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

Table 1 Multimodal, opioid-sparing pain management protocol

Agent	Time of initiation	Dosing
Liposomal bupivacaine 13% injection (13.3 mg/mL)	Intra-operative	133 mg (10 mL) subcutaneously on each side of incision
Ketorolac	Post-operative day 0	15 mg IV Q6H for 3 doses
Hydromorphone IV PCA1	Post-operative day 0	Basal rate: None
		PCA bolus: 0.1 mg
		Lockout interval: 10 minutes
		Four house dose limit: 2.4 mg
Acetaminophen	Post-operative day 1	650 mg PO Q6H
Oxycodone	Post-operative day 1	5 mg PO Q4H as needed for moderate pain
		10 mg PO Q6H as needed for severe pain

¹Discontinued when patient able to tolerate oral medication.

Table 2 Summary of demographic characteristics of study sample by group (n = 52), n (%)

	Pre-protocol group (n = 26)	Post-protocol group (n = 26)
Gender
Female	21 (80.8)	18 (69.2)
Male	5 (19.2)	8 (30.8)
Age (years)
Median [IQR]	47.0 (33.0, 58.0)	49.0 (40.0, 58.0)
≤ 45	12 (46.2)	11 (42.3)
Admission weight (kg)
Median [IQR]	76.8 (64.1, 87.0)	76.8 (68.0, 96.2)
Ethnicity
African-American	7 (26.9)	5 (19.2)
Caucasian	14 (53.8)	14 (53.8)
Hispanic	5 (19.2)	1 (3.8)
Unknown	0 (0.0)	6 (23.1)

Table 3 Medication usage by study group (n = 52)

	Pre-protocol group (n = 26)	Post-protocol group (n = 26)
Acetaminophen received in first 48 hours post-operatively (mg)	3250.0 (2000.0, 4000.0)	2600.0 (1950.0, 4950.0)
OME received in first 48 hours post-operatively	84.5 (42.0, 133.0)	69.0 (18.0, 112.5)
Total OME for admission	113.8 (50.0, 185.0)	69.0 (34.0, 121.5)
OME per LOS (days)	37.9 (18.0, 52.8)	25.7 (9.4, 37.5)
LOS (days)	3.0 (2.0, 3.0)	3.0 (2.0, 3.0)
Mean pain score (POD#1)	5.3 (4.0, 6.4)	4.4 (3.6, 6.7)
Mean pain score (POD#2)	4.7 (3.7, 6.3)	5.2 (2.7, 6.5)
Mean pain score for overall LOS1	4.7 (3.5, 5.6)	4.4 (2.7, 5.9)
Doses of ketorolac received	0.0 (0.0, 0.0)	2.0 (1.0, 3.0)
Received liposomal bupivacaine	0 (0.0%)	23 (88.5%)

¹Mean pain score for overall length of stay had 2 missing values.

Median (IQR) for continuous variables and frequency (%) for categorical variables. OME: Oral morphine equivalent; LOS: Length of stay.

Table 4 Safety endpoints by study group (n = 52)

	Pre-protocol group (n = 26)	Post-protocol group (n = 26)
Admission serum creatinine (mg/dL)	0.8 (0.7, 0.9)	0.9 (0.8, 1.0)
Discharge serum creatinine (mg/dL)	1.2 (1.0, 1.4)	1.3 (1.2, 1.5)
Provider concern for AKI during admission (%)
No	22 (84.6)	26 (100.0)
Yes	4 (15.4)	0 (0.0)
Provider concern for GI bleeding (or any other major form of bleeding) (%)
No	24 (92.3)	26 (100.0)
Yes	2 (7.7)	0 (0.0)

Median (IQR) for continuous variables and frequency (%) for categorical variables. AKI: Acute kidney injury; GI: Gastrointestinal.