Intra-abdominal Infusions of Ropivacaine Following Laparoscopic Ventral Hernia Repair: a Randomised Double-blind Controlled Trial.
试验速览
- 阶段
- 不适用
- 状态
- 撤回
- 发起方
- 试验地点
- 1
- 主要终点
- Morphine equivalent use
研究概览
简要总结
Aim
The general aim of this study is to improve post-operative pain and reduce morphine consumption following laparoscopic ventral hernia repair (LVHR). We specifically aim to conduct a randomized, double blinded, controlled trial to investigate the effect of intra-peritoneal local anaesthesia infusions on post-operative morphine consumption and.
Methods:
Patients will be randomised by computer generated random numbers (random permutation) and opaque envelope methods. At closure, one small 2mm catheter belonging to the AutoFuser pain pump system will be placed in the peritoneal cavity between the onlay mesh and parietal peritoneum. In the treatment arm patients will receive 275mL of 0.2% ropivacaine at 4mL/h. In the placebo arm, 275mL of 0.9% normal saline will be used in a similar fashion. The infusions will run for 68 hours total. All members involved in patient care (with the exception of one independant research fellow) will be blinded to the above. After 68 hours the pump will be stopped and the catheter will be removed. Assessment of post-operative pain will be performed by visual analogue scale, and total opiate consumption will be collected and converted into morphine equivalents.
Health significance:
Local anaesthesia has become an important addition to multimodal regimens of analgesia following surgery. Recent studies have shown that local anaesthetic (LA) wound infiltration has improved post-operative pain when compared with standard opioid regimens for pain relief. Only one previous study looked at bupivacaine infusions into the hernia sac for three days following LVHR. This study found no improvement in post-operative pain or morphine consumption. We aim to demonstrate improved pain and reduced morphine consumption using an alternative catheter insertion technique and ropivacaine as the desired LA agent.
详细描述
Scientific background:
A ventral hernia (VH) is a fascial defect located in the anterior abdominal wall. Primary VH includes epigastric, umbilical and spigelian hernias. A secondary defect or incisional hernia develops at a previous surgical incision site (1). VHs are a common condition and risk factors include obesity, previous abdominal surgery and elevated intra-abdominal pressure (2). With New Zealand's rising obesity epidemic the incidence of VH is projected to increase (3-4). Optimising the peri-operative care of patients undergoing VH repair is critical to cost-effective healthcare of this increasingly significant issue.
Surgical repair aims to relieve symptoms and prevent complications (5-6). Open mesh repair has been the accepted gold standard since proving superior to open suture repair (7). Laparoscopic ventral hernia repair (LVHR) has grown in popularity since its introduction in 1993 (8). Studies have shown advantages over open repair such as fewer infectious complications and shorter hospital stay (9-12). Importantly, LVHR is favourable in obese patients (BMI>30) due to lower complication rates and overall cost of care (13-16). Laparoscopic surgery has been considered less painful in comparison to open surgery, yet trials report no difference in acute or chronic pain (17-19). Severe pain following LVHR is a significant clinical problem impacting on wellbeing, quality of life and patient satisfaction (20). One hypothesis to explain this pain is the use of tacks and sutures for mesh fixation (21-23).
Local anaesthesia has become a key adjunct to multimodal post-operative regimens of analgesia. This is due to fewer side effects such as nausea and vomiting, gut dysmotility and respiratory depression (24). Local anaesthetic (LA) agents are easily applied directly to the injury site blocking afferent nociceptive nerves and reducing the local inflammatory response (25). There are significant benefits to intraperitoneal application of LA agents following abdominal surgery (26-27). Hence, operative insult to the peritoneum following LVHR may be controlled with LA directed to the site of mesh fixation in the intraperitoneal cavity (28).
Objective:
研究设计
- 研究类型
- Interventional
- 分配方式
- Randomized
- 干预模型
- Parallel
- 主要目的
- Health Services Research
- 盲法
- Quadruple (Participant, Care Provider, Investigator, Outcomes Assessor)
入排标准
- 年龄范围
- 18 Years 至 —（Adult, Older Adult）
- 性别
- All
- 接受健康志愿者
- 否
入选标准
- •All consecutive consenting adult patients (≥16 years) undergoing elective LVHR (umbilical / incisional / spigelian) will be screened for inclusion
排除标准
- •acute presentation, open repair of ventral hernia, hepatic dysfunction ALT/AST ≥ 2 x ULN, previous adverse reaction/allergy to ropivacaine, opiate use greater than 6 months, patients with a diagnosis of Chronic Pain Syndrome (CPS), patients under 16 years of age, patient refusal and those without the ability to consent
研究组 & 干预措施
Ropivacaine infusion
Following the insertion of the 2mm fenestrated catheter, the wound catheter will be connected to the 270mL AutoFuser Pain Pump. The intraperitoneal infusion with ropivacaine (0.2%) at 4 mL/hour will start immediately and continue for 68 hours post-operatively uninterrupted.
干预措施: AutoFuser Pain Pump (Device)
Ropivacaine infusion
Following the insertion of the 2mm fenestrated catheter, the wound catheter will be connected to the 270mL AutoFuser Pain Pump. The intraperitoneal infusion with ropivacaine (0.2%) at 4 mL/hour will start immediately and continue for 68 hours post-operatively uninterrupted.
干预措施: Ropivacaine (Drug)
Placebo infusion
In the same manner as described for the ropivacaine infusion arm, 0.9% Normal Saline will be administered over 68 hours.
干预措施: AutoFuser Pain Pump (Device)
Placebo infusion
In the same manner as described for the ropivacaine infusion arm, 0.9% Normal Saline will be administered over 68 hours.
干预措施: Normal Saline (0.9%) (Other)
结局指标
主要结局
Morphine equivalent use
时间窗: Total opiate consumption in the first 24 hours
Total opiate analgesia (all routes) used from immediately post-operative (0h) during the post-operative recovery period up to 24 hours will be recorded and converted into morphine equivalents.
次要结局
- Post-operative pain scores(Until day 7 post-operatively)
研究者
Andrew G Hill, MBChB, MD (Thesis), EdD, FACS, FRACS
Professor of Surgery
University of Auckland, New Zealand