Intraperitoneal Dexmedetomidine Versus Ketamine With Bupivacaine For Postoperative Analgesia
Condition: Obesity
Study type: Interventional

Summary: 
      Post-laparoscopic sleeve pain management is essential for early mobilization of the patient
      and so on decrease post-operative complication. The use of opioids is associated with adverse
      effects such as nausea, pruritus, sedation, and occasionally respiratory depression.

      Previous studies stated that intraperitoneal instillation of bupivacaine alone has been used
      to reduce acute postoperative abdominal and shoulder pain allow early mobilization and
      decrease postoperative opioid requirements and its complications.

      In this study the investigators will compare between intraperitoneal instillation of
      dexmedetomidine with bupivacaine versus ketamine with bupivacaine in patients undergoing
      laparoscopic sleeve gastrectomy under general anesthesia regarding to postoperative pain
      relief to reduce morbidity and mortality.
    

Detailed description: 
      Obesity is a serious condition in developed and developing countries occur due to some
      hormonal disorder or due to reduce energy expenditure with increasing energy uptake [1].
      Nowadays, obesity considered the second cause of deaths after smoking all over the world [2].

      Severe obesity increase the incidence of many chronic disease such as (diabetes mellitus,
      hypertension, cardiovascular diseases and others) [3]. This leads to substantial morbidity,
      early mortality [4], impaired quality of life [5] and excess healthcare expenditures [6].

      Laparoscopic bariatric surgery is the most recommended and effective long-term treatment for
      morbid obesity (which body mass index (BMI) ≥40 kg/m2) and obesity-related complication [7].

      Postoperative pain management after laparoscopic sleeve still considers a major challenge. As
      many of the patients express moderate-to-severe pain in postoperative period [8]. Causes of
      postoperative pain include inflammation of the peritoneum, intra-abdominal cavity stretch and
      irritation of diaphragm by carbon-dioxide (CO2) remains in the abdominal cavity [9].

      Multimodal analgesia regimens such as parenteral opioids, nonsteroidal anti-inflammatory
      drugs and intraperitoneal instillation of different drugs such as local anesthetic drugs
      alone or with adjuvants like; opioid and α2 agonists' drugs such as clonidine and
      dexmedetomidine have been tried to reduce overall pain and postoperative complications of
      patients undergoing laparoscopic surgeries [8, 9].

      Bupivacaine is the most commonly used local anesthetic drug, its intraperitoneal instillation
      has become a popular practice for pain relief after laparoscopic surgery as it causes
      blockade of free afferent nerve endings in peritoneum [10].

      Dexmedetomidine, the pharmacologically active d-isomer of medetomidine, it is a potent and
      highly selective α2-adrenoreceptor agonist with sympatholytic, sedative, amnestic,
      anxiolytic, neuroprotective and analgesic properties [11].

      Ketamine is an immunomodulatory agent and anti-inflammatory drug and it has a noncompetitive
      antagonist of the N-methyl-d-aspartate (NMDA) receptor that blocks nociceptive input and
      reduce hyperalgesia [12].
    

Intervention name(s): normal saline; dexmedetomidine; Ketamine
Intervention type(s): Drug; Drug; Drug
Intervention description(s): At the end of surgery, patient will be shifted to Trendelenburg position and intraperitoneal instillation of 40 ml bupivacaine 0.25% + 5 ml normal saline will be done guided by the camera and sprayed uniformly into the peritoneal cavity by the surgeon.
The patient will be maintained in Trendelenburg position for 5-10 minutes after drug instillation and the abdomen will be deflated by passive exsufflation using gentle abdominal pressure.; At the end of surgery, patient will be shifted to Trendelenburg position and intraperitoneal instillation of the study drug(40 ml bupivacaine 0.25% + 1 µg/kg dexmedetomidine diluted in 5 ml normal saline) will be done guided by the camera and sprayed uniformly into the peritoneal cavity by the surgeon.
The patient will be maintained in Trendelenburg position for 5-10 minutes after drug instillation and the abdomen will be deflated by passive exsufflation using gentle abdominal pressure.; At the end of surgery, patient will be shifted to Trendelenburg position and intraperitoneal instillation of the study drug(40 ml bupivacaine 0.25% + 0.5 mg/kg ketamine diluted in 5 ml normal saline) will be done guided by the camera and sprayed uniformly into the peritoneal cavity by the surgeon.
The patient will be maintained in Trendelenburg position for 5-10 minutes after drug instillation and the abdomen will be deflated by passive exsufflation using gentle abdominal pressure.
Intervention MeSH terms: Dexmedetomidine; Ketamine
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: The patients will be divided randomly by a computer-generated randomization table into three equal groups
Masking: Triple (Participant, Care Provider, Outcomes Assessor)
Primary purpose: Treatment
Keywords: sleeve gastrectomy; postoperative analgesia; intraperitoneal dexmedetomidine; intraperitoneal ketamine