Abstract
Background and Aims:
Postoperative pain management in open live donor hepatectomy is vital. This study aimed to compare postoperative analgesia provided by intrathecal morphine (ITM) and epidural in open live donor hepatectomy.
Material and Methods:
Patients were divided into two groups. In the epidural (EPI) group, a bolus dose of 0.125% levobupivacaine (5–6 mL) with 3 mg of preservative-free morphine (diluted in 5 mL of 0.9% normal saline) was injected. In the postoperative period, infusion of levobupivacaine 0.125% at a rate of 5–8 mL/hour was continued for 3 days. In the intrathecal group (ITM), 0.3 mg morphine with 1.5 mL of 0.5% bupivacaine heavy was injected. General anesthesia was administered. Postoperatively, both groups received intravenous fentanyl patient-controlled analgesia. Numerical rating score (NRS) scores were recorded at 0, 2, 4, 12, 24, 36, 48, and 72 hours postoperatively. Data were analyzed using the Student t-test, Mann–Whitney U test, and Fisher’s exact test. P < 0.05 was considered significant.
Results:
A total of 60 patients were enrolled. The postoperative fentanyl consumption for the first 24 hours was significantly higher in the EPI group compared to the ITM group (162.5 mcg vs. 75 mcg, respectively; P = 0.023). NRS up to 12 hours in the postoperative period at rest, on movement, and for shoulder pain were significantly lower in the ITM group compared to the EPI group (P = 0.000).
Conclusions:
ITM significantly decreased fentanyl consumption in the first 24 hours when compared to the epidural group in patients undergoing open donor hepatectomy.
Keywords: Abdominal pain, analgesia, bupivacaine, epidural, hepatectomy, levobupivacaine, liver transplantation, living donors, morphine derivatives, pain, postoperative, shoulder pain
Key Message: Studies comparing intrathecal morphine with epidural are lacking in patients undergoing open living donor hepatectomy. Most of the previous studies have either included carcinomas or other abdominal surgery patients.
Introduction
In recent decades, the escalating demand for liver transplantation has led to a shortage of cadaveric livers. This crisis has fueled the rapid growth of living donor liver transplants, making it a crucial alternative, especially in developing countries.
Living donors for liver transplants are typically individuals with no prior experience of major surgery-related pain. This procedure subjects these donors to extensive incision and postoperative pain. Effective postoperative pain management in open live donor hepatectomy is vital, given its impact on morbidity. Achieving optimal pain control remains a formidable challenge as this pain can stem from various sources, including the large subcostal incision, rib retraction, diaphragmatic irritation, or visceral factors. Consequently, selecting the most suitable analgesic technique for donor hepatectomy presents a dilemma, requiring a delicate balance between effective pain relief and patient safety.
Commonly used options for managing pain after hepatectomy include epidurals, abdominal wall blocks, wound catheters, and intrathecal opioids. Thoracic epidural analgesia (TEA) is considered a gold standard for major abdominal surgeries, providing adequate pain relief and mitigating the perioperative stress response.[1] However, TEA is invasive, resource-intensive, and has a high failure rate.[2] Hepatectomy increases the risk of epidural hematoma, potentially leading to delayed catheter removal.[3] Recent evidence has raised concerns about TEA.[4]
An alternative to TEA is a single intrathecal morphine (ITM) injection, offering comparable analgesic effects for up to 48 hours postoperatively. ITM has lower technical failure rates and offers benefits such as reduced postoperative fluid requirements and shorter hospital stays.[5] However, concerns about ITM include postoperative nausea, vomiting, pruritus, and respiratory depression.[6] Most of the studies comparing ITM with epidural included patients either undergoing non-donor hepatectomy or other abdominal surgeries. Living donors are healthy patients who do not have any comorbidities, and they may have different thresholds for surgical pain. As per our literature search, studies comparing the ITM and TEA in open live donor hepatectomy are lacking.
