Brief Title
Anesthesia With Propofol, Dexmedetomidine and Lidocaine Infusions for Laparoscopic Cholecystectomy
Official Title
Opioid-free Total Intravenous Anesthesia With Propofol, Dexmedetomidine and Lidocaine Infusions for Laparoscopic Cholecystectomy; Comparison With Propofol, Remifentanil Infusions
Brief Summary
Opioids may attenuate postoperative hyperalgesia and postoperative nausea and vomiting. Our
hypothesis is: opioid-free total intravenous anesthesia with propofol, dexmedetomidine and
lidocaine infusions for laparoscopic cholecystectomy may achieve comparable hemodynamic
stability during laparoscopy, with lower postoperative analgesic consumption and incidence of
postoperative nausea and vomiting.
Detailed Description
Patients are randomly allocated into two groups to have either opioid-free anesthesia (Group
DL) with dexmedetomidine (0.6 mg/kg loading, 0.3 mg/kg/h infusion), lidocaine (1.5 mg/kg
loading, 2 mg/kg/h infusion), and propofol infusions or opioid-based anesthesia (Group RF)
with fentanyl, remifentanil (0.25μg/kg/min), and propofol infusions.
Simple randomization was done using 80 opaque sealed envelopes, 40 for each group, indicating
group assignment and describing the anesthetic protocol. Before anesthesia induction, an
anesthesiologist will open the next envelope in the sequence to reveal the treatment
allocation. This anesthesiologist will only prepare the study medications and will be
involved in neither preoperative and postoperative data collection nor anesthesia management
of the patients.
The drugs will be delivered in 10 ml and 50 ml syringes labeled as "loading" or "infusion"
respectively. To ensure proper blinding, the loading doses of drugs (dexmedetomidine and
lidocaine in Group DL or fentanyl and normal saline in Group RF) will be calculated according
to the patient's body weight and diluted to a 10 ml volume labeled as "loading-1" and
"loading-2" in order of administration. The infusion drugs (dexmedetomidine and lidocaine in
Group DL or remifentanil and normal saline in Group RF) will be prepared in 50 ml syringes
and labeled as "infusion-1" and "infusion-2" respectively.
At the preoperative holding area, patients will be instructed in the use of the verbal
numerical rating scale (VNRS) and patient controlled analgesia (PCA) pump. Same
anesthesiologist (MB) who is blinded to the study groups will perform the anesthesia
management of all procedures.
On arrival at the operating room, standard monitoring will be applied consisting of ECG,
noninvasive blood pressure, pulse oximetry and bispectral index (BIS). After premedication
with intravenous midazolam (0.03 mg/kg), baseline heart rate and mean arterial blood pressure
(MAP) will be determined which are average of three consecutive measurements. Preoxygenation
with 5 L/min of pure oxygen will be performed during administration of loading doses. Before
induction, patients in Group DL received 0.6 μg/kg dexmedetomidine (loading-1) diluted to a
total volume of 10 ml and infused in 10 minutes. To avoid bias, patients in Group RF will
receive 2 μg/kg fentanyl in same fashion. At the induction, dexmedetomidine or remifentanil
(1 μg/ml and 50 μg/ml respectively, infusion-1) infusions 0.3 ml/kg/h will be started and
lidocaine 1.5 mg/kg (loading-2) in Group DL or normal saline in Group RF and propofol 1.5
mg/kg will be administered. Lidocaine (20 mg/ml) or normal saline infusions 0.1 ml/kg/h and
propofol infusion 10 mg/kg/h will be started immediately after loading doses. Vecuronium 0.1
mg/kg i.v. will be given to facilitate tracheal intubation.
The lungs will be mechanically ventilated with a mixture of oxygen in air (FiO2: 50%, tidal
volume 7-10 ml/kg, respiratory rate 10-14/min) to obtain an end-tidal CO2 (EtCO2) value
between 30-35 mmHg. Supplemental neuromuscular blockade will be achieved with vecuronium
after assessment of neuromuscular function with train-of-four.
