- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT02751619
Preventive Skin Analgesia With Lidocaine Patch 5% for Controlling Post-thoracotomy Pain
Preventive Application Of Lidocaine Patch In Adjunction To Intravenous Morphine Analgesia For Management Of Post-Thoracotomy Pain: Results Of A Randomized, Double Blind, Placebo Controlled Study
Thoracotomy is one of the most painful surgical incision. Uncontrolled acute post-thoracotomy pain reducing deep breathing exercises and secretion clearance increased the incidence of postoperative pulmonary complications including atelectasis, hypoxemia, and postoperative pulmonary infections. Thus, an effective analgesia is crucial in order to reduce perioperative morbidity and hospitalization time and also to prevent chronic post-thoracotomy pain.
Thoracic epidural analgesia and thoracic paravertebral analgesia are currently the standard strategies for thoracic surgery but the difficult of performing them in all patients and their potential complications are all factors that limit their use. Systemic administration of opioids is the simplest and common strategy to provide analgesia but it may be associated with several undesirable effects, such as respiratory depression, sedation, nausea, constipation and vomiting.
In the recent years, preventive analgesia is become one of the most promising strategy of postoperative pain control. It is based on the concept of administering analgesic drugs before the occurrence of nociceptive input in order to prevent central sensitization. The efficacy of preemptive analgesia is unclear and there is no a consensus on its efficacy on controlling pain after thoracic procedure.
Pain following thoracotomy has a multifactorial genesis including surgical incision, intercostal nerve injury, pleural inflammation, and damage of pulmonary parenchyma and of diaphragm. Thus, a multimodal analgesia that intercepts the signalizing at numerous locations could be more effective than a single strategy targeting one site along the pain pathway.
Thus, in the present study, the clinical hypothesis was that the preemptive analgesia of the skin using a new tool as the Lidocaine patch 5% would improve the analgesic effects of systemic morphine analgesia for controlling post-operative pain following thoracotomy.
Study Overview
Status
Conditions
Intervention / Treatment
Detailed Description
This was an unicenter, double-blinded, placebo controlled, parallel-group, prospective study conducted at Thoracic Surgery Unit and Anesthesia and Intensive Care Unit of Second University of Naples from January 2013 to May 2015.
All consecutive patients undergoing undergoing anatomical resection by standard lateral thoracotomy for treatment of non small cell lung cancer (NSCLC) were randomly assigned to Lidocaine or Placebo group in 1:1 ratio and no changes to methods after trial commencement as type of randomization or eligibility criteria were attended.
For patients assigned to active group, Lidocaine patch 5% (Lidoderm®, Endo Pharmaceuticals Inc, Malvern, PA, USA) measuring 10 x 14 cm and containing 700 mg of Lidocaine, was applied to cover the planned skin incision, marked with a pen by surgeon. Patch was applied for 12 hours during the night, removed for the subsequent 12 hours during the day, and then a new patch was applied at the same level the night after. This process was continued for 3 days before thoracotomy. In the control group, a placebo patch, that was identical in appearance to the active patch but did not contain Lidocaine, was applied in the same manner for the same time. The pain service, surgical team, and patients were all blinded to treatment group assigned.
All patients received the same anesthetic protocol. All operations were performed in the early morning just after that the patch was removed. The general anesthesia was inducted with i.v. midazolam 0.05 mg/kg, i.v. fentanyl 1-1.4 µg/Kg, i.v. propofol 2.5 mg/kg, i.v. and rocuronium bromide 0.6 mg/kg. The patient was maintained with desflurane 4-6%, sulfentanil 0.5-1 micro/Kg, rocuronium bromide 0.6-0.8 mg/Kg, based on heart rate and blood pressure stability. A selective ventilation was performed with a double-lumen endobronchial tube in all cases and no additional analgesics were injected during surgery.
All patients had the same length of skin incision and a standard muscle-sparing lateral thoracotomy. The latissimus dorsi muscle and the underlying serratus anterior muscle were spared and the chest was entered over the top of the unresected and unshingled sixth rib. A standard Finocchietto chest retractor was then placed and slowly opened to avoid rib fracture. After completion of the appropriate anatomical lung resection, a single 28 F chest drainage was systematically placed in pleural cavity. The same chest closure was performed in all patients in a standard manner using intracostal sutures.
