Best Practices
Radical Nephrectomy/Partial Nephrectomy — Open
All best practices are subject to change and may require modifications depending on a patient’s history and status. Healthcare practitioners should always defer to their clinical judgement and, whenever appropriate, consult with additional resources for further guidance.
| Preoperative | Intraoperative | Postoperative (Inpatient) | Discharge Strategies |
|---|---|---|---|
| •Acetaminophen •Consider regional analgesia (thoracic epidural or fascial plane block) | •Thoracic epidural analgesia •Consider IV lidocaine bolus (1-1.5mg/kg) plus infusion at 0.5-1.5mg/kg/hr if not providing epidural analgesia | •Acetaminophen •Thoracic epidural analgesia •If not providing epidural analgesia: ...•Consider continuing IV lidocaine infusion x 24-48 hrs OR ...•Consider fascial plane block (eg TAP)--intermittent bolus via catheter or single shot •IV PCA if not utilizing regional analgesia •NSAIDs require caution due to potential renal toxicity and function of remaining solitary kidney (use < 5 days) | MANAGEMENT OF PAIN W/O MEDICATION: •Relaxation techniques (breathing, meditation, mindfulness, etc.) CO-ANALGESICS: •Acetaminophen •NSAIDs only if remaining kidney function adequate and only for limited duration (<5 days total & consider a prescription for increased compliance) OPIOID PRESCRIPTION: 20-30 tablets* or up to 60 tablets* if using a.part-fill prescription |
*All tabs for discharge are 5mg oral morphine. To convert this dosage, please visit this page. We encourage prescribers to consider discharge prescriptions of short-acting opioids at the lowest effective dose, with the lowest potency, for the shortest duration.
Before surgery, and at the surgical safety checklist time, the surgical and anesthesia team should work together to develop a multimodal pain management plan with active strategies to optimize perioperative pain management.
Healthcare practitioners are also encouraged to help patients set realistic expectations around pain management, including the use of prescription medications. Additional useful information to enhance recovery after surgery can be found at Enhanced Recovery Canada.
See our full disclaimer here.
References
Clarke HA. Manoo V. Pearsall EA. Goel A. Feinberg A. Weinrib A. et al. Consensus Statement for the Prescription of Pain Medication at Discharge after Elective Adult Surgery. Canadian Journal of Pain. 2020;4(1):67–85.
Mathuram Thiyagarajan U, Bagul A, Nicholson ML. Pain Management in Laparoscopic Donor Nephrectomy: A Review. Pain Res Treat. 2012;2012:201852.
Prostatectomy 2020 Pre-/intra-operative Interventions [Internet]. Geneva. Prospect. The European Society of Regional Anaesthesia & Pain Therapy; [cited 2022 May 12]. Available from: https://esraeurope.org/prospect/procedures/prostatectomy-2020/pre-intra-operative-interventions-14/
Opioid Prescribing Recommendations [Internet]. Ann Arbor (MI). Michigan OPEN; [cited 2022 May]. Available from: https://michigan-open.org/prescribing-recommendations
Varela-Santoyo E, Escamilla-López MI, Izquierdo-Tolosa CD, Arroyave-Ramírez AM, Buerba-Vieregge HH, Dorantes-Heredia R, et al. Impact of the Type of Analgesic Therapy on Postsurgical Complications of Patients with Kidney Cancer Undergoing Nephrectomy. Oncology. 2020;98(2):117-22.
Treatment Altering Factors
Below are a few of the more common and/or impactful health factors that may result in deviation from the above best practices. Please note that the following list is not exhaustive and that the remarks for each factor are not surgery-specific. Healthcare practitioners should always defer to their clinical judgement and, if appropriate, consult with additional resources for further guidance. See our full disclaimer here.
Organ Dysfunction
Hepatic dysfunction/Excessive alcohol intake
| •In general: Limit or avoid acetaminophen altogether, depending on degree of hepatic dysfunction •Preoperative: Avoid or reduce dose of acetaminophen •Intraoperative: Decrease dose of opioids, benzodiazepines, meperdine •Postoperative: Reduce dose of acetaminophen •Discharge: Lower daily maximum dose of tramadol and increase dosing interval; avoid codeine |
Renal dysfunction
| •In general: Limit or avoid NSAIDs altogether, depending on degree of renal dysfunction •Preoperative: Avoid NSAIDs and use gabapentinoids cautiously •Intraoperative: Avoid morphine and meperidine •Postoperative: Avoid NSAIDs and use lower dose of gabapentin •Discharge: Lower daily maximum dose of tramadol and increase dosing interval; avoid codeine |
Patient Specific Factors
Advanced age
| header |
|---|
| •Preoperative: Due to the frequency of multiple comorbidities in advanced age, anesthesia preoperative consult as needed to preoptimize. Also, manage anticoagulants where indicated; avoid long delays in hip fracture patients and practice preemptive analgesia •Intraoperative: Regional anesthesia and peripheral nerve blocks preferable where indicated •Postoperative: Regular dose acetaminophen; oral NSAIDs where indicated •Discharge: Consider minimum amount of opiates based on the surgical procedure, age and comorbidities |
Chronic pain and/or long-term opiate use
| •In general: May attempt to wean chronic opioids if surgery is to treat issues contributing to the chronic pain but otherwise continue chronic pain medication perioperatively if patient uses it •Preoperative: Anesthesia consult where indicated; continue preop opioids on day of surgery and give preemptive analgesia •Intraoperative: Regional anesthesia and peripheral nerve blocks preferable where indicated; use a multi-modal opioid sparing approach; may require higher doses of opioids to account for tolerance •Postoperative: Use a multi-modal opioid sparing approach; may require higher doses of opioids to account for tolerance; regular dose acetaminophen and oral NSAIDs where indicated •Discharge: Consider minimum amount of opiates based on the surgical procedure, age and comorbidities and avoid opioid dose escalation from preop, if possible |
History of difficulty with postop pain management
| •Consider regional anesthetic techniques, if feasible for specific surgical procedure |
Uncontrolled anxiety/depressive symptoms
| •Preoperative: Consider anxiolytics prior to administration of anesthetic •Discharge: While reviewing expected duration of opioid use, as well as opioid safety strategies including the appropriate storage and disposal of unused pills, should be standard practice, it is of paticular importance with patients who have uncontrolled anxiety/depressive symptoms Special note for paediatric surgeries: Given the risk of opioid misuse in youth with depressive symptoms, consider heightened opioid safety factors including reviewing with caregivers at discharge |
System Disorders
Coagulopathy
| •Avoid neuraxial techniques if any abnormal coagulation; consider following ASRA guidelines |
Obstructive sleep apnea
| •Preoperative: Use multi-modal analgesia; reduce or avoid use of gabapentinoids •Intraoperative: Reduce or avoid benzodiazepines; reduce doses of opioid medications •Postoperative: Use multi-modal analgesia; reduce use of opioids and gabapentinoids •Discharge: Reduce opioid dosing |