Pain, Postoperative
Conditions
Keywords
cardiac, surgery, pain
Brief summary
The Inova Heart and Vascular Institute (IHVI) perform over 300 coronary artery bypass graft (CABG) surgeries per year. While opioid medications are the institutional standard of care for post-operative pain therapy little is known about the variation in pain scores, incidence of post- operative complications, and cost of hospitalization when an alternative multimodal pain regimen consisting of oral Gabapentin and intravenous Acetaminophen (IV APAP) is utilized. The objective is to determine whether there is a substantial difference in pain scores, incidence of post-operative complications, and costs associated with hospitalization when a non-opioid multimodal pain regimen is utilized A single- center, open label, prospective, randomized, controlled clinical trial comprised of 20 total patients who have undergone isolated CABG at the IHVI will be conducted. Separate cohorts will include patients receiving opioid medications post-operatively (Group 1) and patients receiving the non-opioid regimen of oral Gabapentin and IV APAP (Group 2) to be followed for 72 hours post CABG surgery. Main outcome measures include pain scores in both study groups, requests for breakthrough pain medication in both groups, gastrointestinal and respiratory complications of ileus and reduction in tidal volumes or forced vital capacity (FVC) at baseline and at 72 hours,increase in serum AST/ALT, and comparison of cost of hospitalization between groups. The objective of this pilot study is to provide evidence that multimodal pain therapy utilizing IV APAP and PO Gabapentin will provide more effective pain relief than standard of care opioids as evidenced by pain scores \<2. And the reduced consumption of opioids will lead to a reduction in ileus, no increase in AST/ALT, post-operative tidal volumes as assessed by incentive spirometry comparable to pre- surgical values, while also showing a positive effect on the cost of hospitalization.
Detailed description
The Cardiovascular Intensive Care Unit (CVICU) of the Inova Heart and Vascular Institute (IHVI) will be the setting of this clinical trial involving two groups of subjects and comparing the opiate based standard of care regimen currently adopted (Group 1) at the IHVI with a treatment group (Group 2). Group 2 will receive a scheduled multimodal pain regimen consisting of PO (pro ora \[oral\]) Gabapentin paired with intravenous Acetaminophen. Opioids will be available for breakthrough pain in the treatment group for pain scores greater than 4. The outcomes of total opioid consumption and minimum/ maximum pain scores will be assessed at the 24 hours, 48 hours, 72 hours, and PRN (pro re nata \[as the situation demands\]) timepoints. Assessment will include amount of opioids consumed in both groups as well as number of requests for breakthrough pain medication in Group 2. Minimum and maximum pain scores in all study groups will be assessed via Numeric Rating Scale (0-10) as per Inova Health System (IHS) policy; 'Pain Management for the Adult Population', at 24 hours, 48 hours, 72 hours, and PRN with opioid requests in all groups and opioid administration follow up within one hour as per IHS inpatient medication administration policy. Follow up medication administration scores will not be recorded as part of study results. Secondary assessments will include the incidence of ileus both during hospitalization, increase in aspartate aminotransferase (AST)/ alanine aminotransferase (ALT), post-operative tidal volumes as assessed by incentive spirometry as compared to pre- surgical values, time from Cardiovascular Intensive Care Unit (CVICU) arrival to extubation in both groups, and the effects of an opioid based regimen versus an opioid sparing regimen on cost of medication and hospitalization. The investigators hypothesize that a scheduled opioid- sparing pain regimen consisting of intravenous Acetaminophen IV APAP and PO Gabapentin for 48 hours post- operatively will reduce opioid consumption while maintaining adequate pain relief as evidenced by pain scores less than two (2), and a reduction in opioid consumption, and that reduced opioid consumption will lead to a reduction in the incidence of ileus, an opioid related side effect, no increase in AST/ALT, post-operative tidal volumes as assessed by incentive spirometry comparable to pre- surgical values, and demonstrate a positive effect on the cost of medication and hospitalization.
Interventions
DRUGOral Gabapentin and Intravenous Acetaminophen (IV APAP)
Scheduled multimodal pain regimen consisting of oral Gabapentin paired with intravenous Acetaminophen following cardiopulmonary bypass surgery.
DRUGOpiate based pain regimen.
Standard of care opiate based pain regimen.
Sponsors
Inova Health Care Services
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
18 Years to 85 Years
Healthy volunteers
No
Inclusion criteria
1. Patient between 18 and 85 years old. 2. Elective or urgent surgery requiring sternotomy approach 3. Subject is able to read and has signed and dated the informed consent document including authorization permitting release of personal health information (PHI) approved by the Inova Institutional Review Board (IRB).