Patient was extubated in the operating room and transferred to the surgical ward. The postoperative analgesia was performed with intravenous morphine administered through Patient Controlled-Analgesia (Automed 3300, AceMedical Co.) delivery. Morphine 1 mg was given for each request and continuous infusion was at a rate of 1 mg/h. Both groups had a 10 min lockout period and a safe higher limit of 20 mg in 4 hours. If VAS scores exceeded 4/10 scores, rescue analgesia was intravenously administered according to a standardized institutional protocol for pain treatment until the pain was relieved to a level falling below a VAS score < 4. Patient Controlled Analgesia (PCA) was continued for up to 2 days, until patients could tolerate oral opioid medications and/or anti-inflammatory analgesics. However, these medications were not considered in the analysis.
The intergroup differences were assessed in order to evaluate whether the pre-emptive analgesia obtained with Lidocaine patch would have effects on pain scores (primary end-point), consumption of analgesics, recovery of respiratory function and peripheral painful pathways (secondary end-points).
Study Type
Enrollment (Actual)
Phase
- Not Applicable
Participation Criteria
Eligibility Criteria
Ages Eligible for Study
Accepts Healthy Volunteers
Genders Eligible for Study
Description
Inclusion Criteria:
- More than 18 years old
- Anatomical resection by standard lateral thoracotomy for treatment of non small cell lung cancer
Exclusion Criteria:
- Allergy to Lidocaine
- American Society of Anaesthesiologist (ASA) classification score more than 3
- History of previous thoracic surgical procedures and/or of chronic pain or taking regular analgesics
- Pneumonectomy or concomitant decortication and/or chest wall injury or resection,
- Psychiatric illness
- Participation to other studies
Study Plan
How is the study designed?
Design Details
- Primary Purpose: Treatment
- Allocation: Randomized
- Interventional Model: Parallel Assignment
- Masking: Double
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
---|---|
Experimental: Lidocaine Group
Lidocaine patch 5% (Lidoderm®, Endo Pharmaceuticals Inc, Malvern, PA, USA) measuring 10 x 14 cm and containing 700 mg of Lidocaine, was applied to cover the planned skin incision, marked with a pen by surgeon.
Patch was applied for 12 hours during the night, removed for the subsequent 12 hours during the day, and then a new patch was applied at the same level the night after.
This process was continued for 3 days before thoracotomy
|
Lidocaine patch 5% was applied to cover the planned skin incision for 12 hours during the night and then was removed for the subsequent 12 hours during the day.
This process was continued for 3 days before thoracotomy
Other Names:
|
Active Comparator: Placebo Patch
A patch, that was identical in appearance to the active patch but did not contain Lidocaine, was applied to cover the planned skin incision, marked with a pen by surgeon.
Patch was applied for 12 hours during the night, removed for the subsequent 12 hours during the day, and then a new patch was applied at the same level the night after.
This process was continued for 3 days before thoracotomy
|
A patch without lidocaine was applied to cover the planned skin incision for 12 hours during the night and then was removed for the subsequent 12 hours during the day.
This process was continued for 3 days before thoracotomy
|
What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Changes in Pain Score measured with Visual Analogue Scale at rest and after coughing
Time Frame: Post-operative follow-up-points: 6 hours, 12 hours , 24 hours , 36 hours, 48 hours and 72 hours
|
10-score Visual Analogue Scale (VAS) ranging from 0=absence of pain to 10= maximal level of pain
|
Post-operative follow-up-points: 6 hours, 12 hours , 24 hours , 36 hours, 48 hours and 72 hours
|
Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
The frequency for hour of activation of PCA Device
Time Frame: Post-operative follow-up: 6 hours; 6-12 hours; 12- 24 hours; 24-36 hours, and 36-48 hours.
|
The sum of the frequency of activation of PCA system
|
Post-operative follow-up: 6 hours; 6-12 hours; 12- 24 hours; 24-36 hours, and 36-48 hours.
|
Morphine consumption
Time Frame: Post-operative follow-up: 6 hours; 6-12 hours; 12- 24 hours; 24-36 hours, and 36-48 hours.
|
The total morphine consumption expressed (the sum of additional intravenous morphine bolus infusions and the morphine delivered by the PCA system)
|
Post-operative follow-up: 6 hours; 6-12 hours; 12- 24 hours; 24-36 hours, and 36-48 hours.