Hence, this study aimed to compare postoperative analgesia provided by ITM and TEA in open live donor hepatectomy. The primary objective is to compare 24-hour postoperative fentanyl consumption. Secondary objectives include comparing postoperative NRS scores, intraoperative parameters, postoperative parameters, and outcomes.
Material and Methods
This was a single-center prospective randomized study [Figure 1]. The study was prospectively registered with the Clinical Trial Registry of India (CTRI/2021/04/033283 dated April 29, 2021). After obtaining approval from the institutional ethical committee (IEC/2021/83/MA02), written informed consent was obtained from the participants. The study included patients aged between 18 and 60 years undergoing open live donor hepatectomy. Patients with contraindications to neuraxial anesthesia, allergies to local anesthetics, history of drug abuse, or insufficient comprehension for the use of patient-controlled analgesia (PCA) were excluded. Based on the computer-generated random number table patients were randomized to either the epidural group (EPI) or the ITM group.
Figure 1.
CONSORT flow diagram; N = Numbers; EPI: Epidural; ITM: Intrathecal Morphine
On the day of surgery, patients were transferred to the operating theatre. All ASA standard monitors, including non-invasive blood pressure (NIBP), pulse oximetry (SPO2), and electrocardiogram (ECG), were attached. An 18-gauge intravenous (IV) cannula was secured. Under strict aseptic precautions, all central neuraxial blocks (CNB) were performed by an experienced anesthesiologist with the patient awake in the sitting position.
In the EPI group, an epidural catheter was inserted between interspaces T7–T10 by using the midline approach. The loss of resistance to air technique was employed after anesthetizing the local area, followed by a test dose (lignocaine 2% with 15 micrograms of adrenaline – 3 mL) to confirm catheter placement. A bolus dose of 0.125% levobupivacaine (5–6 mL) with 3 mg of preservative-free morphine (diluted in 5 mL of 0.9% normal saline) was injected before the induction of anesthesia.
In the ITM group, a dural puncture was performed at the L3–L4 or L4–L5 space with a 25-G Quincke’s needle after local anesthesia. Following the aspiration of clear and free-flowing cerebrospinal fluid (CSF), 0.3 mg of preservative-free morphine with 1.5 mL (7.5 mg) of 0.5% bupivacaine heavy was injected.
After performing CNB, all patients were administered general anesthesia as per our hospital protocol. Injection fentanyl (1–2 μg/kg), propofol (1–2 mg/kg), and rocuronium (0.8–1 mg/kg) were administered, followed by endotracheal intubation. Anesthesia was maintained with isoflurane in a 50% oxygen-air mixture. After induction, a 20-G arterial cannula was secured in the left radial artery. A 7-Fr triple lumen central line was placed in the right internal jugular vein under ultrasound guidance.
Intraoperatively, in the EPI group, continuous epidural infusion of levobupivacaine 0.125% at 5–8 mL/hour was initiated. A decrease in mean arterial pressure (MAP) by ≥20% from the baseline value was treated with a bolus of injection ephedrine (3–6 mg) or phenylephrine (50–100 mcg), and a decrease in HR to less than 50 beats per minute was treated with a bolus of injection atropine (0.6 mg).
In all patients, a right subcostal incision was made, extending medially to the xiphoid process. Thirty minutes before extubation, all patients in both groups received intravenous ondansetron (0.1 mg/kg IV) and paracetamol (500 mg IV). Following surgery, all patients were extubated in the operating room. In the EPI group, epidural analgesia was continued through an infusion of levobupivacaine 0.125% at a rate of 5–8 mL/hour until postoperative day 3.
Postoperatively, both groups received intravenous fentanyl patient-controlled analgesia (IV f-PCA) with a concentration of 10 μg/mL. It was initiated with a 2.5 mL (25 μg) bolus dose, a lockout interval of 15 minutes, and a maximum of four doses per hour for 3 days. In addition, all patients in both groups received intravenous paracetamol (500 mg) every 6 hours for 3 days.
