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Laurence Weinberg Staff Anaesthetist, Austin Hospital, Victoria Clinical Fellow, Department of Surgery, The University of Melbourne. Length of stay after open radical prostatectomy with intravenous lignocaine followed by 24-hour subcutaneous infusion: blinded, randomized, placebo controlled multicentre trial
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Acknowledgements o ANZCA: Project Grant o University of Melbourne Story D, Gordon I, Christophi C o Co-investigators Rachbuch C, Beilby D, Trinca J, Howard W, Yeomans M, Yanezas M, James K, McNicol L
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Intravenous Lignocaine Clear advantages: abdominal surgery Lower pain scores Opioid sparing effects Enhances functional recovery Reduces immune alterations Decreases length of hospital stay
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Subcutaneous Lignocaine Neuropathic pain Ischaemic pain Limited data for ACUTE postoperative pain
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Hypothesis Intraoperative IV lignocaine + 24 hrs post-operative SC lignocaine Enhances recovery Shortens length of hospital stay after open radical retropubic prostatectomy
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Study Design Prospective randomised multicentre Blinded Inclusion criterion Adults (age > 18 years < 75 years) Elective open radical prostatectomy ASA I-III patients Exclusion criterion x Creatinine > 200 umoll/L, Abn LFT’s x Chronic opioid use x Allergy: morphine, LA x Cardiac conduction defects/Class I anti-arrhythmic agents
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Study Design Human Research Ethics approval Consenting patients randomised 2 groups GA: standardized, no regional anaesthesia All patients: 1.Induction: Propofol: 1-3 mg/kg; Fentanyl 3 ug/kg 2.Maintenance: Volatile anaesthesia: 0.6-1 MAC, Fentanyl infusion 2.5 ug/kg/hr 3.Surgical closure: Paracetamol IV 1 g, Ketorolac 30 mg 4.Postoperatively: Morphine PCA, 1 mg boluses, 5 min lockout QID paracetamol, NSAID, Acute Pain Service
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Study Design Lignocaine group: Pre-induction Loading dose IV: 1.5 mg/kg Intraop infusion IV: 1.5 mg/kg/hr
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Study Design Lignocaine group: Post-op SUBCUT infusion: 1.5 mg/kg/hr
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Study Design Control group: Normal saline: equal volume delivered in the same way
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Study Design Primary outcome 1.Length of hospital stay Secondary outcomes 1.GI function 2.Time to mobilise 3.Rescue analgesia and anti-emetic therapy 4.Visual Analogue Scores for pain (VAS) 0 to 100mm 5.Morphine consumption: 24 hours 6.Patient satisfaction 7.Opioid & lignocaine side effects 8.Lignocaine plasma levels: PACU & 24 hours 9.Adverse events
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Statistics analyses Power analyses: based on a PILOT STUDY* for patients undergoing open radical prostatectomy (2007/8) who received PCA morphine alone: mean hospital stay 4.5 days (SD 26.4 hrs) Sample size: 18 hour difference in hospital stay, power 0.8, significance level of 0.05, 38 patients per group Analyses: intention-to-treat bases * Weinberg L, et al. Anaesthesia & Intensive Care 2010; 38: A1116
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Consort diagram Total patients consented N = 85 Total patients consented N = 85 Patients excluded N = 10 Laparoscopic retropubic prostatectomy N = 9 Procedure aborted (anaphylaxis) N = 1 Patients excluded N = 10 Laparoscopic retropubic prostatectomy N = 9 Procedure aborted (anaphylaxis) N = 1 Inclusion critreria met N = 75 Randomised Inclusion critreria met N = 75 Randomised Placebo Group N = 38 Placebo Group N = 38 Lignocaine Group N = 37 Lignocaine Group N = 37 Intention to treat