|
Flow Expiratory Volume in one second (FEV1%)
Time Frame: Post-operative follow-up: 72 hours; 96 hours; 120 hours
|
The best of three efforts measured with a spirometer was used for the analysis.
|
Post-operative follow-up: 72 hours; 96 hours; 120 hours
|
Forced Vital Capacity (FVC%)
Time Frame: Post-operative follow-up: 72 hours; 96 hours; 120 hours
|
The best of three efforts measured with a spirometer was used for the analysis.
|
Post-operative follow-up: 72 hours; 96 hours; 120 hours
|
Laser Evoked Potential Tests.
Time Frame: Follow-up: 1 month, 3 months, and 6 months after operation
|
Laser stimulation, delivered by Nd:YAG (neodymium-doped yttrium aluminium garnet (Nd:YAG) laser, was applied at level of thoracotomy scar, the main territory corresponding to the distribution of pain.
The results were evaluated for amplitude and latency differences between the vertex negativity (N2) appearing around 240 ms and the following positivity (P2) appearing around 360 ms after stimulus onset.
|
Follow-up: 1 month, 3 months, and 6 months after operation
|
Collaborators and Investigators
Investigators
- Study Chair: Mario Santini, MD, University of Campania "Luigi Vanvitelli"
Publications and helpful links
General Publications
- Cerfolio RJ, Bryant AS, Bass CS, Bartolucci AA. A prospective, double-blinded, randomized trial evaluating the use of preemptive analgesia of the skin before thoracotomy. Ann Thorac Surg. 2003 Oct;76(4):1055-8. doi: 10.1016/s0003-4975(03)01023-3.
- Garzon-Rodriguez C, Casals Merchan M, Calsina-Berna A, Lopez-Romboli E, Porta-Sales J. Lidocaine 5 % patches as an effective short-term co-analgesic in cancer pain. Preliminary results. Support Care Cancer. 2013 Nov;21(11):3153-8. doi: 10.1007/s00520-013-1948-7. Epub 2013 Sep 3.
- Vrooman B, Kapural L, Sarwar S, Mascha EJ, Mihaljevic T, Gillinov M, Qavi S, Sessler DI. Lidocaine 5% Patch for Treatment of Acute Pain After Robotic Cardiac Surgery and Prevention of Persistent Incisional Pain: A Randomized, Placebo-Controlled, Double-Blind Trial. Pain Med. 2015 Aug;16(8):1610-21. doi: 10.1111/pme.12721. Epub 2015 Jul 14.
- Habib AS, Polascik TJ, Weizer AZ, White WD, Moul JW, ElGasim MA, Gan TJ. Lidocaine patch for postoperative analgesia after radical retropubic prostatectomy. Anesth Analg. 2009 Jun;108(6):1950-3. doi: 10.1213/ane.0b013e3181a21185.
- Cheng YJ. Lidocaine Skin Patch (Lidopat(R) 5%) Is Effective in the Treatment of Traumatic Rib Fractures: A Prospective Double-Blinded and Vehicle-Controlled Study. Med Princ Pract. 2016;25(1):36-9. doi: 10.1159/000441002. Epub 2015 Nov 6.
Study record dates
Study Major Dates
Study Start
Primary Completion (Actual)
Study Completion (Actual)
Study Registration Dates
First Submitted
First Submitted That Met QC Criteria
First Posted (Estimate)
Study Record Updates
Last Update Posted (Estimate)
Last Update Submitted That Met QC Criteria
Last Verified
More Information
Terms related to this study
Additional Relevant MeSH Terms
- Pathologic Processes
- Postoperative Complications
- Pain
- Neurologic Manifestations
- Pain, Postoperative
- Physiological Effects of Drugs
- Molecular Mechanisms of Pharmacological Action
- Anti-Arrhythmia Agents
- Central Nervous System Depressants
- Peripheral Nervous System Agents
- Sensory System Agents
- Anesthetics
- Membrane Transport Modulators
- Anesthetics, Local
- Voltage-Gated Sodium Channel Blockers
- Sodium Channel Blockers
- Lidocaine
Other Study ID Numbers
- 436/2012
Plan for Individual participant data (IPD)
Plan to Share Individual Participant Data (IPD)?
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