The quality of analgesia was assessed using the numerical rating score (NRS), ranging from 0 (no pain) to 10 (worst possible pain). NRS scores were recorded at rest and during movement (including incentive spirometry, and coughing) for both abdominal and shoulder pain by bedside nursing staff. NRS scores were recorded at 0, 2, 4, 12, 24, 36, 48, and 72 hours postoperatively. The time to the first analgesia was also recorded. Additional doses of intravenous fentanyl (25–50 μm IV) were administered as rescue analgesia. Postoperative sedation scores were assessed using the modified Ramsay Sedation Scale at hourly intervals for the first 12 hours, followed by every 2 hours until 24 hours, and then every 4 hours until 72 hours. Arterial blood gas (ABG) analysis was performed at 0, 2, 4, 12, and 24 hours postoperatively. The time to ambulate outside of the bed and the time to first pass the flatus were also recorded.
Postoperative complications, such as nausea, vomiting, sedation, respiratory depression, pruritus, motor weakness or sensory deficits, ileus, post-dural puncture headache (PDPH), epidural/spinal hematoma, and deep venous thrombosis, were noted. Respiratory depression was defined as a respiratory rate of ≤8 breaths per minute, retention of PaCO2 (≥50 mmHg), or a sedation score above 4 according to the modified Ramsay Sedation Score. Respiratory depression, if present, was reversed with an IV bolus of naloxone (100–200 mcg), repeated if necessary. For nausea and vomiting, intravenous ondansetron (4 mg) was administered, and if needed, intravenous metoclopramide (0.2 mg/kg) and intravenous dexamethasone (0.1 mg/kg) were given. For pruritus, intravenous ondansetron (0.1 mg/kg) was administered, and if required, intravenous naloxone (0.25–1 mcg/kg/hour) was given. The epidural catheter was removed between postoperative day 3 and day 5, only if the platelet count was above 100 × 109/L and the INR was below 1.50.
Based on the hospital data for 14 cases, with 7 in each group, the fentanyl consumption in the first 24 hours was 230 ± 165 mcg in the EPI group and 120.33 ± 142 mcg in the ITM group, with an alpha level of 5% and a power of 80%. Accordingly, we determined that a total of 58 cases (29 in each group) need to be enrolled. Thus, we decided to enroll a total of 60 cases, with 30 in each group. Allocation to these two groups was done randomly using the block randomization method, with a block size of 10. Data were entered into Microsoft Excel and analyzed using SPSS version 22. Data were analyzed using the Student t-test, Mann–Whitney U test, Chi-square test, and Fisher’s exact test, as applicable. Continuous data were presented as mean (standard deviation) for normally distributed data and as median (interquartile range) for data with an abnormal distribution. Categorical variables were presented as percentages. To assess trends over time, repeated measures analysis was performed, followed by postoperative comparisons using the least significant difference method. A significance level of < 0.05 was used.
Results
A total of 60 patients were enrolled in this study, with 30 patients in the ITM group and 30 patients in the EPI group [Figure 1]. Patient demographics are demonstrated in Table 1. Intraoperative parameters and vasopressor requirements are shown in Table 1. None of the patients in either group required any other vasopressors or inotropic support. Vital signs such as heart rate, systolic blood pressure, diastolic blood pressure, MAP, pulse pressure variation, and central venous pressure readings were comparable between the two groups [Figure 2]. None of the patients required any additional doses of fentanyl during the surgery.
Table 1.
