IntroductionPain management in patients with chronic kidney disease is challenging. Due to impaired kidney function, analgesic options are limited. Postoperative analgesia in transplant recipients is further complicated by their vulnerability to infections, titrated fluid management and optimal haemodynamics to maintain graft function. Erector spinae plane (ESP) blocks have been used successfully in a variety of surgeries. This study is a quality improvement project aiming to assess the efficacy of continuous erector spinae plane catheter analgesia in the postoperative management of kidney transplant recipients. MethodsWe conducted an initial audit over a period of three months. All patients who underwent kidney transplantation under general anaesthesia with erector spinae plane catheters were included. Erector spinae plane catheters were secured prior to induction, and continuous local anaesthetic infusion was maintained postoperatively. Pain scores using the numerical rating scale (NRS) were recorded at intervals in the first 24 hours postoperatively, and supplementary analgesics given were noted. Following satisfactory results from the initial audit, we implemented erector spinae plane catheters as part of multimodal analgesia in transplant patients in our centre. We re-audited all transplants done over the next year to reassess the quality of postoperative analgesia. ResultsFive patients were audited during the initial audit. The average NRS score ranged from 0 at rest to a maximum of 5 during mobilisation. All patients were given only paracetamol to supplement analgesia, and none required opioids. During the re-audit, data was collected on postoperative pain management in 13 subsequent transplants conducted over the next year. The NRS scores ranged from 0 at rest to 6 on mobilisation. Two patients required boluses of fentanyl 25 mcg via the catheter, and the rest reported satisfactory analgesia with paracetamol as needed. ConclusionThis quality improvement project changed our centre's practice in managing postoperative pain in kidney transplantations. We switched from securing epidural catheters to erector spinae plane catheters due to better safety profile, minimal use of opioids and lesser adverse effects. We shall continue to re-audit our practices for the best outcomes.
IntroductIonDexmedetomidine is a highly selective α-2 adrenoceptor agonist commonly used in anesthesia practice. Dexmedetomidine produces sedation, hypnosis, analgesia, anxiolysis, and sympatholysis with minimal respiratory depression. [1] The central effects are due to the activation of α-2A receptors in locus coeruleus, and cardiovascular effects are due to a dose-dependent decrease in the central sympathetic outflow. The transient hypertensive response is seen initially due to its effects on α-2B receptors present in the vascular smooth muscle until there is a decrease in the central sympathetic outflow. [2] Dexmedetomidine has been shown to reduce perioperative oxygen consumption and blunt the sympathetic response to laryngoscopy and surgical stimuli, resulting in improved cardiac outcomes. [3,4] Dexmedetomidine infusions postoperatively have been shown to reduce plasma catecholamine levels and lesser hemodynamic fluctuations. [5] Dexmedetomidine has also been shown to reduce anesthetic and analgesic requirements. [6,7] The above-stated properties make dexmedetomidine an ideal preanesthetic agent. A study demonstrated that single preanesthetic dose of dexmedetomidine decreased the thiopental dose requirement without any serious hemodynamic changes. [7] Objective: To find out the dose of propofol consumption for induction and also the variation in hemodynamics following single-dose dexmedetomidine premedication. Methods: A total of 60 American Society of Anesthesiologists Class 1 and 2 patients aged between 18 and 80 years, posted for elective surgeries were randomized into two groups: Group C -premedication with 2 mcg/kg fentanyl and Group D -premedication with 1 mcg/kg dexmedetomidine + 2 mcg/kg fentanyl. Both groups were preloaded with 10 ml/kg crystalloid solution. The parameters measured were propofol requirements, heart rate (HR), mean arterial pressure (MAP), cardiac index (CI), cardiac output (CO), and stroke volume variation (SVV). Results: Propofol requirements were 26.6% lesser in Group D (P < 0.001). In Group C, HR was significantly low at baseline (P = 0.008), induction (P = 0.006), and at intubation (P = 0.001) in Group D. Cardiovascular parameters such as MAP (P = 0.007), CI (P = 0.038), and CO (P = 0.021) were significantly lower in Group D compared to Group C only at baseline. There were no differences at any other point during the study. SVV was noted to be significantly lower (P = 0.018) in Group D only at intubation. Conclusion: Dexmedetomidine decreases the requirements of propofol for induction and also attenuates the hemodynamic response to intubation. Cardiovascular parameters such as MAP, CI, and CO were significantly lower in Group D only at baseline. Hemodynamic stability is mainly attributed to adequate preloading and less propofol requirement in the dexmedetomidine group.
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