Abstract
Purpose
Liver resection has a risk of postoperative hepatic dysfunction, including drug metabolism. Since fentanyl is primarily metabolized in the liver, liver resection requires exercising caution against fentanyl overdose in postoperative analgesia. The rationale for dose adjustment of fentanyl in the preoperative prescription for patients undergoing liver resection remains unclear. We examined whether postoperative fentanyl consumption is associated with the future liver remnant after liver resection and investigated factors influencing fentanyl consumption.
Methods
In this retrospective study, 89 living liver donors undergoing open liver resection received intravenous patient-controlled analgesia with fentanyl 2 mg with thoracic epidural analgesia. The primary outcome was postoperative hourly consumption of intravenous patient-controlled analgesia with fentanyl. Future liver remnant volume (ml) and the ratio of future liver remnant volume to whole liver volume (%) were estimated by computed tomography volumetry and compared to determine which correlated more strongly with fentanyl hourly consumption. Multivariable analysis identified independent factors affecting fentanyl consumption, with adjustments for patient characteristics and intravenous patient-controlled analgesia setting.
Results
Future liver remnant volume (ml) was significantly correlated more strongly than the ratio of future liver remnant (%) with postoperative fentanyl consumption (r = 0.53 vs. 0.36, p < 0.001). Larger future liver remnant volume (β = 0.25, p = 0.006) and age < 45 years (β = 0.24, p = 0.009) were independently associated with higher fentanyl consumption, while sex and weight were not.
Conclusions
Future liver remnant volume was significantly associated with postoperative fentanyl consumption. Smaller remnant liver volume and older age (≥ 45 years) were independent factors reducing postoperative fentanyl consumption in patients undergoing open donor hepatectomy.
Similar content being viewed by others
References
Dewe G, Steyaert A, de Kock M, Lois F, Reding R, Forget P. Pain management in living related adult donor hepatectomy: feasibility of an evidence-based protocol in 100 consecutive donors. BMC Res Notes. 2018;11:834.
Dudek P, Zawadka M, Andruszkiewicz P, Gelo R, Pugliese F, Bilotta F. Postoperative analgesia after open liver surgery: systematic review of clinical evidence. J Clin Med. 2021;10:3662.
Wrighton LJ, O’Bosky KR, Namm JP, Senthil M. Postoperative management after hepatic resection. J Gastrointest Oncol. 2012;3:41–74.
Rudin A, Lundberg JF, Hammarlund-Udenaes M, Flisberg P, Werner MU. Morphine metabolism after major liver surgery. Anesth Analg. 2007;104:1409–14.
Moss CR, Caldwell JC, Afilaka B, Iskandarani K, Chinchilli VM, McQuillan P, Cooper A, Gusani N, Bezinover D. Hepatic resection is associated with reduced postoperative opioid requirement. J Anaesthesiol Clin Pharmacol. 2016;32:307–13.
Verbeeck RK. Pharmacokinetics and dosage adjustment in patients with hepatic dysfunction. Eur J Clin Pharmacol. 2008;64:1147–61.
Siu J, McCall J, Connor S. Systematic review of pathophysiological changes following hepatic resection. HPB (Oxford). 2014;16:407–21.
Hanna SS, Pagliarello G, Ing A. Liver blood flow after major hepatic resection. Can J Surg. 1988;31:363–7.
Haberer JP, Schoeffler P, Couderc E, Duvaldestin P. Fentanyl pharmacokinetics in anaesthetized patients with cirrhosis. Br J Anaesth. 1982;54:1267–70.
Murphy EJ. Acute pain management pharmacology for the patient with concurrent renal or hepatic disease. Anaesth Intensive Care. 2005;33:311–22.
Imani F, Motavaf M, Safari S, Alavian SM. The therapeutic use of analgesics in patients with liver cirrhosis: a literature review and evidence-based recommendations. Hepat Mon. 2014;14: e23539.
Soleimanpour H, Safari S, Nia KS, Sanaie S, Alavian SM. Opioid drugs in patients with liver disease: a systematic review. Hepat Mon. 2016;16: e32636.
Pulitano C, Crawford M, Joseph D, Aldrighetti L, Sandroussi C. Preoperative assessment of postoperative liver function: the importance of residual liver volume. J Surg Oncol. 2014;110:445–50.
Khan AS, Garcia-Aroz S, Ansari MA, Atiq SM, Senter-Zapata M, Kathryn Fowler MB, Doyle WCC. Assessment and optimization of liver volume before major hepatic resection: current guidelines and a narrative review. Int J Surg. 2018;52:74–81. https://doi.org/10.1016/j.ijsu.2018.01.042.