Patient variables
| n=60 | EPI [n=30] | ITM [n=30] | P |
|---|---|---|---|
| Age (years) | 36.67±9.6 | 35.03±9.4 | 0.511 |
| Male | 5 (16.7%) | 9 (30%) | 0.222 |
| Female | 25 (83.3%) | 21 (70%) | 0.222 |
| BMI (kg/m2) | 25±2.3 | 25.64±3.0 | 0.359 |
| Crystalloid (mL) | 3941.67±426.1 | 3950±489 | 0.944 |
| 5% Albumin (mL) | 208.33±115.2 | 170±133.6 | 0.239 |
| Blood loss (mL) | 405.33±151.1 | 421.67±182.7 | 0.707 |
| Urine output (mL) | 642.5±221.2 | 764.67±357.8 | 0.117 |
| Duration of surgery (min) | 474.73±57.3 | 471.50±60.5 | 0.832 |
| Actual graft volume (g) | 587.73±158.03 | 623.67±146.2 | 0.364 |
| Residual volume (cc) | 555.43±235.5 | 529.33±248.6 | 0.678 |
| Right lobe | 21 (70%) | 23 (76.66%) | 0.559 |
| Left lobe | 8 (26.66%) | 5 (16.66%) | 0.347 |
| Left lateral lobe | 1 (3.33%) | 2 (6.66%) | 0.554 |
| Ephedrine (mg) | 6 (2.2–12) | 6 (3–9) | 1 |
| Phenylephrine (mcg) | 40 (20–60) | 30 (17.5–40) | 0.037 |
n=Numbers; mcg: microgram; EPI: Epidural; ITM: Intrathecal morphine; BMI: Body mass index; Student t-test/Mann-Whitney U test/Chi-square test
Figure 2.
Intraoperative vitals. EPI: Epidural; ITM: Intrathecal morphine; HR: Heart Rate; MAP: Mean arterial pressure: PPV: Pulse pressure variation; CVP: Central venous pressure; Timepoints on X axis are as follows: 1- Baseline; 2: Immediately after induction; 3: 2 hours after induction; 4:4 hours after induction; 5: At abdomen closure; HR: Heart Rate; MAP; Mean Arterial Pressure; PPV: Pulse Pressure Variation; CVP: Central Venous Pressure a: Showing the changes in Heart rate during surgery b: Showing changes in Mean arterial pressure during surgery c: Showing changes in pulse pressure variation during surgery d: Showing changes in central venous pressure during surgery
The postoperative fentanyl consumption for the first 24 hours was significantly higher in the EPI group compared to the ITM group (162.5 mcg vs. 75 mcg, respectively; P = 0.023) [Table 2]. The cumulative postoperative fentanyl consumption at 48 hours and 72 hours was comparable (375 mcg vs. 312.5 mcg, P = 0.6, and 462.5 mcg vs. 462.5 mcg, P = 0.9, respectively; Table 2). Postoperative rescue analgesia was requested by four (13.33%) patients in the EPI group and three (10%) patients in the ITM group, and it was comparable [Table 2]. Time to first analgesia was significantly longer in the ITM group (16.89 hours vs. 12.69 hours; P = 0.001; Table 2). Postoperative length of stay, time to mobilization, and time to pass flatus were not significantly different between the two groups [Table 2].
Table 2.
Postoperative fentanyl consumption and postoperative complications
| Fentanyl (mcg) | EPI (n=30) | ITM (n=30) | P |
|---|---|---|---|
| 24 h | 162.5 (75–337.5) | 75 (43.7–187.5) | 0.02 |
| 48 h | 375 (193.7–475) | 312.5 (218 0.7–418.7) | 0.6 |
| 72 h | 462.5 (262.5–637.5) | 462.5 (268.7–593.7) | 0.9 |
| Rescue analgesia n (%) | 4 (13.33)% | 3 (10%) | 1 |
| Dose (mcg) | 125±70.7 | 108.33±62.9 | 0.76 |
| Time to first dose of analgesia (h) | 12.69±4.2 | 16.89±4.6 | 0.001 |
| Time to mobilize (days) | 1±0 | 1±0 | 1 |
| Time to pass flatus (days) | 2.5±0.6 | 2.56±0.5 | 0.7 |
| Length of stay (days) | 8±1.05 | 8.63±2.2 | 0.166 |
n=Numbers; mcg: microgram; EPI: Epidural; ITM: Intrathecal morphine; Mann-Whitney U test, Fisher’s exact test
NRS up to 12 hours in the postoperative period at rest (P < 0.001), on movement (P < 0.001), and for shoulder pain (P = 0.001) were significantly lower in the ITM group compared to the EPI group patients [Table 3]. The incidence of shoulder pain in the EPI group was 41.38%, while it was 13.79% in the ITM group (P < 0.001).