Dexmedetomidine and lidocaine infusions in Group DL or remifentanil and normal saline
infusions in Group RF will kept constant during surgery. Propofol infusion rate will be
adjusted 3-12 mg/kg/h to maintain the MAP within ±20% of the baseline value, and to maintain
a BIS reading below 50. The lidocaine or normal saline administration will be terminated
after gallbladder extraction (or 10 min before the end of surgery). Dexmedetomidine or
remifentanil and propofol administration will be terminated during skin closure.
All patients in both groups will receive 8 mg dexamethasone and 50 mg dexketoprofen
trometamol i.v. after anesthesia induction and 1 g paracetamol i.v. after gallbladder
extraction. Laparoscopic portals will be infiltrated with 20 ml 0.5% bupivacaine including
1/80.000 adrenaline before skin closure.
Surgery: Surgeons who are experienced in laparoscopic cholecystectomy will performed the
operations using standard 4-trocar technique. A blunt-tipped 12-mm trocar will be used to
access the peritoneal cavity. Pneumoperitoneum will be achieved with carbon dioxide, and
intra-abdominal pressure will be maintained at 12-14 mmHg throughout surgery. Three
additional 5-mm ports will be introduced and patients will be positioned in 30 degrees
anti-Trendelenburg position and be rotated toward the left side to facilitate exposure of the
gallbladder. After endotracheal intubation a nasogastric tube will be inserted and stomach
content will be aspirated. At the end of surgery, the inflated carbon dioxide will carefully
be evacuated by manuel compression of the abdomen.
A PCA pump will be ready to use immediately after extubation. The PCA pump will set to
deliver fentanyl i.v. with a bolus dose of 20 μg, a lock-out of 5 min, without continuous
infusion and dose limit for 6 hours after surgery. Trained nurses, blinded to treatment
allocation and with no access to the intraoperative records, will perform all outcome
assessments in the postanesthesia care unit (PACU) and surgical ward. Pain scores will be
assessed using the 11-point VNRS (0 corresponding to no pain and 10 to the worst imaginable
pain).
Transition from PACU to surgical ward will be considered to be safe when patient will
achieved a Modified Aldrete Score ≥ 9. Although laparoscopic cholecystectomy is established
as a day-case procedure, our protocol is designed to admit all patients for 24 h to ensure
adequate follow-up of patients and for proper data collection.
Study Phase
Phase 4
Study Type
Interventional
Primary Outcome
Postoperative fentanyl consumption
Secondary Outcome
Recovery time
Condition
Chronic Cholecystitis
Intervention
Dexmedetomidine and lidocaine
Study Arms / Comparison Groups
Opiod-free group
Description: Opioid-free anesthesia (Group DL) with dexmedetomidine (0.6 mg/kg loading, 0.3 mg/kg/h infusion), lidocaine (1.5 mg/kg loading, 2 mg/kg/h infusion), and propofol infusions (3-12 mg/kg/h).
Publications
* Includes publications given by the data provider as well as publications identified by National Clinical Trials Identifier (NCT ID) in Medline.
Recruitment Information
Recruitment Status
Drug
Estimated Enrollment
80
Start Date
June 2012
Completion Date
April 2013
Primary Completion Date
April 2013
Eligibility Criteria
Inclusion Criteria:
- American Society of Anesthesiologists I-II patients
- 20-60 years
Exclusion Criteria:
- American Society of Anesthesiologists III and above patients
- BMI: 35 and above
- Hepatic, renal or cardiac insufficiency
- 2 degree Heart block and above
- Diabetes
- Psychiatric disease
- History of chronic pain
- Alcohol or drug abuse
- Allergy to any of a drug in the study groups
- Pregnant, breast-feeding or menstruating women
- Inability to use a patient-controlled analgesia device
- Any analgesic or antiemetic use in last 24 hours before anesthesia induction
- Any surgical complication that may affect the outcomes of the study (open surgery
etc.)
Gender
All
Ages
20 Years - 60 Years
Accepts Healthy Volunteers
No
Contacts
, ,
Location Countries
Turkey
Location Countries
Turkey
Administrative Informations
NCT ID
NCT01833819
Organization ID
B.30.2.BAV.0.05.05/346
Responsible Party
Sponsor
Study Sponsor
Bezmialem Vakif University
Study Sponsor
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Verification Date
November 2013