- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT03349034
Local Infusion of Ropivacaine for Post-Op Pain Control After Osseocutaneous Free Flaps
Role of Continuous Local Infusion of Ropivacaine for Post-Operative Pain Management in Patients Receiving Osseocutaneous Free Flaps
Head and neck oncologic surgery often requires the use of free tissue transfer, or microvascular reconstruction, to reconstruct defects created by tumor resections. Although there are several techniques for the reconstruction of defects, resection of large tumors leave defects that require the transfer of vascularized tissue from one part of the body to repair the defect. For example, the removal of a segment of diseased mandible requires free tissue transfer containing the component parts - skin, muscle, and bone - to reconstruct the deficit created by the resection of the tumor. Over the years, microvascular surgeons have focused their attention on maximizing the success of these technically difficult surgeries. However, now, with free flap reconstruction rates in excess of 95%, surgeons are afforded the opportunity to turn their focus toward the morbidities associated with these surgeries. While much has been published about donor site wound healing, pain control in the post-operative period has largely been neglected in the head and neck reconstruction literature. Systemic analgesia with opioids is standard of care, which has been shown to lead to increased confusion, significantly increased length of stay and increased risk of pulmonary complications. In addition, it has been shown that early mobilization and optimal wound care can decrease donor site morbidity.
In this study the clinical team aims to better control donor site pain utilizing local, targeted analgesia to relieve pain at the donor site for osseocutaneous free-flaps. To reduce confounding and bias, the study will be a double-blind prospective randomized placebo controlled trial wherein patients undergoing osseocutaneous free flap surgery will be randomized to receive continuous infusion of ropivacaine or normal saline (placebo) via local continuous infusion catheter, which will be placed intraoperatively at the time of donor site closure. Patients' pain will be monitored for the first 48hrs after surgery. Donor site and global pain at rest will be evaluated every 8 hours for the first two postoperative days using a visual analogue pain scale (VAS). Essentially, there is a 100 millimeter line drawn on a piece of paper, with "no pain" marking the left end of the line and "worst pain" marking the right end of the line. Subjects mark with a pen along the line where pain is felt fits along that continuum. A researcher then measures how far along the line that mark is placed and then it is recorded. Median daily opiate use via PCA will also be tracked. Donor site-specific range of motion and strength will be assessed with a formal physical therapy evaluation on post-operative day 2 or soonest non-holiday weekday. Information on patient satisfaction, time to ambulation, and length of stay will also be collected. Subgroup analysis will be performed.
Study Overview
Status
Conditions
Intervention / Treatment
Detailed Description
Procedures involved in this study include:
- Intraoperatively, following procurement of the fibula or scapula bone graft and at the time of surgical wound closure, all patients will receive the placement of a continuous infusion catheter into the donor site wound bed. The infusion reservoir will be connected to a catheter-based On-Q pump, and the catheter will be placed in the donor site. A stab incision separate from the surgical wound will be used to bring the catheter through the skin. Patients will be randomized to receive 6 ml/hr of 0.2% Ropivacaine or 6 ml/hr of normal saline via the infusion reservoir. The catheter will be left in place with continuous infusion for first 48 hours of the post-operative period. The catheters will be removed by the housestaff on POD2. There is minimal risk to removing the OnQ catheter. Any opening in the skin will be covered with gauze to allow primary healing. Solutions of saline and ropivacaine will be prepared and made available for infusion by the Mount Sinai Pharmacy. Solutions will be blinded, and identical in appearance. Patients will be assigned to ropivacaine or saline intervention by the research pharmacy through coded envelopes. Patients, physicians, nurses, and research personnel will be blinded to treatment assignment. Every 8 hours for the first 48 hours, patients will be asked to complete a visual analogue scale (VAS) for reporting their pain. The VAS will be performed six times over the course of the 48hrs. These will be performed during regular flap check monitoring, to ensure patients are not disrupted additional times throughout the day for this study. Patients will otherwise receive standard of care pain management, including Tylenol 650 q6hr standing as well as a dilaudid PCA set to low-dose, opioid naïve. On post-operative day 2 patient will receive a physical therapy evaluation.
