A Randomized Study of the Effects of Perioperative i.v. Ketorolac-lidocaine on the Hemodynamic Response in the Patients With Valvular Heart Diseases During Cesarean Delivery
Trial Snapshot
- Phase
- Phase 2
- Status
- Suspended
- Sponsor
- Mansoura University
- Enrollment
- 90
- Locations
- 1
- Primary Endpoint
- hemodynamics
Study Overview
Brief Summary
Rheumatic heart valve diseases are prevalent among the young people in Egypt secondary to the socioeconomic conditions. The goal of anesthetic management of these patients is maintenance of sinus rhythm, systemic blood pressure, preload, coronary perfusion, and cardiac output. Many women still prefer general anesthesia rather than regional techniques at the author's country.
The pharmacological modifications of the sympathetic response to tracheal intubation and surgical stimulation using opioids have adverse effects on the neonatal outcome after cesarean delivery. The authors have demonstrated in their previous studies the safety of both perioperative infusion of both of ketorolac and lidocaine in the attenuation of the hemodynamic and hormonal responses of tracheal intubation and surgery during cesarean delivery with favorable neonatal outcome and without added risk of perioperative bleeding. Therefore, the authors reported successful anesthetic management of a parturient with infective endocarditis on top of rheumatic mitral valve disease with use of paracetamol-lidocaine-ketorolac-propofol anesthesia.
The investigators hypothesize that the perioperative use of ketorolac-lidocaine would reduce the maternal hemodynamic responses to intubation and surgery without any harmful effects on mother or baby during uncomplicated cesarean delivery in the parturients with valvular hear diseases.
The investigators are aiming to compare the effects of ketorolac-lidocaine and fentanyl on surgical stress responses, intraoperative fentanyl and vasoactive drugs consumption and neonatal outcome during cesarean delivery in the parturients with valvular hear diseases.
Detailed Description
All parturients will receive oral ranitidine 150 mg on the night and the morning of surgery and 30 mL of 0.3 mol/L sodium citrate, 15 min before induction.
All operations will be performed by the same obstetricians. Voluven 6% solution 7 mL/kg will be infused over 30 min. Left uterine displacement will be maintained before induction. All routine medications except angiotensin-converting enzyme inhibitors will be continued until the morning of the operation.
All patients will be monitored with pulse oximetry, non-invasive blood pressure and five leads electrocardiography (leads II and V5). A radial artery catheter and a central venous catheter will be placed under local anesthesia before induction. On-screen pressure tracing will be used to determine end-expiration, and the CVP will be averaged over three respiratory cycles to eliminate respiratory artifacts. All staff in the operating room will be unaware of the randomization code.
After pre-oxygenation for 5 min, a rapid sequence induction will be performed with propofol 1-2.5 mg/kg and suxamethonium 1.5 mg/kg. Cricoid pressure will be applied, laryngoscopy will be performed after the 1-min blood pressure recording, and tracheal intubation will be completed before the 2-min reading. Anesthesia will be maintained with end-tidal concentrations of 2-2.5% of sevoflurane, in combination with 50% nitrous oxide in oxygen and cisatarcurium 0.1-0.2 mg/kg. The patients' lungs will be ventilated to maintain an EtCO2 of 4-4.6 kPa.
After the umbilical cord was clamped, infusion of 5-10 U oxytocin, midazolam 0.05 mg/kg and fentanyl 1-2 µg/kg will be given and nitrous oxide will be increased to 70%. Sevoflurane will be discontinued at the start of skin closure and the nitrous oxide will be discontinued after the last skin suture will be applied. At the end of surgery, residual neuromuscular block will be antagonized with neostigmine 50 µg/kg and atropine 20 µg/kg, and trachea will be extubated.
Study Design
- Study Type
- Interventional
- Allocation
- Randomized
- Intervention Model
- Parallel
- Primary Purpose
- Treatment
- Masking
- Quadruple (Participant, Care Provider, Investigator, Outcomes Assessor)
Eligibility Criteria
- Ages
- 18 Years to 45 Years (Adult)
- Sex
- Female
- Accepts Healthy Volunteers
- No
Inclusion Criteria
- •90 ASA II & IV women
- •with documented valvular heart disease
- •uncomplicated
- •singleton pregnancies of at least 36 weeks' gestation
- •scheduled for elective cesarean delivery
- •under general anesthesia
Exclusion Criteria
- •history of un-controlled hypertension
- •ischemic heart disease
- •left-ventricular ejection fraction less than 45%
- •severe pulmonary hypertension
- •critical aortic stenosis
- •peripheral vascular disease
- •thyrotoxicosis
- •neurological diseases
- •hepatic diseases w
- •renal diseases
- •those requiring preoperative inotropic, vasopressor,
- •mechanical circulatory or ventilatory support
- •pregnancy-induced hypertension
- •evidence of intrauterine growth restriction
- •fetal compromise.
Arms & Interventions
group SF
either saline infusion and intravenous fentanyl boluses
Intervention: Placebo (Drug)
group KL
ketorolac-lidocaine infusion and intravenous saline boluses
Intervention: Ketorolac-Lidocaine (Drug)
Outcomes
Primary Outcomes
hemodynamics
Time Frame: Baseline, intraoperative, an expected average of 1 hour
changes in blood pressures and heart rate
Secondary Outcomes
- changes in fentanyl consumption(intraoperative, an expected average of 1 hour)
- uterine tone(intraoperative, an expected average of 1 hour)
- postoperative pain(up to 24 after surgery)
- perioperative bleeding(intraoperative, an expected average of 1 hour, up to 24 hours after surgery)
- perioperative side effects(up to 24 after surgery)
- neonatal outcome(up to 24 hours after delivery)
Investigators
Mohamed R El Tahan
Principal Investigator
Mansoura University