Table 3.
Numerical rating score
| NRS scoring | EPI | ITM | P |
|---|---|---|---|
| NRSR (0 h) | 1 (0–2) | 0 (0–0) | <0.001 |
| NRSR (2 h) | 1 (1–2) | 0 (0–1) | <0.001 |
| NRSR (4 h) | 2 (1.7–3) | 0 (0–1) | <0.001 |
| NRSR (12 h) | 2 (1–3) | 1 (0–1) | <0.001 |
| NRSR (24 h) | 2 (1–3) | 2 (1–3) | 0.888 |
| NRSR (36 h) | 2 (1–2) | 2 (1–2) | 0.552 |
| NRSR (48 h) | 1 (1–2) | 1 (1–2) | 0.707 |
| NRSR (72 h) | 0 (0–1) | 1 (0–1) | 0.442 |
| NRSM (0 h) | 2 (0.7–3) | 0 (0–1) | <0.001 |
| NRSM (2 h) | 2.5 (2–3) | 1 (0–2) | <0.001 |
| NRSM (4 h) | 3 (2–4) | 1.5 (0.75–2) | <0.001 |
| NRSM (12 h) | 3 (3–4) | 2 (1.7–3) | <0.001 |
| NRSM (24 h) | 3 (2.7–4) | 3 (2.7–4) | 0.677 |
| NRSM (36 h) | 3 (2–4) | 3 (2–4) | 0.826 |
| NRSM (48 h) | 3 (2–3) | 3 (2–3) | 0.879 |
| NRSM (72 h) | 2 (1–2.2) | 2 (2–2) | 0.339 |
| NRS SP (0 h) | 0 (0–2) | 0 (0–0) | 0.003 |
| NRS SP (2 h) | 1 (0–2) | 0 (0–0.25) | 0.006 |
| NRS SP (4 h) | 1 (0–2.2) | 0 (0–1) | 0.016 |
| NRS SP (12 h) | 1 (0–2) | 0 (0–1) | 0.001 |
| NRS SP (24 h) | 0.5 (0–2) | 0 (0–1) | 0.106 |
| NRS SP (36 h) | 0 (0–1) | 0 (0–1) | 0.985 |
| NRS SP (48 h) | 0 (0–0) | 0 (0–0) | 0.467 |
| NRS SP (72 h) | 0 (0–0) | 0 (0–0) | 0.363 |
n=Numbers; EPI: Epidural; ITM: Intrathecal morphine; NRS: Numerical rating score; NRSR: Numerical rating score at rest; NRSM: Numerical rating score at movement; NRS SP: Numerical rating score for shoulder pain; Student t-test/Mann-Whitney U test
Postoperative sedation scores were comparable between the two groups [Table 4]. The epidural catheter was removed on POD 4.03 ± 0.55. The postoperative complications were comparable between the two groups [Table 4].
Table 4.
