Cardiovascular Protection Conservative Effects of Esketamine Versus µ-opioid Receptor Agonists in General Anesthesia

Perioperative Cardiovascular Protection Conservative Effects of Esketamine Versus µ-opioid Receptor Agonists in Total Intravenous General Anesthesia: Study Protocol for a Randomized Controlled Pilot Trial

Sponsors

Lead Sponsor: Second Hospital of Shanxi Medical University

Source Second Hospital of Shanxi Medical University
Brief Summary

Pain has two sides. The 'bad pain' refers to the adverse impact of pain on humans, which disturbs daily life of the sufferers. Evidence indicates that in the transduction and transmission of the painful signals some molecules may retrogradely moving to the tissues where the pain was initiated, to provide protection to the cells and the organ being insulted by the nociceptive stimulation. Transient receptor potential vanilloid 1 (TRPV1), as a nociceptor, promotes the release of calcitonin gene-related peptide (CGRP) and substance P (SP) in the small diameter primary sensory neurons, mediating the pain signals from nociceptor to the spinal dorsal horn, sending the pain signals to the central nervous system. In the same time, the neuropeptides are released from the peripheral nerve terminals of the innervating neurons, where the harmful stimulation occurred, including the heart and vasculature. CGRP and SP play important roles in cardio-protection and homeostasis of systemic hemodynamics via the neurogenic mechanism. All the beneficial effects initiated by pain is mentioned as 'good pain' by physiologists.

Surgery-related pain is mostly so severe and disturbing that must be medically treated. Unfortunately, the beneficial aspect of pain is commonly ignored in daily clinical practice. Does it matter to the patients' outcomes? We don't know yet! What we have been seeing is the shocking outcomes of patients underwent surgery, which shows about 0.8% and 7% of mortalities in the period of 48 hours and 30 days after surgery, respectively (https://www.rcplondon.ac.uk/projects/outputs/national-hip-fracture-database-annual-report-20 16; Injury. 2017; 48(10): 2180-2183). What causes the disaster? Piles of evidence demonstrate that deep anesthesia or deep sedation is related to the high mortality of the patients (Anesthesiology. 2012; 116:1195-1203; Crit Care. 2014; 18(4):R156 ). What about the effect of analgesia, especially the over-analgesia, on the patients' outcome in and after surgery? Opioids are the most commonly used drugs in the treatment of moderate and sever pain including intra- and postoperative pain. The µ-opioid receptor agonists induce analgesic effect via inhibition of the transduction and the transmission of pain signals, by suppression of the release of CGRP and SP from the nerve terminals. The protective effects on cardiovascular system mediated by CGRP and SP can be inhibited, if the same effect is produced by the action of opioids in the peripheral nerve terminals innervating the heart and the vasculature. Our previous research shows that intrathecal administration of morphine or epidural administration of ropivacaine (1%, in 20 μL) significantly attenuates the increases of CGRP and its coding mRNA in ventricular myocardium and the innervating dorsal root ganglion neurons following occlusion of coronary artery in experimental animals. Based on the evidence, we hypothesize that over-analgesia using opioids significantly suppresses the activity of TRPV1/CGRP、SP mechanism and reduces the amount of CGRP and SP released, which results in an effective de-protection of the cardiovascular system. The severer myocardial damage under some insulting circumstances and eventful systemic hemodynamics is likely occurring upon some surgical/pathological/pharmacological insults in the intra- and postoperative periods.

This parallel, randomized controlled trial will be conducted in eleven centers in Shanxi province, China, which is designed to investigate the perioperative incidence of adverse cardiovascular events and alteration of cardiac troponin I (cTnI) in the patients (one thousand patients, ASA Physical Status 1-II, older than 16 years, regardless of the gender) undergoing surgery under total intravenous general anesthesia with conventional µ-opioid agonists or Esketamine, as the major analgesic. Clinically appropriate anesthesia depth or BIS readings will be used for judgement of anesthetic depth. Conventional monitoring parameters, including blood pressures, heart rate, SpO2 and ECG, will be recorded and analyzed. Blood samples will be collected at 30 min before induction of anesthesia, at the end of surgery and 24 h after the surgery. The association of the perioperative adverse cardiovascular events and the alterations of the levels of serum TRPV1, CGRP, SP and cTnI in the patients underwent general anesthesia using different analgesics (µ-opioid agonists vs Esketamine) will be evaluated. Postoperative outcome, including the functions of the brain and cardiovascular system, is also going to be traced for 1 year postoperatively.

Overall Status Not yet recruiting
Start Date October 15, 2020
Completion Date October 14, 2022
Primary Completion Date October 14, 2021
Phase N/A
Study Type Interventional
Primary Outcome
Measure Time Frame
Perioperative adverse cardiac events 72 hours
Cardiac protection related molecules, including transient receptor potential vanilloid 1 (TRPV1), calcitonin gene-related peptide (CGRP) and substance P. 24 hours
Enrollment 1000
Condition
Intervention

Intervention Type: Drug

Intervention Name: Esketamine, Sulfentanil or/and Remifentanil

Description: The esketamine or the opioids will be intravenously injected or infused to the patients with propofol and one of the muscle relaxants to induce and maitain general anesthesia.

Other Name: Propofol, Atracurium Besilate or Cisatracurium besylate or Rocuronium Bromide

Eligibility

Criteria:

Inclusion Criteria:

- Patients undergoing general anesthesia

Exclusion Criteria:

- Patients with diabetes and neuropathy

Gender: All

Minimum Age: N/A

Maximum Age: N/A

Healthy Volunteers: No

Verification Date

September 2020

Responsible Party

Type: Principal Investigator

Investigator Affiliation: Second Hospital of Shanxi Medical University

Investigator Full Name: Zheng Guo

Investigator Title: Professor

Has Expanded Access No
Number Of Arms 2
Arm Group

Label: Opioid analgesics

Type: Active Comparator

Description: Mu-opioid receptor agonists (remifentanil, sulfentanil) will be used as the only analgesic(s) in the surgery.

Label: Ketamine

Type: Experimental

Description: Esketamine will be used as the only anagesic in the surgey.

Study Design Info

Allocation: Randomized

Intervention Model: Parallel Assignment

Primary Purpose: Prevention

Masking: Double (Participant, Care Provider)

Source: ClinicalTrials.gov