Neuromuscular Blockade on Shoulder Pain of Elderly
- Conditions
- Malignant Neoplasms of Digestive OrgansMalignant Neoplasms of Female Genital OrgansMalignant Neoplasms of Male Genital OrgansMalignant Neoplasms of Urinary Tract
- Interventions
- Drug: Deep Neuromuscular Blockade (NMB)Drug: Moderate Neuromuscular Blockade (NMB)Behavioral: Pain Assessment
- Registration Number
- NCT03210376
- Lead Sponsor
- M.D. Anderson Cancer Center
- Brief Summary
Insufflation pressure (IP) is the creation of a pressure barrier of air/gas within the abdomen to allow the surgeon more space to work during abdominal surgery. Shoulder pain is a common complaint from patients who have had abdominal surgery and the pain is thought to be related to the use of IP.
In addition to anesthesia (which keeps you asleep during surgery), the current standard practice is to block the nerve-muscle junction with a type of drug called neuromuscular blockade (NMB) which paralyzes the abdominal muscles. This means that a lower level of insufflation pressure is needed by the surgeon.
To reverse the effects of NMB after surgery, a drug called neostigmine is given.
The goal of this clinical research study is to compare the use of standard-of-care moderate NMB and neostigmine to the use of deep NMB and a drug called Sugammadex when given to elderly patients (patients who are 65 years of age or older) who are scheduled to have robotic abdominal surgery. "Deep" and "moderate" in this study refers to the dose or strength of the NMB given.
This is an investigational study. Sugammadex and neostigmine are FDA approved and commercially available for the reversal of NMB. It is considered investigational to compare Sugammadex and neostigmine to learn if the use of one or the other in elderly patients can reduce the level of shoulder pain after surgery.
Up to 100 participants will be enrolled in this study. All will take part at MD Anderson.
- Detailed Description
Study Groups:
If you are found to be eligible to take part in this study, you will be randomly assigned (as in the flip of a coin) to 1 of 2 study groups before your surgery. This is done because no one knows if one group is better, the same, or worse than the other.
* In Group 1, you will receive deep NMB and Sugammadex.
* In Group 2, you will receive moderate NMB and neostigmine.
Neither you nor the surgeon or surgical staff will know to which group you have been assigned. The surgeon will not know which group you are in because researchers want to learn how much, if at all, the surgeon needs to adjust the insufflation pressure during surgery. However, if needed for your safety, the surgeon will be able to find out which group you are in.
For your safety, the anesthesiologist will know to which group you have been assigned.
Surgery and Study Drug Administration:
After you have been assigned to a study group, you will have your surgery as scheduled. You will sign a separate consent form for surgery which describes the procedure and its risks in more detail. You will also sign a separate consent form to receive anesthesia.
Before your surgery, blood (about 2 teaspoons) will be drawn for biomarker testing. Biomarkers are found in the blood/tissue and may be related to the status of the disease and/or your reaction to the study drug(s).
During the surgery, the insufflation pressure that is being used, including any changes that are made to the pressure, will be recorded. After the surgery has been completed, you will receive either Sugammadex or neostigmine by vein until the effects of the NMB have been reversed.
You will recover after surgery in the post-anesthesia care unit (PACU). At about 15, 45, and 90 minutes after your surgery, a PACU nurse will ask you about any shoulder pain you are feeling and if so, how intense the pain is. Information about how long you stay in the hospital after surgery and if you have any side effects after surgery (such as nausea/vomiting or shoulder pain) will also be collected from your medical record.
Follow-Up:
After 30 days after you leave the hospital, you will be called by a member of the study staff to ask how you are doing and if you have had any additional hospitalizations since leaving the hospital. This phone call should last about 5-10 minutes.
Length of Study Participation:
Your participation in this study will be over after completing the 30-day follow up phone call.
Recruitment & Eligibility
- Status
- COMPLETED
- Sex
- All
- Target Recruitment
- 100
- Patients 65 years of age or older
- Patients having robotic prostatectomy
- Written informed consent
- Patient with known hypersensitivity to Rocuronium, Sugammadex or its components
- Patients with severe renal insufficiency, defined and confirmed by an estimated creatinine clearance equal or lower than 30 mL/min, per institutional laboratory.
- Patients with history of severe liver disease, defined as and confirmed by elevated ALT and AST greater than 1.5 times the Upper Limit of Normal along with Albumin less than 3 OR INR 1.5 or greater per institutional laboratory.
