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Researchers are experimenting with new agents to minimize narcotics in the postoperative period without compromising pain control.
Munich, Germany-Laparoscopic donor nephrectomy has emerged as the standard of care for renal transplantation, but consensus is lacking on the ideal postoperative pain management regimen. Based on new research, urologists at the University of Toronto say the preferred choice is the nonsteroidal anti-inflammatory drug ketorolac (Toradol) plus narcotic patient-controlled analgesia (PCA).
Despite the minimally invasive approach and small incisions, patients still require intravenous analgesia following the procedure. Traditionally, opioids have been used to control pain in the postoperative setting. While effective, opioid use has been associated with decreased activity, development of ileus, and drug tolerance and dependence. The Toronto researchers are experimenting with new agents to minimize narcotics in the postoperative period without compromising pain control.
"The 10-mg dose was chosen by our pain service in order to be conservative in the donor nephrectomy population. We now load with 30 mg IV in the recovery room, and then give 15 mg IV every 6 hours for 48 hours," said Dr. Pace, who presented the study at the World Congress of Endourology in Munich, Germany.
Patients receiving ketorolac needed less narcotics (114.9 mg of morphine vs. 148.0 mg, p=.02). Quality of life scores were statistically significantly better in the ketorolac group than in the group receiving PCA alone in the immediate post-op period; postoperative recovery scale (PRS) scores were 50% higher in the ketorolac arm 24 hours after surgery (30.8 vs. 21.0, p=.025). As expected, since ketorolac was only used for 48 hours postoperatively, there were no differences in quality of life scores 2 weeks and 3 months after surgery, Dr. Pace reported.
There was also a lower incidence of postoperative ileus in the ketorolac group, likely due to the decrease in narcotic dose. In addition, there was no difference in final serum creatinine between the groups, indicating that renal function was not at all compromised by the addition of ketorolac.
The use of ketorolac in the postoperative period has historically been avoided because of the theoretical risks of renal failure and postoperative hemhorrage. This study showed no increased incidence of renal failure or even upward trend in creatinine in a very sensitive solitary kidney population.
When asked about the potential for bleeding with ketorolac, Dr. Pace told Urology Times, "We have seen no evidence for increased risk of bleeding. I use it routinely after radical prostatectomy and even laparoscopic partial nephrectomy."
Dr. Pace noted that practice patterns have changed at the University of Toronto so that ketorolac is used routinely after donor nephrectomy round-the-clock for the first 48 hours, assuming the patient has no contraindication to the drug.