Introduction: Opioids have been the mainstay for perioperative analgesia. Non-opioid drugs with analgesic properties improve intraoperative multimodal analgesia and lead to a decrease in analgesic consumption, reduction in pain scores, postoperative rescue analgesia and in postoperative nausea and vomiting. We report a case of a patient with Alport Syndrome and End Stage Renal Disease (ESRD) proposed for elective Living-Donor Renal Transplantation, with reported allergies/intolerance to opioids.
Case report: 30-year-old male patient, American Society of Anesthesiologists physical status IV, medical history of Alport Syndrome, ESRD treated with peritoneal dialysis, allergy to tramadol and morphine intolerance. A general intravenous anaesthesia and TAP block was performed. Remifentanil and propofol were used until loss of consciousness. Propofol infusion was then started for effect-site concentration. Maintenance of anaesthesia was achieved with remifentanil infusion to target effect-site, dexmedetomidine infusion and a bolus of ketamine. An ultrasound guided TAP block was performed, using ropivacaine. Analgesia was complemented with paracetamol. Surgical procedure lasted 2 h during which patient was stable, with no record of any adverse events. Emergence of anaesthesia was smooth and painless, and there were no analgesic needs during the time-spent in the recovery unit. Postoperative analgesia plan was PCA pump of morphine with ketamine, and paracetamol every 6 h. During the first 48 h, acute pain team reported no PCA pump requirements, no important discomfort and no complications. Patient improved uneventfully, with a total length of hospital stay of 8 days.
Discussion and learning points: Patients proposed for renal transplantation surgery, with ESRD, present significant challenges for the anaesthesiologist and alternatives to use of opioids could be an option. An opioid sparing technique using regional anaesthesia combined with several drugs with analgesic properties was performed and good analgesic control was accomplished, with no adverse effects, providing a good and fast recovery after a renal transplantation.