Lidocaine and Outpatient Gynecologic Laparoscopy
| Status: | Recruiting |
|---|---|
| Conditions: | Chronic Pain |
| Therapuetic Areas: | Musculoskeletal |
| Healthy: | No |
| Age Range: | 18 - 64 |
| Updated: | 5/27/2013 |
| Start Date: | November 2010 |
| Contact: | Gildasio De Oliveira, MD |
| Email: | gildasiojunior@hotmail.com |
| Phone: | 312-926-8373 |
The Effect of Perioperative Systemic Lidocaine on Quality of Recovery After Outpatient Gynecologic Laparoscopy
Although ambulatory gynecological laparoscopy is considered to be a minimally invasive
surgical procedure, only 60% of patients undergoing this procedure are satisfied with
postoperative pain control (1). Postoperative pain can lead to physiological, immunological
and psychological derangements in patients(2,3).It also has been shown to be the most
common cause of hospital admission after outpatient surgery(4).
Opioids constitute the most commonly used pain management strategy after surgery, however
they have many undesirable side effects including nausea, vomiting and respiratory
depression. Different strategies have been developed to decrease the amount of opioid
required after surgery. Opioid sparing drugs as well as regional anesthesia have been shown
to be effective. (4, 5) Systemic administration of lidocaine has been shown to decrease
opioid consumption, improve recovery of bowel function and promote a better recovery after
inpatient procedures (6-8). Lidocaine has been shown to have analgesic (9), antihyperalgesic
and anti-inflammatory (10) properties. It also has an excellent safety profile when give by
a low-dose infusion (6-8).
The improvement of surgical technique and anesthesia care has made major adverse outcomes
infrequent, especially in the ambulatory setting. Assessing patient's
quality of recovery has become an important outcome in several studies (11, 12). The
patient's capacity to return to his normal activities is one of the most important sign of a
successful outpatient procedure and it has significant economic implications (13).
Quality of recovery -40(QoR-40) is a validated 40 item instrument to assess the quality of
post-operative recovery (14). Myles et al. (15) have concluded that the QoR-40 would be a
useful outcome measure to assess the impact on changes in health care delivery, but
anesthesia studies underutilize this instrument.
The research question: does the use of systemic perioperative lidocaine improve quality of
recovery after outpatient laparoscopy?
60 subjects will be randomly allocated into 2 groups, using a computer generated table of
random numbers. Group A (study group) will receive lidocaine. Group B (control group) will
receive the same volume of saline infusion. The study drugs will be prepared by one of the
investigators in the study(GDO,SA,CA,AP,RJM) Subjects will be recruited up to 21 days prior
to surgeryThey will be premedicated with intravenous (IV) midazolam 0.04 mg/kg. Routine ASA
monitors will be applied. Anesthesia will be induced with remifentanil infusion started at
0.1 mcg/kg/minute titrated to keep blood pressure within 20% of the baseline and propofol
1.0 -2.0 mg/kg. Group A will receive lidocaine 1.5mg/kg bolus and Group B the equivalent
volume of saline. Subjects will be monitored with a 5 lead EKG throughout the lidocaine
administration and if any arrhythmia is detected. The study drug will be stopped and
investigators unblinded.
Tracheal intubation will be facilitated with rocuronium (0.6 mg/kg) or succinylcholine
(1-2mg /kg). Immediately after the induction, group A will receive lidocaine infusion (2
mg/kg/hr IV). Group B will receive the equivalent volume of saline; both infusions will be
continued until 1 hour after arrival in the PACU. Anesthesia will be maintained with
desflurane titrated to maintain a bispectral index (BIS) between 40-60 , remifentanil
infusion started at 0.1mcg/kg/min titrated to keep blood pressure within 20 % of baseline
values , and rocuronium that will be administered at the discretion of the anesthesiologist.
Upon termination of the surgery, neuromuscular blockade will be antagonized with a
combination of neostigmine 0.05mg/kg and glycopyrrolate 0.01 mg/kg. Ondansetron 4 mg IV
will be administered to prevent postoperative nausea and vomiting. Subject will be evaluated
for pain in the OR after extubation, using a numeric rating scale, if pain greater than 4/10
they will receive hydromorphone (10 mcg/kg IV). In PACU, subjects will receive IV
hydromorphone in divided doses as needed to achieve a verbal rating score for pain <4 out of
10 and they will be evaluated every 15 minutes .They will also receive metoclopramide (20 mg
IV ) as rescue antiemetic in PACU. Discharge readiness will be assessed by a PACU nurse
using the modified Post Anesthesia Discharge Scoring System (MPADSS) score every 15 minutes
for about 3 hours or until ready for discharge.The primary and secondary outcomes will be
assessed by an independent observer who will be blinded to group allocation (GDO,CA, AP, SA,
RJM and PF). Study personnel will contact the subject at 24 hours to assess well being,
(nausea, vomiting and opioid consumption. Subject will be contacted by telephone by the
study staff and will complete the MQOR (modified quality of recovery 40 question survey) at
24 hours post surgery.
Inclusion Criteria:
- Female patients undergoing outpatient laparoscopic gynecologic surgery
- ASA PS I and II
- Age between 18 and 64 years
- Fluent in English
- BMI less than 35
Exclusion Criteria:
- History of allergy to local anesthetics
- History of chronic opioid use
- Pregnant patients
- BMI greater than 35
- History of EKG abnormalities
- Hepatic Impairment
- History of congestive heart failure
- EKG abnormalities
- History of heart block (subject with history of heart block
- Current use of anti-arrhythmic medications
Drop -Outs:
- Patient or surgeon request
- Conversion of the surgery from laparoscopic to open
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