Postoperative sedation score and complications
| Sedation score | EPI (n=30) | ITM (n=30) | P |
|---|---|---|---|
| 0 h | 3.03±0.7 | 3.23±0.5 | 0.231 |
| 2 h | 3±0.6 | 3.1±0.6 | 0.535 |
| 4 h | 2.8±0.6 | 2.9±0.8 | 0.599 |
| 12 h | 2.46±0.7 | 2.7±0.5 | 0.15 |
| 24 h | 2.43±0.6 | 2.46±0.6 | 0.858 |
| 36 h | 2.03±0.5 | 1.96±0.5 | 0.605 |
| 48 h | 1.63±0.5 | 1.76±0.6 | 0.415 |
| 72 h | 1.36±0.5 | 1.26±0.4 | 0.4 |
| Nausea/vomiting | 6 (20%) | 9 (30%) | 0.371 |
| Giddiness | 2 (6.7%) | 1 (3.3%) | 1 |
| Ileus | 2 (6.7%) | 1 (3.3%) | 1 |
| Pruritus | 0 (0%) | 1 (3.3%) | 1 |
| CO2 retention | 0 (0%) | 1 (3.3%) | 1 |
| Motor weakness | 1 (3.3%) | 0 (0%) | 1 |
| Fever | 0 (0%) | 2 (6.7%) | 0.492 |
n=Numbers; EPI: Epidural; ITM: Intrathecal morphine; NRS: Numerical rating score; CO2: Carbon dioxide; Student t-test/Mann-Whitney U test
Discussion
Regional anesthesia, including CNB, is a major component of multimodal pain control and a mode to reduce perioperative stress.[7] In our study, we found that patients in the ITM group consumed less fentanyl dose when compared to patients in the EPI group in the first 24 hours, while there was no statistically significant difference at 48 and 72 hours. The longer duration of action by single-shot ITM could be because most of the ITM remained in the CSF for a longer time with a lesser degree of vascular reabsorption, which allowed a considerable amount of it to be spread in cephalad direction inside the spinal cord, resulting in good analgesic effect for a longer time. Hydrophilic opioids (e.g. morphine) maintain their concentration in the CSF for a longer time, giving a longer duration of action and more analgesic spread above the injection point. This greater spread superiorly provides a broader analgesic coverage. The CSF concentration of ITM starts to decrease after 12 hours.[8,9] In a study by Tang J et al.,[10] they found that ITM reduced postoperative opioid requirements and improved analgesia for 24 hours after surgery in open non-donor liver surgeries. In another study by JS Ko et al.,[11] they also found that ITM is an effective and safe option for providing immediate postoperative pain control in live liver donors. In their study, they divided the patients into two groups as ITM + IV PCA and IV PCA groups. Moreover, they used a higher dose of ITM of 400 mcg in a 4 mL normal saline solution, while in our study, we used 300 mcg of ITM with a low dose of 7.5 mg of hyperbaric 0.5% bupivacaine. The major advantage of adding low-dose bupivacaine to ITM is that it could provide a bridge before the onset of action of ITM, which can act as preemptive analgesia and can decrease the intraoperative and postoperative requirement of opioids. In a retrospective study by AK Abdel Kader, they studied the effect of adding 11.25 mg (1.5 mL) of 0.75% heavy bupivacaine to 250 mcg of ITM in non-donor patients undergoing open liver resection and found that cumulative intraoperative morphine was significantly less in the ITM with bupivacaine group when compared to the only ITM group.[12]
In a study by, Duncan et al., they showed that there were more calls to pain services in the EPI group as compared to the ITM group in the first 2 postoperative days.[13] In contrast, Sakowska et al.[14] did a study in patients undergoing major open hepatopancreatic surgery study and found that a significantly higher proportion of patients in the intrathecal group required additional analgesia in the ICU (ITM 68% vs. TEA 16%, P < 0.001). The reason could be that they used a decreased dose of morphine (200 mcg) in the ITM group as compared to our study (300 mcg).
The main concern with ITM is delayed respiratory depression, which is due to slower onset and prolonged action of morphine. The incidence of respiratory depression is around 0.5% for intrathecal opioids (morphine dose varies from 100 to 800 mcg).[15] Gehling and Tryba in their meta-analysis found a higher incidence of respiratory depression at a dose of more than 300 mcg in patients undergoing various types of surgeries.[16] Therefore, in our study, we decided to use 300 mcg morphine intrathecally, and there was no respiratory depression in any of the cases.
