Analgesia, Analgesics, Analgesics Non-narcotic, Central Nervous System Depressants, Dexmedetomidine, Ketamine, Lidocaine, Pain, Acute, Pain, Chronic, Pain, Neuropathic, Pain, Nociceptive, Pain, Postoperative
Conditions
Brief summary
The aim of this study will be to investigate the effect of an opioid-free anesthesia regimen with a mixture of dexmedetomidine-lidocaine-ketamine in the same syringe versus fentanyl analgesia in elective laparoscopic gynecological surgery
Detailed description
Inadequately treated postoperative pain after gynecological surgery may untowardly affect early recovery and also lead to the development of chronic pain. Laparoscopic surgery is associated with diminished postoperative pain but this does not mean that patients subjected to laparoscopic operations are not in need for analgesia intra- and postoperatively. Opioid-based analgesia is associated with side-effects, such as respiratory depression, postoperative nausea and vomiting and occasional induction of tolerance and hyperalgesia. Therefore, in recent years research has focused on the quest for non-opioid-based regimens for perioperative analgesia in the context of multimodal analgesic techniques. These techniques have been shown to possess significant advantages, such as allowing earlier mobilization after surgery, early resumption of enteral feeding and reduced hospital length of stay. In this context, the intraoperative intravenous injection of lidocaine has been reported to improve postoperative pain control, reduce opioid consumption and improve the quality of postoperative functional recovery after general anesthesia. Intraoperative infusions of ketamine (an N-methyl-D-aspartate receptor inhibitor) have also been correlated with reduced pain scores and a decrease in analgesic requirements postoperatively. Lastly, dexmedetomidine is a highly selective alfa-2 adreno-ceptor agonist that provides sedation, analgesia, and sympatholysis. Its perioperative intravenous administration has been associated with a reduction in postoperative pain intensity, analgesic consumption and nausea. There is insufficient data in literature investigating the effect of combinations of these agents intraoperatively. It would be of interest to demonstrate whether the administration of combinations can be used towards the achievement of a completely opioid-free anesthetic regimen. Additionally, it can be hypothesized that the combination of non-opioid drugs with different targets can lead to enhanced postoperative recovery, an improved opioid-sparing effect and a decrease in the development of chronic pain as compared to the administration of opioids. Therefore, the aim of this study will be to investigate the effect of a combination of intravenous infusions of lidocaine-ketamine-dexmedetomidine versus fentanyl on recovery profile, quality of recovery and postoperative pain after elective laparoscopic gynecological surgery.
Interventions
In the KLD group, patients will be administered 0,25 mcg/kg Dexmedetomidine in 100 mL of normal saline within 10 minutes. Followingly, they will receive 1mL/10 kg of the solution containing ketamine, lidocaine and dexmedetomidine at predefined concentrations. As maintenance, they will be receiving 1mL/10kg/h of the aforementioned solution.
DRUGfentanyl
In the fentanyl group, patients will be administered 2 mcg/kg fentanyl in 100 mL of normal saline within 10 minutes. Followingly, they will receive 1mL/10 kg of normal saline solution 0.9%. As maintenance, they will be receiving 1mL/10kg/h of normal saline solution 0.9%.
Sponsors
Aretaieion University Hospital
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
PREVENTION
Masking
QUADRUPLE (Subject, Caregiver, Investigator, Outcomes Assessor)
Eligibility
Sex/Gender
FEMALE
Age
25 Years to 75 Years
Healthy volunteers
No
Inclusion criteria
* adult female patients * American Society of Anesthesiologists (ASA) classification I-II * elective laparoscopic gynecological surgery
Exclusion criteria
* body mass index (BMI) \>35 kg/m2 * contraindications to local anesthetic administration or non-steroidal agents administration * systematic use of analgesic agents preoperatively * chronic pain syndromes preoperatively * neurological or psychiatric disease on treatment * pregnancy * severe hepatic or renal disease * history of cardiovascular diseases/ arrhythmias/ conduction abnormalities * bradycardia(\<55 beats/minute) * drug or alcohol abuse * language or communication barriers lack of informed consent
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| pain score 6 hours postoperatively | 6 hours postoperatively | pain score by the use of Numeric Rating Scale (NRS) 6 hours postoperatively, ranging from 0 to 10, where 0 means no pain and 10 means worst pain imaginable |
| pain score 24 hours postoperatively | 24 hours postoperatively | pain score by the use of Numeric Rating Scale (NRS) 24 hours postoperatively, ranging from 0 to 10, where 0 means no pain and 10 means worst pain imaginable |
| change from baseline in Quality of Recovery (QoR)-15 score after surgery | 24 hours postoperatively | The QoR-15 is a quality of recovery scale that consists of 15 questions (items),including questions regarding pain (2 items), physical comfort (5 items), self-care ability (2 items), psychological support (2 items) and emotional state (4 items). Every item is scored on a scale of 10, with the lowest total score of 0 and the highest score of 150. The higher the score, the better the recovery quality of the patient |
