were correlated (Figure 1). Eight LDs (20%) suffered respiratory complications requiring higher level care (PACU, ICU), respiratory interventions (i. e. re-intubation), reversal agents, and adjustments in ordered pain medications. The centers modified their standard of care to a multi-modal opioid sparing regimen. CONCLUSIONS: LDs experience significant pain after donation according to their subjective pain scores, despite extensive multifaceted pain regimens. Most pain is experienced as IV drugs are switched to PO regimen. Despite close monitoring, a significant portion of patients experience sequelae of over narcotization which presents significant patient safety risks to LDs. Pain management in LDs needs to be improved to ensure safety while providing better pain control with zero tolerance for respiratory events.
Robert S. Brown - Consulting: Salix, Janssen, Vertex; Grant/Research Support: Gilead, Merck, Vertex, AbbVie, Salix, Janssen, BI; Speaking and Teaching: Genentech, Gilead, Merck
The following people have nothing to disclose: Daniela Ladner, Robert A. Fisher, Elizabeth A. Pomfret, Mary Ann Simpson, Amna Daud, Kathryn Waitzman, John R. Joseph, Donna Woods tumors express less CAR protein than normal liver. Conclusions: TCP rescues mice exposed to SFSS after extended liver resections and liver transplantation. Molecular changes induced by CAR activation act on downstream targets of pathways promoting cell cycle progression (Foxm1b) and uncoupling from organ size control (miR375/YAP) to override the regenerative deficits of marginal liver remnants. Reduced CAR expression in tumors suggests a subset of HCCs may not respond to CAR activation, pointing to a patient group amenable to this treatment. Studies in humanized mice and on ex vivo human liver tissue will address the clinical potential of CAR activation by enhancing liver regeneration after extended resections for primarily unresectable liver tumors.
The following people have nothing to disclose: Christoph Tschuor, Ekaterina Kachaylo, Perparim Limani, Amedeo Columbano, Andrea Schlegel, Jae Hwi Jang, Dimitri A. Raptis, Emmanuel Melloul, Yinghua Tian, Rolf Graf, Bostjan Humar, Pierre A. Clavien