Epidural

anesthesia is an effective pain management option and adjunct to intravenous opioids for large abdominal operations. It helps to reduce the pulmonary complications, duration of ileus and provides better pain control than opioids alone (36,37). Risks associated with epidural catheter placement include epidural hematoma, epidural abscess, and spinal cord injury. These risks are increased post hepatectomy due to alterations in coagulation profile. Postoperative coagulopathy is at its peak 2-5 days post surgery. This time frame coincides with the recommended time of removal Inhibitors,research,lifescience,medical for epidural catheters and may necessitate transfusion of fresh frozen plasma and/or platelets (32,38-40). Due to these risks, the role of single dose epidural shots has been examined. Inhibitors,research,lifescience,medical Ko et al. reported that the combination of single

intrathecal injection of morphine combined with postoperative patient controlled analgesia (PCA) resulted in improved pain control in the early postoperative period than PCA alone (41). Epidural catheter use in hepatic resection has also been associated with greater transfusion requirement (see Page and Kooby, this issue). There are other drugs that may be useful as adjuncts to opioid administration. Intravenous acetaminophen has recently become available in the United States. The recommended maximal dose Inhibitors,research,lifescience,medical is 2 g/day in patients with hepatic impairment (35). NSAID Inhibitors,research,lifescience,medical use is generally not

recommended post hepatectomy, in cirrhotic patients, or in patients with renal scientific study insufficiency due to the risks of bleeding and hepatorenal syndrome (35,42). Other non-opioid analgesics such as nefopam is widely used in European countries but is Inhibitors,research,lifescience,medical not currently FDA (Food and Drug Administration) approved for routine use in United States. The use of local anesthetic infusions via the On-Q Pain Buster system placed in the musculofascial layer of the subcostal wound combined with PCA decreased total morphine consumption and improved pain at rest and after spirometry when compared to PCA alone in patients who underwent open hepatic resection (43). An infusion of no more than 0.25% ropivacaine or duration of infusion of less than 2 days is recommended due to increased plasma levels post hepatectomy. There are also case reports Dacomitinib of the use of paravertebral infusion of local anesthetic with PCA. However comparative studies are needed prior to routine use of this technique (44). There are many options available for post hepatectomy pain control. A multimodal approach specifically chosen for an individual patient is recommended and may consist of intravenous opioids, non-opioid injectables, continuous or single dose epidural anesthesia, and local anesthetic infusions with the transition to oral opioids as tolerated.