| pain score on arrival to Post-Anesthesia Care Unit (PACU) | immediately postoperatively | pain score by the use of Numeric Rating Scale (NRS) on arrival to PACU, ranging from 0 to 10, where 0 means no pain and 10 means worst pain imaginable |
| pain score at discharge from Post-Anesthesia Care Unit (PACU) | at discharge from Post Anesthesia Care Unit (PACU), approximately 1 hour postoperatively | pain score by the use of Numeric Rating Scale (NRS) at discharge from PACU, ranging from 0 to 10, where 0 means no pain and 10 means worst pain imaginable |
| pain score 3 hours postoperatively | 3 hours postoperatively | pain score by the use of Numeric Rating Scale (NRS) 3 hours postoperatively, ranging from 0 to 10, where 0 means no pain and 10 means worst pain imaginable |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| morphine consumption in Post-Anesthesia Care Unit (PACU) | immediately postoperatively | mg of morphine requested during patient PACU stay |
| tramadol consumption in the first 48 hours | 48 hours postoperatively | patients will be followed for cumulative tramadol consumption for 48 hours postoperatively |
| sleep quality | 24 hours postoperatively | subjective evaluation of sleep quality by patients, based on a sleep questionnaire (evaluation of sleep duration, number of nocturnal awakenings and marking of sleep quality) |
| first mobilization after surgery | 24 hours postoperatively | patients will be questioned regarding the time at which they mobilized after surgery |
| gastrointestinal recovery after surgery | 24 hours postoperatively | patients will be questioned regarding the time they first felt enteral sounds and the time they had their first flatus after surgery |
| satisfaction from postoperative analgesia | 24 hours postoperatively | satisfaction from postoperative analgesia on a six-point Likert scale with 1 marked as minimal satisfaction and 6 as maximal satisfaction |
| first solid intake | 24 hours postoperatively | patients will be questioned regarding the time they had their first solid intake |
| hospitalization time | 96 hours postoperatively | duration of hospital stay after surgery in hours |
| fentanyl requirement during surgery | intraoperatively | dose of required fentanyl intraoperatively to maintain systolic arterial blood pressure and heart rate within the 20% of baseline value |
| side effects intraoperatively | intraoperatively | patients will be monitored for side-effects of the administered agents intraoperatively |
| side effects postoperatively | 48 hours postoperatively | patients will be monitored for side-effects of the administered agents postoperatively |
| incidence of chronic pain 1 month after surgery | 1 month after surgery | occurrence of chronic pain at the site of the operation 1 month after surgery, with the use of the Numeric Rating Scale (NRS), at rest and during movement |
| incidence of chronic pain 3 months after surgery | 3 months after surgery | occurrence of chronic pain at the site of the operation 3 months after surgery, with the use of the Numeric Rating Scale (NRS), at rest and during movement |
| first fluid intake | 24 hours postoperatively | patients will be questioned regarding the time they had their first fluid intake |
| Post Anesthesia Care Unit (PACU) duration of stay | immediately postoperatively | duration of patient stay at PACU |
| sedation on arrival to Post-Anesthesia Care Unit | immediately postoperatively | sedation will be assessed with a 5-point sedation scale, where: 1, patient perfectly conscious; 2, patient feels a little drowsy; 3, patient seems to be sleeping but immediately reacts to verbal stimulation; 4, patient seems to be sleeping but slowly reacts to verbal stimulation and 5, patient seems to be sleeping and does not react to verbal stimulation but does react to a stimulus such as shaking or pain |
| sedation at discharge from Post-Anesthesia Care (PACU) Unit | at discharge from Post Anesthesia Care Unit (PACU), approximately 1 hour postoperatively | sedation will be assessed with a 5-point sedation scale, where: 1, patient perfectly conscious; 2, patient feels a little drowsy; 3, patient seems to be sleeping but immediately reacts to verbal stimulation; 4, patient seems to be sleeping but slowly reacts to verbal stimulation and 5, patient seems to be sleeping and does not react to verbal stimulation but does react to a stimulus such as shaking or pain |
| sevoflurane consumption during general anesthesia | change of sevoflurane vaporizer weight from before induction to end of anesthesia, an average period of 2-3 hours | the sevoflurane vaporizer will be weighed before anesthetic induction and at the end of anesthesia and consequently sevoflurane consumption during anesthesia will be determined |
| time to first request for analgesia | during stay in Post-Anesthesia Care Unit (PACU), approximately 1 hour postoperatively | the time for the first patient request for analgesia will be noted |
Other
| Measure | Time frame | Description |
|---|---|---|
| time to emergence | up to 2-3 hours after start of surgery | time from sevoflurane discontinuation to first patient response (eye opening) |
| time to extubation | up to 2-3 hours after start of surgery | time from sevoflurane discontinuation to tracheal extubation |
Countries
Greece
Contacts
Primary ContactKassiani Theodoraki, PhD, DESA
Backup ContactSofia Apostolidou, MD
Outcome results
None listed