Implementation of an opioid-sparing protocol utilizing liposomal bupivacaine and intravenous ketorolac for pain management after living kidney donation.

Background: Opioids are commonly used for management of post-operative pain in living kidney donors. Reducing exposure to opioids is desirable to minimize risk of dependence and potential side effects such as nausea, vomiting, and constipation which may delay discharge. Liposomal bupivacaine, ketorolac, and scheduled acetaminophen have all demonstrated efficacy for management of post-operative pain in this population.

Aim: To assess the efficacy and safety of an opioid-sparing protocol utilizing a multimodal pain management approach in living kidney donors post-nephrectomy.

Methods: Single-center, retrospective chart review study examining 52 living kidney donors (26 pre-protocol implementation, 26 post-protocol implementation) from May 24^th, 2019 to September 27^th, 2023. Patients in the post-protocol group received intraoperative liposomal bupivacaine, hydromorphone PCA (until able to tolerate oral medications), 15 mg of intravenous ketorolac every 6 hours for 3 doses, and scheduled oral acetaminophen, in addition to oxycodone as needed for moderate to severe pain. The primary endpoint was oral morphine equivalent (OME) use within 48 hours post-surgery. Secondary endpoints include average daily pain scale within 48 hours post-surgery, length of stay (LOS) (days), and incidence of new acute kidney injury (AKI) or gastrointestinal (GI) bleed during admission per provider. Differences between the pre- and post-protocol implementation groups were compared utilizing the exact Wilcoxon test for continuous variables and either the Fisher's Exact or χ ² test for categorical variables.

Results: Patients in the pre-protocol implementation group received more OME (mg) within 48 hours post-surgery when compared to the post-protocol group (median: 84.5 vs 69.0). The median of total OME over the course of admission was numerically greater the pre-protocol group (105.0 vs 69.0), and was significantly more per LOS (41.3 vs 25.7, P = 0.02). Average daily pain score was not statistically significantly different between the two groups on post-operative day 1 (median: 5.3 vs 4.4; P = 0.43) and post-operative day 2 (median: 4.7 vs 5.2; P = 0.96). No significant differences were found in provider-identified incidences of AKI or GI bleeding during admission. There was no difference in serum creatinine at the time of discharge between the two groups.

Conclusion: A multimodal, opioid-sparing pain management protocol was as effective for pain control and resulted in significantly less opioid daily exposure over LOS. No adverse events were found related to use of ketorolac in patients undergoing donor nephrectomy. Our findings suggest that an opioid-sparing protocol is both safe and effective at minimizing opioid exposure and managing post-operative pain within the first 48 hours post-surgery.