Exclusion criteria
1. Patients lacking enteral access on post-operative day 0 2. Inability to communicate 3. Active chronic pain with opioid therapy 4. Active chronic use of gabapentin or pregabalin 5. Active substance abuse 6. Current self- report of alcoholism 7. End stage renal disease 8. Active renal dialysis therapy
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| The Number of Patients With Requests for Breakthrough Opioid Pain Medication in Opioid Standard of Care Regimen Compared to Non-opioid Multimodal Pain Relief Regimen (Experimental Group). | 24 hours, 48 hours, 72 hours after post-surgical treatment | Number of patients with requests for breakthrough pain medication. Requests for breakthrough pain medication is defined as having pain scores \>4 using the Numeric Rating Scale: a dimensional measurement of pain intensity; 0-10 scale for scoring pain (0= no pain, 10worst pain imaginable) |
| Average Pain Score at 24, 48 and 72 Hours Post-operatively | at 24, 48, and 72 hours after the start of post-operative treatment | Participants were assessed by rating their pain according to the Numeric Rating Scale: a dimensional measurement of pain intensity; 0-10 scale for scoring pain (0= no pain, 10=worst pain imaginable) The minimum and maximum pain scores per participant were aggregated at timepoints of 24 hours, 48 hours, and 72 hours after the start of post-operative treatment |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Number of Participants With Ileus During Hospitalization | Surgery completion through study completion up to one week. | The number of participants with occurrences of ileus during hospitalization. |
Countries
United States
Participant flow
Participants by arm
| Arm | Count |
|---|---|
| Opioid Based Standard of Care Regimen. Inova Heart and Vascular Institute (IHVI) opioid based standard of care regimen given for post operative cardiac surgery pain.
Opiate based pain regimen.: Standard of care opiate based pain regimen. | 8 |
| Opioid Sparing Pain Regimen. Multimodal pain regimen consisting of PO Gabapentin paired with intravenous Acetaminophen given for post operative cardiac surgery pain.
Oral Gabapentin and Intravenous Acetaminophen (IV APAP): Scheduled multimodal pain regimen consisting of oral Gabapentin paired with intravenous Acetaminophen following cardiopulmonary bypass surgery. | 11 |
| Total | 19 |
Baseline characteristics
| Characteristic | Opioid Based Standard of Care Regimen. | Opioid Sparing Pain Regimen. | Total |
|---|---|---|---|
| Age, Continuous | 68.1 years | 65.5 years | 66.8 years |
| Race/Ethnicity, Customized Race African American | 0 Participants | 0 Participants | 0 Participants |
| Race/Ethnicity, Customized Race Asian | 0 Participants | 1 Participants | 1 Participants |
| Race/Ethnicity, Customized Race Caucasian | 8 Participants | 9 Participants | 17 Participants |
| Race/Ethnicity, Customized Race Other | 0 Participants | 1 Participants | 1 Participants |
| Region of Enrollment United States | 8 participants | 11 participants | 19 participants |
| Sex: Female, Male Female | 0 Participants | 1 Participants | 1 Participants |
| Sex: Female, Male Male | 8 Participants | 10 Participants | 18 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk |
|---|---|---|
| deaths Total, all-cause mortality | 0 / 8 | 0 / 11 |
| other Total, other adverse events | 0 / 8 | 0 / 11 |
| serious Total, serious adverse events | 0 / 8 | 0 / 11 |
Outcome results
Primary
Average Pain Score at 24, 48 and 72 Hours Post-operatively
Participants were assessed by rating their pain according to the Numeric Rating Scale: a dimensional measurement of pain intensity; 0-10 scale for scoring pain (0= no pain, 10=worst pain imaginable) The minimum and maximum pain scores per participant were aggregated at timepoints of 24 hours, 48 hours, and 72 hours after the start of post-operative treatment
Time frame: at 24, 48, and 72 hours after the start of post-operative treatment
| Arm | Measure | Group | Value (MEAN) |
|---|---|---|---|
| Opioid Based Standard of Care Regimen. | Average Pain Score at 24, 48 and 72 Hours Post-operatively | Maximum Pain Score at 72 hours | 2.5 score on a scale |
| Opioid Based Standard of Care Regimen. | Average Pain Score at 24, 48 and 72 Hours Post-operatively | Minimum Pain Score at 48 hours | 1 score on a scale |