Prior to discharge from the hospital, the study subjects will be asked to complete a brief survey (APS-POQ-R Pain Survey) regarding their experience, with regard to pain management.
Study Type
Enrollment (Actual)
Phase
- Phase 2
Contacts and Locations
Study Locations
-
-
New York
-
New York, New York, United States, 10129
- Icahn School of Medicine At Mount Sinai
-
-
Participation Criteria
Eligibility Criteria
Ages Eligible for Study
Accepts Healthy Volunteers
Genders Eligible for Study
Description
Inclusion Criteria:
- Patients receiving osseocutaneous free tissue transfer regardless of the indication for free tissue transfer.
This includes osseocutaneous tissue from fibula and scapula
- Age ≥ 18
Exclusion Criteria:
- Patients unable to understand the research protocol and/or provide informed consent
- Patients under the age of 18
- Patients with a history of allergic reaction to Ropivacaine or other local amide anesthetics
- Patients whose participation in this trial would require exclusion from participation in another clinical research trial related to the patient's malignant diagnosis.
- Patients with previous pain disorders or drug abuse requiring chronic narcotic use.
- Vulnerable populations (adults unable to consent, individuals who are not yet adults, wards of the state, prisoners)
Study Plan
How is the study designed?
Design Details
- Primary Purpose: Supportive Care
- Allocation: Randomized
- Interventional Model: Parallel Assignment
- Masking: Quadruple
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
---|---|
Experimental: Test Group
Local Ropivicaine Infusion
|
Patients will be randomized to receive a local continuous infusion of 6 ml/hr of 0.2% Ropivacaine via On-Q infusion pump, at the donor site, for the first 48 hours of the postoperative period.
|
Placebo Comparator: Control Group
Local Saline Infusion
|
Patients will be randomized to receive a local continuous infusion of 6 ml/hr of 0.9% normal saline via On-Q infusion pump, at the donor site, for the first 48 hours of the postoperative period.
|
What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Post-Operative Pain at Donor-Site
Time Frame: 8, 16, 24, 32, 40 and 48 hours
|
Pain assessed every 8 hours for the first 48 hours using a visual analogue pain scale at rest.
A visual analogue pain scale is a validated pain measure.
Essentially, there is a 100 millimeter line drawn on a piece of paper, with "no pain" marking the left end of the line and "worst pain" marking the right end of the line.
Subjects mark with a pen along the line where pain is felt fits along that continuum.
A researcher then measures how far along the line that mark is placed and then it is recorded.
Full scale from 0-100, higher score indicates more pain.
|
8, 16, 24, 32, 40 and 48 hours
|
Post-Operative Pain - Global Pain
Time Frame: 8, 16, 24, 32, 40 and 48 hours
|
Pain assessed every 8 hours for the first 48 hours using a visual analogue pain scale at rest.
A visual analogue pain scale is a validated pain measure.
Essentially, there is a 100 millimeter line drawn on a piece of paper, with "no pain" marking the left end of the line and "worst pain" marking the right end of the line.
Subjects mark with a pen along the line where pain is felt fits along that continuum.
A researcher then measures how far along the line that mark is placed and then it is recorded.
Full scale from 0-100, higher score indicates more pain.
|
8, 16, 24, 32, 40 and 48 hours
|
Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Opioid Consumption
Time Frame: 48 hours
|
All subjects receive standing tylenol 650mg every 6 hours as well as a dilaudid PCA set for low-dose, opioid-naive patients for the first 48 hours post-operatively.
Total opioid consumption for each subject during the first 48 hours is recorded measured in oral morphine equivalents (OME).
|
48 hours
|
Range of Motion
Time Frame: 48 hours
|
At 48 hours all subjects will receive a physical therapy evaluation.
