Continuous Nerve Block Block vs Combination of Single Block Plus Intravenous Lidocaine for Postoperative Pain.
Condition: Postoperative Pain
MeSH terms: Pain, Postoperative
Intervention: Continuous Erector Spinae Plane Nerve Block; Continuous Quadratus Lumborum Nerve Block; Single Erector Spinae Plane Nerve Block; Single Quadratus Lumborum Nerve Block; Lidocaine IV; Ropivacaine 0.5% Injectable Solution; Dexamethasone; Dexmedetomidine; Lidocaine
Intervention description: To be administered to subjects in the active comparator group receiving primary unilateral thoracic surgery.; To be administered to subjects in the active comparator group receiving primary major abdominal surgery.; To be administered to subjects in the experimental group receiving primary unilateral thoracic surgery.; To be administered to subjects in the experimental group receiving primary major abdominal surgery.; To be given postoperatively as a continuous infusion at a dose of 50 mg/hr in the experimental group.; To be used in both treatment arms as nerve block initial bolus injection.; To be used in the experimental arm as a nerve block adjuvant to promote prolonged single block duration, as is standard of care in this institution.; To be used in the experimental arm as a nerve block adjuvant to promote prolonged single block duration, as is standard of care in this institution.; To be used perineurally as a 0.25% solution in the active comparator group at a rate of 10 ml/hr per perineural catheter.
Intervention MeSH terms: Dexamethasone; Lidocaine; Dexmedetomidine; Ropivacaine
Phase: Phase 4
Study type: Interventional
Primary purpose: Treatment
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Two groups of patients will be studied simultaneously. One group will receive continuous peripheral nerve blocks and the other group will receive single blocks plus postoperative intravenous lidocaine infusion.
Masking: Single (Outcomes Assessor)
Masking description: For study participants, the investigator placing the block will record in the narrative that "this patient is a study participant and received Paravertebral block with ESP approach" or "this patient is a study participant and received TAP block with QL approach". By documenting blocks in this way, the research team member collecting the data will be blinded to whether the patient received continuous block with 0.5% ropivacaine, or single block with 0.5% ropivacaine, dexamethasone, and dexmedetomidine.
Enrollment: 17.0
Sex: All
Minimum age: 18 Years
Maximum age: 90 Years
Healthy volunteers: No
Keywords: intravenous lidocaine; erector spinae plane block; quadratus lumborum block; thoracic surgery; abdominal surgery; continuous peripheral nerve block

Summary:

      A multimodal analgesic regimen including regional anesthesia is used at UPMC Shadyside for
      primary thoracic and major abdominal surgeries. The current standard-of-care regional
      anesthesia techniques include Erector Spinae Plane (ESP) block for video assisted thorascopic
      surgery (VATS) and Quadratus Lumborum (QL) block for major abdominal surgery. These blocks
      are routinely administered as a continuous catheter technique in order to extend the duration
      of postoperative analgesia. Although rare, continuous nerve block techniques carry risks and
      limitations, including catheter dislodgement, migration, kinking and leaking at the site,
      bleeding, and infection. They are also much more expensive to perform and maintain than
      single-injection nerve blocks at this institution. Perioperative intravenous (IV) lidocaine
      is one of the safest local anesthetics, and its use has been shown to provide analgesia and
      reduce opioid requirements. Furthermore, it has been hypothesized that part of the analgesic
      efficacy of continuous peripheral nerve blocks may be due to the systemic effects of the
      local anesthetic infused at the site. Therefore, it is possible that the combination of a
      single block followed by an infusion of IV lidocaine may provide the same benefits as a
      continuous nerve block at a lower cost. The purpose of this study is to show that a single
      block technique plus IV lidocaine is non-inferior to a continuous block technique. For the
      purpose of this study we chose two surgical models--VATS and major abdominal surgery--and ESP
      and QL blocks, respectively. The study will be conducted as a prospective, randomized (1:1),
      open-label, active-comparator, noninferiority trial. The study will prospectively investigate
      the efficacy of continuous block versus single block plus IV lidocaine infusion for
      postoperative pain management in patients undergoing primary unilateral VATS or primary major
      abdominal surgery.
    

Eligibility criteria:

        Inclusion Criteria:

          -  18-90 years old

          -  Primary unilateral VATS or major abdominal surgery

          -  BMI 20-36, weight ≥ 50kg

          -  Male and Female

          -  All races

        Exclusion Criteria:

          -  Patient refusal

          -  Inpatient status at the time of surgery

          -  ASA class 4 or greater

          -  Pregnancy

          -  Non-English speaking or inability to participate in the study

          -  Patients with coagulopathy or on therapeutic anticoagulation

          -  Chronic steroid use

          -  Opioid use disorder

          -  Contraindication to performing any of the proposed blocks - active infection at the
             block site, systemic infection, allergy to local anesthetic medications

          -  Patients undergoing second surgery or urgent/emergent surgery

          -  Patients weighing < 50kg

          -  History of chronic pain and/or opioid tolerant

          -  Anticipated requirement for patient-controlled analgesia (PCA)

          -  Allergy or intolerance to any medication specified in the study protocol or
             postoperative pain management regimen

          -  Liver disease