Thoracic Epidural Analgesia Safe and Effective for Patients Receiving Liver Transplantation

liver transplant, transplantation, surgery
Increasingly, patients receive liver transplants for other indications than end-stage liver disease and do not have coagulopathy, allowing insertion of an epidural catheter.

Thoracic epidural analgesia (TEA) had similar pain management for patients receiving liver transplants as non-TEA without risk for serious complications. These findings from a retrospective observational study were published in Transplantation Direct.

Patients (N=685) who received a first liver transplant between 2008 and 2017 at the Oslo University Hospital were included in this study. Patients received TEA primarily on the basis of their coagulation profile. Clinical outcomes and long-term opioid use were compared between patients receiving TEA (n=327) and non-TEA (n=358).

Patients receiving TEA and non-TEA had a mean age of 55.1 and 55.2 years and 61% and 59% were men, respectively. The patients receiving TEA were more likely to be diagnosed with malignant liver disease (P <.001), less likely to have nonmalignant chronic liver disease (P <.001) or acute liver failure (P <.001), and had a lower model of end-stage liver disease (P <.001) and lower American Society of Anesthesiologists (P <.001) scores compared with the non-TEA recipients.

Most patients (95%) received their TEA prior to their transplant and no serious adverse events were observed.

Using a pain intensity rating scale from 0 to 10, the TEA recipients reported lower pain scores (median, 1.4; interquartile range [IQR], 0.3-2.2) compared with the non-TEA recipients (median, 1.8; IQR, 0.6-2.7; P <.001) for the first 5 days after surgery. The patients who received TEA were administered fewer intraoperative opioids (median, 800 vs 900 mg; P =.004) and spent fewer hours in the intensive care unit (median, 19 vs 30 hours; P <.001), and fewer were readmitted to the intensive care unit (6% vs 15%; P <.001).

Among the TEA recipients, 11.3% experienced weakness in their lower extremity that was resolved after catheter removal. Some patients (10.4%) required a second epidural due to insufficient pain relief or inadvertent catheter removal. The median time to catheter removal was 7 days (range, 0-50 days).

At 12 months after liver transplant, no difference (P =.72) was observed for the proportion of patients still using opioids on the basis of TEA (9%) or non-TEA (8%) received during their surgery.

This study was limited because it did not include the exact amount of opioid dosage equivalents and it remains unclear whether these values differed between groups.

These data indicated patients receiving a liver transplant had sufficient pain relief from both TEA and non-TEA modalities. TEA did not pose a risk for serious adverse effects such as epidural hematoma or abscess. Additional studies are needed to determine whether patients without coagulopathies have a similar response to TEA.


Hausken J, Haugaa H, Hagness M, Line PD, Melum E, Tønnessen TI. Thoracic epidural analgesia for postoperative pain management in liver transplantation: a 10-year study on 685 liver transplant recipients. Transplant Direct. 2021;7(2):e648. doi:10.1097/TXD.0000000000001101