Golriz M, El Sakka S, Majlesara A, Edalatpour A, Hafezi M, Rezaei N, Garoussi C, Arwin J, Saffari A, Raisi H, Abbasi A, Mehrabi A. Hepatic hemodynamic changes following stepwise liver resection. J Gastrointest Surg. 2016;20(3):587–94. https://doi.org/10.1007/s11605-015-3021-y.
Murry DJ, Crom WR, Peddick WE, Bhargava R, Evans WE. Liver volume as a determinant of drug clearance in children and adolescents. Drug Metab Dispos. 1995;23:1110–6.
Dernedde M, Stadler M, Bardiau F, Boogaerts J. Comparison of different concentrations of levobupivacaine for post-operative epidural analgesia. Acta Anaesthesiol Scand. 2003;47:884–90.
Perotti L, Cusato M, Ingelmo P, Niebel TL, Somaini M, Riva F, Tinelli C, De Andrés J, Fanelli G, Braschi A, Regazzi M, Allegri M. A comparison of differences between the systemic pharmacokinetics of levobupivacaine and ropivacaine during continuous epidural infusion. A prospective, randomized, multicenter, double-blind controlled trial. Anesth Analg. 2015;121:348–56.
Casati A, Santorsola R, Aldegheri G, Ravasi F, Fanelli G, Berti M, Fraschini G, Torri G. Intraoperative epidural anesthesia and postoperative analgesia with levobupivacaine for major orthopedic surgery: a double-blind, randomized comparison of racemic bupivacaine and ropivacaine. J Clin Anesth. 2003;15:126–31.
Yoshida M, Utsunomiya D, Kidoh M, Yuki H, Oda S, Shiraishi S, Yamamoto H, Inomata Y, Yamashita Y. CT evaluation of living liver donor: can 100-kVp plus iterative reconstruction protocol provide accurate liver volume and vascular anatomy for liver transplantation with reduced radiation and contrast dose? Med (Baltimore). 2017;96: e6973.
Kuip EJM, Zandvliet ML, Koolen SLW, Mathijssen RHJ, van der Rijt CCD. A review of factors explaining variability in fentanyl pharmacokinetics; focus on implications for cancer patients. Br J Clin Pharmacol. 2017;83:294–313.
Grass JA. Patient-controlled analgesia. Anesth Analg. 2005;101:S44-61.
Burns JW, Hodsman NBA, McLintock TTC, Gillies GWA, Kenny GNC, McArdle CS. The influence of patient characteristics on the requirements for postoperative analgesia. Anaesthesia. 1989;44:2–6.
Marino IR, Doyle HR, Aldrighetti L, Doria C, McMichael J, Gayowski T, Fung JJ, Tzakis AG, Starzl TE. Effect of donor age and sex on the outcome of liver transplantation. Hepatology. 1995;22:1754–62.
Alexander JW, Vaughn WK. The use of “marginal” donors for organ transplantation: the influence of donor age on outcome. Transplantation. 1991;51:135–41.
Dayoub JC, Cortese F, Anžič A, Grum T, de Magalhães JP. The effects of donor age on organ transplants: a review and implications for aging research. Exp Gerontol. 2018;110:230–40.
Steiger JH. Tests for comparing elements of a correlation matrix. Psychol Bull. 1980;87:245–51.
Diedenhofen B, Musch J. Cocor: a comprehensive solution for the statistical comparison of correlations. PLoS ONE. 2015;10: e0121945.
Kanda Y. Investigation of the freely available easy-to-use software ‘EZR’ for medical statistics. Bone Marrow Transplant. 2013;48:452–8.
Faul F, Erdfelder E, Buchner A, Lang AG. Statistical power analyses using G*Power 3.1: tests for correlation and regression analyses. Behav Res Methods. 2009;41:1149–60.
Wilson Van Voorhis CR, Morgan BL. Understanding power and rules of thumb for determining sample sizes. Tutor Quant Methods Psychol. 2007;3:43–50.
Leelaudomlipi S, Sugawara Y, Kaneko J, Matsui Y, Ohkubo T, Makuuchi M. Volumetric analysis of liver segments in 155 living donors. Liver Transpl. 2002;8:612–4.
Klinge M, Coppler T, Liebschutz JM, Dugum M, Wassan A, DiMartini A, Rogal S. The assessment and management of pain in cirrhosis. Curr Hepatol Rep. 2018;17:42–51.
Almazroo OA, Miah MK, Venkataramanan R. Drug metabolism in the liver. Clin Liver Dis. 2017;21:1–20.