In our study, the NRS score on rest and on movement was significantly less in the ITM group for the initial 12 hours when compared to the epidural group. This could be due to the fact that ITM provides an intense analgesia in the immediate postoperative period leading to a better NRS score. In a study by Tang J et al.[10] in non-donor patients undergoing major liver resections, they found that ITM effectively reduces pain scores for the initial 24 hours when given as a part of multimodal analgesia. In a study by Duncan et al.,[13] where they recruited patients undergoing major abdominal surgeries, they found that pain scores both at rest and on movement were consistently lower in the intrathecal group when compared to the epidural on postoperative days 1, 2, and 3. In a study by SH Lee[17] in living donors where they compared ITM with continuous wound infusion catheter, they found that the VAS score at rest during the first 12 postoperative hours was significantly lower for the ITM group, while at other times, the VAS scores were comparable between the groups. In contrast to our study, a study by Kasivisvanathan[5] on non-donor patients undergoing hepatic resections found that pain scores were significantly lower in the TEA group when compared to the ITM group up to 24 hours postoperatively (P < 0.001), and there was no difference in the pain scores after 24 hours.
In addition to abdominal pain, shoulder pain after hepatectomy is common and debilitating for the patients. The main contributing factors for postoperative shoulder pain after liver resection are diaphragm irritation, subcoastal incision, and rib retraction.[18] In a study by Y Yang et al.[18] they studied the shoulder pain incidence after liver resection and found a high incidence of 41% in patients undergoing major liver resections, which is similar to the epidural group in our study. The decreased incidence of shoulder pain in the ITM group could be because ITM spreads more rostrally and can cover upper dermatomes when compared to the epidural route, which results in better analgesia.
Intraoperative vasopressor requirement (phenylephrine) was found to be significantly higher in the EPI group when compared to the ITM group (P = 0.03), while ephedrine requirement was not different between the two groups. In support of our study, a study by Kasivisvanathan et al.[5] also demonstrated that vasopressor requirement was significantly higher in the TEA group when compared to the ITM + fPCA group (P = 0.004).
Other intraoperative parameters such as IV fluids, blood transfusion, surgery duration, hemodynamic parameters, and blood loss were all comparable between the two groups. However, Sakowska et al.[14] assessed fluid administration between intrathecal and epidural groups in patients undergoing major hepatopancreatic surgery and found that patients treated with epidural analgesia had significantly increased fluid administration compared to the ITM group and suggested that local anesthetic agent used in the epidural group causes more hypotension due to the sympathetic blockade. In contrast, in our study, there was no difference in IV fluids administration as a low concentration of local anesthetic agent (0.125% levobupivacaine) was used. In a randomized controlled trial by Aloia et al.,[19] they suggested that hypotension caused by epidural anesthesia can be minimized in major open hepatobiliary surgery by using a lower than the standard concentration of local anesthetic (0.075% bupivacaine).
The major strength of our study is that it is a randomized controlled trial where we recruited only healthy liver donors. The presently available literature includes patients undergoing liver resections for malignancies or other major abdominal surgeries. The literature on the use of ITM in healthy donors is scarce, and this study highlights the effectiveness of ITM in the postoperative period. However, a major limitation of our study is that both the patient and the anesthesiologist performing CNB were not blinded. Another limitation was the lack of long-term follow-up to determine which group of patients had developed chronic postoperative pain. To conclude, ITM significantly decreased fentanyl consumption in the first 24 hours after surgery when compared to the epidural group and also resulted in better pain scores. Therefore, it can be a good alternative to epidural analgesia in patients undergoing open live donor hepatectomy.
Data availability
The data that support the findings of this study are available from the corresponding author, [RS, GS, NG, MKA, VP, NM], upon reasonable request.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author, [RS, GS, NG, MKA, VP, NM], upon reasonable request.