Range of motion will be measured in degrees
|
48 hours
|
Distance Ambulated
Time Frame: 48 hours
|
At 48 hours all subjects received a physical therapy evaluation.
Distance ambulated measured in feet.
|
48 hours
|
Strength
Time Frame: 48 hours
|
At 48 hours all subjects received a physical therapy evaluation.
Strength measured on a standard neurological 5 point scale: 0 = Complete Paralysis to 5 = Normal Power.
|
48 hours
|
American Pain Society-Patient Outcome Questionnaire - (APS-POQ-R)
Time Frame: 48 hours
|
Pain question on APS-POQ-R - A standardized pain satisfaction survey distributed to subjects at 48 hours rating their overall satisfaction with postoperative pain management.
a 16-item questions measured on a 10-point numeric likert scale, with higher scores indicating more pain.
Total range from 0 (no pain) to 200 (severe pain).
|
48 hours
|
Collaborators and Investigators
Investigators
- Principal Investigator: Brett Miles, MD, Icahn School of Medicine At Mount Sinai
- Study Chair: Eric Genden, MD, Icahn School of Medicine At Mount Sinai
Publications and helpful links
General Publications
- Gerbershagen HJ, Aduckathil S, van Wijck AJ, Peelen LM, Kalkman CJ, Meissner W. Pain intensity on the first day after surgery: a prospective cohort study comparing 179 surgical procedures. Anesthesiology. 2013 Apr;118(4):934-44. doi: 10.1097/ALN.0b013e31828866b3.
- Blumenthal S, Dullenkopf A, Rentsch K, Borgeat A. Continuous infusion of ropivacaine for pain relief after iliac crest bone grafting for shoulder surgery. Anesthesiology. 2005 Feb;102(2):392-7. doi: 10.1097/00000542-200502000-00023.
- Oderda GM, Said Q, Evans RS, Stoddard GJ, Lloyd J, Jackson K, Rublee D, Samore MH. Opioid-related adverse drug events in surgical hospitalizations: impact on costs and length of stay. Ann Pharmacother. 2007 Mar;41(3):400-6. doi: 10.1345/aph.1H386. Epub 2007 Mar 6.
- Singh K, Samartzis D, Strom J, Manning D, Campbell-Hupp M, Wetzel FT, Gupta P, Phillips FM. A prospective, randomized, double-blind study evaluating the efficacy of postoperative continuous local anesthetic infusion at the iliac crest bone graft site after spinal arthrodesis. Spine (Phila Pa 1976). 2005 Nov 15;30(22):2477-83. doi: 10.1097/01.brs.0000186323.11285.b1. Erratum In: Spine. 2006 Jan 1;31(1):43. Dip, Dino Samartzis [corrected to Samartzis, Dino].
- Roof S, Ferrandino R, Eden C, Khelemsky Y, Teng M, Genden E, DeMaria S Jr, Miles BA. Local infusion of ropivacaine for pain control after osseous free flaps: Randomized controlled trial. Head Neck. 2021 Apr;43(4):1063-1072. doi: 10.1002/hed.26562. Epub 2021 Feb 23.
Study record dates
Study Major Dates
Study Start (Actual)
Primary Completion (Actual)
Study Completion (Actual)
Study Registration Dates
First Submitted
First Submitted That Met QC Criteria
First Posted (Actual)
Study Record Updates
Last Update Posted (Actual)
Last Update Submitted That Met QC Criteria
Last Verified
More Information
Terms related to this study
Keywords
Additional Relevant MeSH Terms
Other Study ID Numbers
- GCO 17-1391
Plan for Individual participant data (IPD)
Plan to Share Individual Participant Data (IPD)?
Drug and device information, study documents
Studies a U.S. FDA-regulated drug product
Studies a U.S. FDA-regulated device product
This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.
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