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Demographics Lignocaine GroupPlacebo Group Patients (n)3738 Age * (yrs)61 (6.3, 44-70)60.0 (7.6, 38-71) Weight * (kg)85 (14.1, 52-117)83 (11.9, 60-123) Body mass index * (kg/m 2 )28 (5.05, 16.9-42.2)26 (3.53, 21.2-35.9) ASA Class - I / II / III24 / 13 / 026 / 12 / 0 Gleason Scores7 (0.86)7 (0.62) PSA8.7 (5.02)7.8 (4.85) * Data presented as SD, range
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Hospital Stay Hospital stay (days) 3.3 (0.80)4.6 (3.18)-1.3 0.017 -2.40 to -0.25 LignocainePlacebo Mean (SD) Difference P 95% CI
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Operative variables Surgery duration (min) 155.7 (34.2) 141.6 (44.6) 0.13(-4.27, 32.47) Lowest intraop temp ( 0 C) 35.5 (0.5) 35.6 (0.5) 0.41(-0.34, 0.14) Blood loss (ml) 1050.8 (750.9) 940.3 (651.1) 0.50(-218, 439) Blood Tx* (% patients) 5.4%7.9% 1.00*(-16.0%, 10.9%) Colloids (total) 843.9 (926.6) 742.6 (713.8) 0.60(-281, 483) Crystalloids (total) 3281.1 (1094.6) 2552.6 (1173.5) 0.007(206, 1251) LignocainePlacebo Mean (SD) P 95% CI For comparison of means, standard two-sample t-tests were used Uses Fisher's Exact Test due to comparison of proportions with small sample size
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Postoperative variables Oral sips (hrs) 7.2 (3.6) 8.6 (4.3) -1.40.17 (-3.39, 0.60) Free fluid (hrs) 9.7 (4.5) 13.6 (5.0) -3.90.002 (-6.30, -1.53) Light diet (hrs) 15.5 (4.9) 20.9 (7.5) -5.40.002 (-8.61, -2.13) Time to mobilise (hrs) 17.4 (3.8) 22.0 (4.4) -4.6<0.001 (-6.68, -2.52) LignocainePlacebo Mean SD Difference P 95% CI Two-sample t-test was used for the comparisons of means For the comparison of percentages, Fisher’s exact test was used for the p-values and the Newcombe-Wilson approximation for the confidence intervals
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Adverse Effects (% patients) Nausea/Vomiting 51.4%44.7% 0.6 Pruritis 16.2%23.7% 0.6 Dizziness 37.1%54.1% 0.17 Visual disturbances 11.4%16.2% 0.7 Peri-oral numbness 5.9%5.4% 1.0 Muscle weakness 2.9%8.1% 0.6 Paraesthesia 9.1%8.1% 1.0 Constipation 10.8%26.3% 0.14 LignocainePlacebo P
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Post-op Complications Hypotension requiring medical intervention 5.4%2.6% 0.6 Other cardiovascular 0.0% 1.0 Respiratory depression 0.0% 1.0 Pneumonia 0.0% 1.0 Intra-abdominal sepsis 0.0%2.6% 1.0 Wound healing 0.0% 1.0 Renal 0.0% 1.0 LignocainePlacebo P
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Pain Rest MEAN LignocainePlacebo 19.3 mm37.3 mm Difference: 18 mm 95% CI: 7.3 – 28 mm P = 0.001
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Cumulative Morphine LignocainePlacebo 38.3 mg52.3 mg MEAN Difference: 13.9 mg 95% CI: 2.2 - 25.7 P = 0.02
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Cumulative Morphine LignocainePlacebo 1.4 mg/hr2.0 mg/hr MEAN SLOPE Difference: -0.62 95% CI: -0.14 to -0.02 P = 0.02
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Adverse events SC cannulae: nil complications Inadvertent administration of lignocaine
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Lignocaine Levels Recovery * 1.36 (0.48) 0.5 – 2.19 < 0.5 0.00<0.001 * (0.63-0.94) 24-hours 3.20 (0.95) 1.1 – 4.96 < 0.5 Lignocaine (ug/mL)Placebo (ug/mL) Mean (SD) RangeMean SDP 95% CI * Uses Mann-Whitney of medians (adjusted for ties) due to non-Normal data Not appropriate for formal analyses of the 24-hour data as all values in placebo were recorded as < 0.5.
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Conclusions IV lignocaine followed by 24-hr SC infusion Shorter length of stay (1.3 days) Accelerated acute rehabilitation Free fluid (3.9 hrs) Diet (5.4 hrs) Mobilisation (4.6 hrs) Less 24-hour morphine use Lower pain scores Safety factors: paramount
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Future directions Plasma levels & pain scores Cancer recurrence Chronic pain Utility in laparoscopic radical prostatectomy
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Thank you 谢谢
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Future directions Pearson’s correlation is r = 0.09 here, a weak positive correlation (P = 0.6)
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