Multimodal opioid‐sparing pain management after lung transplantation and the impact of liposomal bupivacaine intercostal nerve block

Abstract

Opioid analgesics are commonly used post-lung transplant, but have many side effects and are associated with worse outcomes. We conducted a retrospective review of all lung transplant recipients who were treated with a multimodal opioid-sparing pain protocol. The use of liposomal bupivacaine intercostal nerve block was variable due to hospital restrictions. The primary objective was to describe opioid requirements and patient-reported pain scores early post-lung transplant and to assess the impact of intraoperative liposomal bupivacaine intercostal nerve block. We treated 64 lung transplant recipients with our protocol. Opioid utilization decreased to a mean of 43 milligram oral morphine equivalents by postoperative day 4. Median pain scores peaked at 4 on postoperative day 1 and decreased thereafter. Only three patients were discharged home with opioids, all of whom were taking opioid agonist therapy pretransplant for opioid use disorder. Patients who received liposomal bupivacaine intercostal nerve block in the operating room had a significant reduction in opioid consumption over postoperative day 1 through 4 (228 mg vs. 517 mg, P= .032). A multimodal opioid-sparing pain management protocol is feasible and resulted in weaning of opioids prior to hospital discharge.

A Breath of Fresh Air - Lung Transplantation Has Come of Age

“…Several entry incisions exist for lung transplantation. Whether it be an anterolateral or posterolateral thoracotomy, median sternotomy, or clamshell thoracosternotomy all are associated with significant postoperative pain that can impair both respiratory function and participation in physical rehabilitation [104,105]. Painful incision sites following transplantation can significantly impair chest wall mechanics leading to ineffective chest wall expansion that may increase the risk of atelectasis, ventilation/perfusion mismatch, hypoxemia, and infection [104].…”

“…Painful incision sites following transplantation can significantly impair chest wall mechanics leading to ineffective chest wall expansion that may increase the risk of atelectasis, ventilation/perfusion mismatch, hypoxemia, and infection [104]. Additionally, poor management of acute post-operative pain is associated with post-thoracotomy pain syndrome (PTPS) [104][105][106]. PTPS is chronic pain that persists along a thoracotomy incision for at least 2 months post-op, it is described as typical neuropathic pain with features of burning and dysesthesia [106].…”

“…Opioids however are associated with multiple adverse effects, including respiratory depression, sedation, post-operative nausea and vomiting, urinary retention, ileus, as well as eventual tolerance and dependence [105,106]. Of recent years, thoracic epidural anesthesia (TEA) has become a technique of choice for post thoracotomy pain management as it adequately controls postoperative pain while allowing for continued dosing without the associated risk profile of systemic opioids [104,105]. TEA has been found to be associated with decreased ICU length of stay as well as mechanical ventilation duration [105].…”

“…Of recent years, thoracic epidural anesthesia (TEA) has become a technique of choice for post thoracotomy pain management as it adequately controls postoperative pain while allowing for continued dosing without the associated risk profile of systemic opioids [104,105]. TEA has been found to be associated with decreased ICU length of stay as well as mechanical ventilation duration [105]. On the contrary, TEA is not always feasible due to its associated risks of epidural abscess, epidural hematoma, sympathetic blockade, and is often contraindicated in the setting of ECMO as bridge to recovery [104][105][106].…”

“…TEA has been found to be associated with decreased ICU length of stay as well as mechanical ventilation duration [105]. On the contrary, TEA is not always feasible due to its associated risks of epidural abscess, epidural hematoma, sympathetic blockade, and is often contraindicated in the setting of ECMO as bridge to recovery [104][105][106]. Recent alternatives to TEA include regional analgesia as intercostal nerve blockade with liposomal bupivacaine injections or intercostal cryoanalgesia.…”