Catheter-based Peripheral Regional Anesthesia After Orthopedic Surgery to the Foot or Ankle

Phase 4

Completed

• Conditions: Postoperative Pain
• Interventions: Drug: Ropivacaine 0.2%

• Registration Number: NCT03372304
• Lead Sponsor: Nordsjaellands Hospital

Brief Summary

BACKGROUND

Orthopedic surgery can be severely painful, and peripheral regional anesthesia is highly recommended as part of the perioperative pain treatment. Whether catheter-based techniques are better than single injection techniques are debatable. Furthermore, in catheter-based techniques, whether a low-dose automated, periodic infusion can produce similar analgesic effectiveness compared to a conventional, high dose, continuous infusion has never been explored.

AIM

Comparison of the analgesic effectiveness of a low-dose automated, periodic infusion, a conventional continuous infusion and patient-controlled boluses only in catheter-based nerve blocks for patients undergoing orthopedic surgery to the foot or ankle.

Detailed Description

BACKGROUND

Orthopedic surgery has been reported to be moderate to severely painful in approximately 50 % of patients.

Peripheral regional anesthesia (PRA) using single injection nerve blocks is highly recommended as part of a multimodal, perioperative, analgesic treatment. Patients who are expected to have postoperative, severe pain exceeding the duration of a single injection nerve block may benefit from a catheter-based nerve block (CBNB) using either a continuous infusion (CI) or intermittent infusions of local anesthetics (LA). Intermittent boluses can be either patient-controlled or prescribed in combination with a continuous infusion or as prespecified intermittent boluses. Whether a CBNB treatment is superior to a single injection nerve block after orthopedic surgery remains unanswered.

There are several challenges when using a CBNB treatment: The dosing or delivery method may be either insufficient and thus not pain relieving or too powerful resulting in dense motor block and limb anesthesia which may compromise safety and rehabilitation. The peripheral nerve block catheter may also displace and therefore deposit LA too far from the targeted nerve(s) to produce an effective nerve block.

Previous studies suggest that an automated periodic infusion (API) regimen is superior to CI. It seems that an API produces better pain control, a lower analgesic consumption over time and less motor inhibition. This is well-described for epidural catheters for laboring women, but evidence is also apparent in PRA. Adding a PCA bolus option to a catheter-based nerve block treatment may even out the difference in pain scores between API and CI. However, it seems that API groups require less LA via PCA function. Reducing LA consumption is of great importance for ambulatory patients whose LA reservoir is limited, but also for all other orthopedic patients whose motor block should be minimized in order to optimize rehabilitation.

OBJECTIVES

To investigate whether a low-dose API with patient-controlled bolus option can produce a similar analgesic effect compared to a conventional, high dose, CI with patient-controlled bolus option in catheter-based peripheral nerve blocks for patients undergoing orthopedic surgery to the foot or ankle. Analgesic effectiveness will be compared with a group only given the patient-controlled bolus option.

HYPOTHESIS

Low dose API with supplemental patient-controlled bolus option will provide pain-relieving therapy not inferior to a conventional CI with supplemental patient-controlled bolus option. The intervention group receiving patient-controlled boluses only will experience more pain breakthrough.

Study Timeline

• Study Start: 2017-11-29
• Study First Submitted: 2017-12-10
• Study First Submitted QC: 2017-12-12
• Study First Posted: 2017-12-13
• Primary Completion: 2019-02-01
• Study Completion: 2019-02-25
• Status Verified: 2019-09
• Last Update Submitted: 2019-09-14
• Last Update Posted: 2019-09-17

Recruitment & Eligibility

• Status: COMPLETED
• Sex: All
• Target Recruitment: 85

Inclusion Criteria

1. American Society of Anesthesiologists Classification I-III
2. Normal cognitive function in order to sign written, informed consent and to understand trial protocol
3. Agreement to the trial protocol, including the randomized manner

Exclusion Criteria

1. Allergy to LA
2. Infection in or near insertion site of the peripheral nerve catheter
3. Anatomical abnormalities preventing successful peripheral nerve catheter insertion
4. Habitual use of opioids
5. Pregnancy or breastfeeding (disproved by a negative pregnancy test before trial inclusion)

Study & Design

• Study Type: INTERVENTIONAL
• Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
PCA only	Ropivacaine 0.2%	Patient-initiated bolus of ropivacaine 0.2 %, 10 mL. Lock-out time: 4 hours.
API+PCA	Ropivacaine 0.2%	Infusion of ropivacaine 0.2 %, 10 mL, every 8th hour. Patient-initiated bolus of ropivacaine 0.2 %, 10 mL. Lock-out time: 4 hours.
CI+PCA	Ropivacaine 0.2%	Continuous infusion of ropivacaine 0.2 %, 6 mL/hour. Patient-initiated bolus of ropivacaine 0.2 %, 10 mL. Lock-out time: 4 hours.

Primary Outcome Measures

Name	Time	Method
Postoperative pain, 1-72 hours postoperatively	1-72 hours	Postoperative pain using the visual analogue pain scale (VAS, 0-100 milimetres). Measurements will be patient-reported.

Secondary Outcome Measures

Name	Time	Method
Opioid consumption, 1-72 hours postoperatively	1-72 hours	Tablets consumed during the period of investigation
Volume of patient-initiated boluses, 1-72 hours postoperatively	1-72 hours	Volume of ropivacaine 0.2 % (mL) used for patient-initiated boluses, 1-72 hours postoperatively

Trial Locations

Locations (1)

Department of Anesthesiology, Nordsjællands Hospital Hillerød; 🇩🇰 Hillerød, Denmark