| Opioid Based Standard of Care Regimen. | Average Pain Score at 24, 48 and 72 Hours Post-operatively | Minimum Pain Score at 24 hours | 1 score on a scale |
| Opioid Based Standard of Care Regimen. | Average Pain Score at 24, 48 and 72 Hours Post-operatively | Maximum Pain Score at 48 hours | 6.75 score on a scale |
| Opioid Based Standard of Care Regimen. | Average Pain Score at 24, 48 and 72 Hours Post-operatively | Minimum Pain Score at 72 hours | 0 score on a scale |
| Opioid Based Standard of Care Regimen. | Average Pain Score at 24, 48 and 72 Hours Post-operatively | Maximum Pain Score at 24 hours | 7 score on a scale |
| Opioid Sparing Pain Regimen. | Average Pain Score at 24, 48 and 72 Hours Post-operatively | Maximum Pain Score at 72 hours | 2.36 score on a scale |
| Opioid Sparing Pain Regimen. | Average Pain Score at 24, 48 and 72 Hours Post-operatively | Minimum Pain Score at 24 hours | 0.09 score on a scale |
| Opioid Sparing Pain Regimen. | Average Pain Score at 24, 48 and 72 Hours Post-operatively | Maximum Pain Score at 24 hours | 3.18 score on a scale |
| Opioid Sparing Pain Regimen. | Average Pain Score at 24, 48 and 72 Hours Post-operatively | Minimum Pain Score at 48 hours | 0.18 score on a scale |
| Opioid Sparing Pain Regimen. | Average Pain Score at 24, 48 and 72 Hours Post-operatively | Minimum Pain Score at 72 hours | 0 score on a scale |
| Opioid Sparing Pain Regimen. | Average Pain Score at 24, 48 and 72 Hours Post-operatively | Maximum Pain Score at 48 hours | 3.64 score on a scale |
Primary
The Number of Patients With Requests for Breakthrough Opioid Pain Medication in Opioid Standard of Care Regimen Compared to Non-opioid Multimodal Pain Relief Regimen (Experimental Group).
Number of patients with requests for breakthrough pain medication. Requests for breakthrough pain medication is defined as having pain scores \>4 using the Numeric Rating Scale: a dimensional measurement of pain intensity; 0-10 scale for scoring pain (0= no pain, 10worst pain imaginable)
Time frame: 24 hours, 48 hours, 72 hours after post-surgical treatment
| Arm | Measure | Group | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|---|
| Opioid Based Standard of Care Regimen. | The Number of Patients With Requests for Breakthrough Opioid Pain Medication in Opioid Standard of Care Regimen Compared to Non-opioid Multimodal Pain Relief Regimen (Experimental Group). | 72 hours | 1 Participants |
| Opioid Based Standard of Care Regimen. | The Number of Patients With Requests for Breakthrough Opioid Pain Medication in Opioid Standard of Care Regimen Compared to Non-opioid Multimodal Pain Relief Regimen (Experimental Group). | 24 hours | 7 Participants |
| Opioid Based Standard of Care Regimen. | The Number of Patients With Requests for Breakthrough Opioid Pain Medication in Opioid Standard of Care Regimen Compared to Non-opioid Multimodal Pain Relief Regimen (Experimental Group). | 48 hours | 7 Participants |
| Opioid Sparing Pain Regimen. | The Number of Patients With Requests for Breakthrough Opioid Pain Medication in Opioid Standard of Care Regimen Compared to Non-opioid Multimodal Pain Relief Regimen (Experimental Group). | 48 hours | 1 Participants |
| Opioid Sparing Pain Regimen. | The Number of Patients With Requests for Breakthrough Opioid Pain Medication in Opioid Standard of Care Regimen Compared to Non-opioid Multimodal Pain Relief Regimen (Experimental Group). | 24 hours | 2 Participants |
| Opioid Sparing Pain Regimen. | The Number of Patients With Requests for Breakthrough Opioid Pain Medication in Opioid Standard of Care Regimen Compared to Non-opioid Multimodal Pain Relief Regimen (Experimental Group). | 72 hours | 1 Participants |
Secondary
Number of Participants With Ileus During Hospitalization
The number of participants with occurrences of ileus during hospitalization.
Time frame: Surgery completion through study completion up to one week.
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Opioid Based Standard of Care Regimen. | Number of Participants With Ileus During Hospitalization | 0 Participants |
| Opioid Sparing Pain Regimen. | Number of Participants With Ileus During Hospitalization | 0 Participants |