Macintyre PE, Jarvis DA. Age is the best predictor of postoperative morphine requirements. Pain. 1996;64:357–64.
Scott JC, Stanski DR. Decreased fentanyl and alfentanil dose requirements with age. A simultaneous pharmacokinetic and pharmacodynamic evaluation. J Pharmacol Exp Ther. 1987;240:159–66.
Wynne HA, Cope LH, Mutch E, Rawlins MD, Woodhouse KW, James OF. The effect of age upon liver volume and apparent liver blood flow in healthy man. Hepatology. 1989;9:297–301.
Cusack BJ. Pharmacokinetics in older persons. Am J Geriatr Pharmacother. 2004;2:274–302.
Chen JP, Jawan B, Chen CL, Wang CH, Cheng KW, Wang CC, Concejero AM, Villagomeza E, Huang CJ. Comparison of postoperative morphine requirements in healthy living liver donors, patients with hepatocellular carcinoma undergoing partial hepatectomy, and liver transplant recipients. Transplant Proc. 2010;42:701–2.
Ko JS, Shin YH, Gwak MS, Jang CH, Kim GS, Lee SK. The relationship between postoperative intravenous patient-controlled fentanyl analgesic requirements and severity of liver disease. Transplant Proc. 2012;44:445–7.
Yoneyama T, Asonuma K, Okajima H, Lee K-J, Yamamoto H, Takeichi T, Nakayama Y, Inomata Y. Coefficient factor for graft weight estimation from preoperative computed tomography volumetry in living donor liver transplantation. Liver Transpl. 2011;17:369–72.
Hwang J, Min SK, Chae YJ, Lim GM, Joe HB. Continuous fentanyl background infusion regimen optimised by patient-controlled analgesia for acute postoperative pain management: a randomised controlled trial. J Clin Med. 2020;9:211.
Badner NH, Doyle JA, Smith MH, Herrick IA. Effect of varying intravenous patient-controlled analgesia dose and lockout interval while maintaining a constant hourly maximum dose. J Clin Anesth. 1996;8:382–5. https://doi.org/10.1016/0952-8180(96)00077-3.
Hoetzel A, Ryan H, Schmidt R. Anesthetic considerations for the patient with liver disease. Curr Opin Anaesthesiol. 2012;25:340–7.
Kiamanesh D, Rumley J, Moitra VK. Monitoring and managing hepatic disease in anaesthesia. Br J Anaesth. 2013;111:i50-61.
Gelman S. General anesthesia and hepatic circulation. Can J Physiol Pharmacol. 1987;65:1762–79.
Fassoulaki A, Melemeni A, Paraskeva A, Siafaka I, Sarantopoulos C. Postoperative pain and analgesic requirements after anesthesia with sevoflurane, desflurane or propofol. Anesth Analg. 2008;107:1715–9.
Peng K, Liu H-Y, Wu S-R, Liu H, Zhang Z-C, Ji F-H. Does propofol anesthesia lead to less postoperative pain compared with inhalational anesthesia?: A systematic review and meta-analysis. Anesth Analg. 2016;123:846–58.
Holley FO, van Steennis C. Postoperative analgesia with fentanyl: pharmacokinetics and pharmacodynamics of constant-rate i.v. and transdermal delivery. Br J Anaesth. 1988;60:608–13.
Tamsen A, Hartvig P, Fagerlund C, Dahlström B. Patient-controlled analgesic therapy, part ii: individual analgesic demand and analgesic plasma concentrations of pethidine in postoperative pain. Clin Pharmacokinet. 1982;7:164–75.
Gourlay GK, Kowalski SR, Plummer JL, Cousins MJ, Armstrong PJ. Fentanyl blood concentration-analgesic response relationship in the treatment of postoperative pain. Anesth Analg. 1988;67:329–37.
Choi BM. A new therapeutic option for postoperative pain management with oxycodone HCI injection. Korean J Anesthesiol. 2016;69:211–8.
Author information
Authors and Affiliations
Contributions
YT, MS, and TY contributed to the study conception and design. YT and MS conducted the study, data collection and analysis. NH and TY supervised the study. The first draft of the manuscript was written by YT and all co-authors reviewed and revised the manuscript. All authors read and approved the final manuscript.
Corresponding author
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Tsukano, Y., Sugita, M., Hirata, N. et al. Future liver remnant volume is associated with postoperative fentanyl consumption following open donor hepatectomy: a retrospective multivariate analysis. J Anesth 36, 731–739 (2022). https://doi.org/10.1007/s00540-022-03110-2
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00540-022-03110-2