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- PARALLEL
- Arm && Interventions
Group Intervention Description Deep Neuromuscular Blockade (NMB) + Sugammadex Deep Neuromuscular Blockade (NMB) Deep Neuromuscular Blockade (NMB) given during surgery. Sugammadex intravenously as a single bolus injection after surgery. Pain assessment done at about 15, 45, and 90 minutes after surgery. Moderate Neuromuscular Blockade (NMB) + Neostigmine Pain Assessment Moderate Neuromuscular Blockade (NMB) given during surgery. Neostigmine intravenously slowly over a period of at least 1 minute after surgery. Pain assessment done at about 15, 45, and 90 minutes after surgery. Moderate Neuromuscular Blockade (NMB) + Neostigmine Moderate Neuromuscular Blockade (NMB) Moderate Neuromuscular Blockade (NMB) given during surgery. Neostigmine intravenously slowly over a period of at least 1 minute after surgery. Pain assessment done at about 15, 45, and 90 minutes after surgery. Deep Neuromuscular Blockade (NMB) + Sugammadex Pain Assessment Deep Neuromuscular Blockade (NMB) given during surgery. Sugammadex intravenously as a single bolus injection after surgery. Pain assessment done at about 15, 45, and 90 minutes after surgery. Deep Neuromuscular Blockade (NMB) + Sugammadex Sugammadex Deep Neuromuscular Blockade (NMB) given during surgery. Sugammadex intravenously as a single bolus injection after surgery. Pain assessment done at about 15, 45, and 90 minutes after surgery. Moderate Neuromuscular Blockade (NMB) + Neostigmine Neostigmine Moderate Neuromuscular Blockade (NMB) given during surgery. Neostigmine intravenously slowly over a period of at least 1 minute after surgery. Pain assessment done at about 15, 45, and 90 minutes after surgery.
- Primary Outcome Measures
Name Time Method Percentage of Patients Who Reported Shoulder Pain 30 days Visual Analog Scale (VAS) pain score (0-10) for shoulder pain recorded, where 0 means no pain and 10 means the worst pain ever experienced . Percentage of participants who experienced should pain.
- Secondary Outcome Measures
Name Time Method Cumulative Intraoperative Insufflation Pressure Day 0 - IntraOperative-From beginning of pneumoperitoneum to desufflation (an average of 166 minutes) Intra-abdominal insufflation time and pressure directed by the surgeon and recorded continuously by the clinical coordinator until the time of desufflation.
Percentage of Muscle Response Using Train-of-Four (TOF) in Post-Anesthesia Care Unit (PACU) to Measure Residual Muscle Relaxation Day 0 - Arrival time at PACU, an average of 3 minutes The patients will be started on a continuous Rocuronium intravenous infusion following intubation. Insert recommendations and Institutional Standards will be used for Rocuronium. For the DNMB group, the rate will be adjusted and boluses given to maintain 1-2 post tetanic responses during the pneumoperitoneum. NMB will be reversed with Sugammadex 4 mg/Kg, intravenously as a single bolus injection, at the end of the surgery. Percentage of measured contraction strength of the fourth stimulus compared to the first stimulus.
Readiness to Discharge From the Post-Anesthesia Care Unit (PACU) Assessed at 15, 45, 90 minutes during PACU stay. Determined by the Dansk Selskab for Anæstesiologi og Intensiv Medicin(DASAIM)discharge criteria.Pts considered ready to discharge when the sum of all categories is\<4 and no single category has a score of \>1.Sedation.0:Patient is fully awake.1: Patient is asleep,aroused by verbal stimulation.2:Patient is asleep, aroused by physical stimulation.3:Patient is asleep,cannot be aroused.Respiratory Rate.0:Respiratory rate\>10. 1: Snoring,10\< RR\<30. 2:R\<10 or RR\>30/min.3:Periods of apnea or obstructive patterns.Oxygen Saturation.0:SpO2 ≥ 94%.1:90%≤SpO2\<94%. 2:85%≤ SpO2 \< 90%.3:SpO2 \< 85%. Systolic Blood Pressure. 0:SBP ≥ 100mmHg.1:90mmHg≤SBP\< 100mmHg.2:80mmHg≤SBP\< 90mmHg or SBP\>220mmHg.3:SBP\<80mmHg.Heart Rate.0:50\<HR≤100.1:100\<HR≤120.2:40\<HR≤ 50 or 120\<HR≤130.3:HR\<40 or HR\>130.Pain at rest.0:No pain 1:Light pain.2:Moderate pain.3:Severe pain.Nausea.0:No nausea or vomiting.1:Light nausea or vomiting without previous nausea. 2:Moderate nausea and/or vomiting.3:Severe nausea and/or vomiting.
Percentage of Participants With Nausea and/or Vomiting in PACU Day 0 - PACU stay, an average of 120 minutes Degree of Post-Operative Nausea determined per Visual Analog Scale per nurse in Post-Anesthesia Care Unit (PACU).
Surgical Exposure Grading Day 0 - IntraOperative, from incision time to closing time(average 190 minutes) Length of Hospital Stay length of hospital stay(average of 3 days)
Trial Locations
- Locations (1)
University of Texas MD Anderson Cancer Center
🇺🇸Houston, Texas, United States