TEA vs. PVB vs. PCA in Liver Resection Surgery

Study Overview
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Brief Summary
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This study aims to compare the efficacy and safety of three alternative methods of analgesia in patients undergoing complex liver resection surgery: 1) thoracic epidural analgesia (TEA), 2) continuous paravertebral block (PVB) with patient-controlled analgesia (PCA) and 3) patient-controlled analgesia (PCA) alone. Regional anesthesia techniques such as TEA and PVB may improve recovery and decrease postoperative pain scores in addition to other benefits such earlier return of bowel function and shortened length of hospital stay, although some practitioners have voiced concerns about the safety and efficacy of these techniques in patients after liver resection who may develop postoperative coagulation abnormalities. The investigators plan to enroll a total of 150 patients (adults >/= 18 years of age who meet study criteria) scheduled for complex liver resection surgery in this study, who will then be randomized into 50 patients per arm of the study (3 total arms). Postoperative pain scores will be collected in PACU and throughout the patient's hospital stay as well as routine blood tests including complete blood count, coagulation labs (PT/INR, aPTT) and serum creatinine to measure renal function. The study team will also collect additional data prospectively on all patients enrolled in the study; these parameters will include age, sex, type of operation performed, length of operation, volume of intraoperative blood loss, volume of intraoperative fluid administration including blood products, daily postoperative intravenous fluid administration, length of time to first feeding, day of epidural catheter removal, length of hospital stay and incidence of major postoperative complications (surgical, respiratory, cardiac, renal, etc.). Once primary and secondary data points are obtained, the data will undergo rigorous statistical analysis using the appropriate statistical techniques to determine the outcomes. The investigators propose that epidural and/or paravertebral analgesia may improve recovery times and decrease hospital length of stay, which would be beneficial for the patient as well as decrease hospital costs. In addition, if better postoperative pain management scores can be achieved with epidural or paravertebral analgesia, and no significant prolonged postoperative coagulopathy is associated with patients undergoing major hepatic resection surgical procedures, these regional analgesia strategies can be considered a safe option for pain management in this patient population.

Official Title
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A Comparison of the Efficacy of Alternative Analgesia Modalities in Complex Hepatic Resection Surgery: Thoracic Epidural Analgesia Versus Continuous Paravertebral Block With Patient-Controlled Analgesia Versus Patient-Controlled Analgesia

Conditions
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Pain Management Strategies in Liver Resection Surgery

Intervention / Treatment
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* Device: thoracic epidural
* Device: continuous paravertebral catheter
* Drug: Patient-Controlled Analgesia


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Age >/= 18 years and </= 80 years Scheduled for elective hepatic resection surgery Exclusion Criteria: Preexisting coagulopathy (INR >1.5) Spinal stenosis Local infection in area where catheter will be inserted Severe cardiovascular disease (NYHA Class III/IV) Severe pulmonary disease (FEV1 <50% of predicted value) Allergy or sensitivity to narcotics or local anesthetics BMI >45 Inability to give informed consent

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 80 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Single Group Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Thoracic Epidural<br> | Device: thoracic epidural<br>* Thoracic Epidural catheters will be placed between T8-12 interspaces preoperatively. Epidural hydromorphone (200-600mcg) will be given preoperatively. TEA will be dosed intraoperatively with a continuous infusion of 0.25% bupivacaine at 3-6ml per hour. At the end of surgery, infusion will be changed to 0.125% bupivacaine + 10mcg/ml hydromorphone at 4-6ml/hour. In PACU, a PCEA button will given to the patient for bolus dosing of 1-2ml and a lockout of 30 minutes. Changes to the epidural infusion solution, rate, and PCEA bolus dosing will be made clinically as required by the Acute Pain Service (APS).<br>|
| Active Comparator: Continuous Paravertebral Catheter<br> | Device: continuous paravertebral catheter<br>* Bilateral PVB catheters will be placed between the T8-12 interspaces preoperatively. 10ml of 0.5% ropivacaine will be injected into the paravertebral space, then catheter placed. The same procedure will be used for the placement of the PVB catheter on the opposite side. The catheter may be bolused with 5ml 0.5% ropivacaine hourly intraoperatively if needed. In PACU, PVB catheters will be infused continuously with 0.2% ropivacaine at 8-12ml/hr. Subjects will also be given a hydromorphone PCA button to deliver additional IV opioid medication to the patient as needed.<br>|
| Active Comparator: Patient-Controlled Analgesia<br> | Drug: Patient-Controlled Analgesia<br>* Intravenous hydromorphone PCA will be initiated postoperatively with dosing prescriptions made by the primary surgical team.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Highest VAS Pain Score at Rest | Post-operative pain scores at rest, as assessed by Pain Assessment Scales (Wong-Baker Faces Scale and Visual Analog Pain Scale (VAS) will be the primary outcome measured. Pain scores will be collected per standard PACU protocol (every 60 minutes) and on the hospital ward at hours 2, 4, 6 and 12, and then daily until day 3 or when the epidural/paravertebral catheter is removed. Postoperative pain at rest will be defined as the highest VAS pain score reported by each patient at any time. Pain score is from 0 (no hurt) to 10 (hurts worst). | postoperatively until regional catheter removed, with an expected average of 3 days and up to 7 days | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Hospital Length of Stay | Hospital length of stay will be recorded for each of the 3 groups to see if there is a statistical difference between groups. | time to discharge after surgery, with an expected average of approximately 7-10 days, up to 6 weeks if complications arise | 
| Gastrointestinal Recovery | Postoperative return of bowel function and time to first feeding will be recorded for each of the 3 groups. | postoperatively until return of bowel function, up to 7 days | 
| Cumulative Postoperative Opioid Requirement | Cumulative postoperative opioid use in morphine equivalents will be recorded for subjects in the 3 arms of the study. The investigators hypothesize that the TEA and/or PVB arms may show less opioid use over PCA. | postpoperatively until regional catheter removed or subjects transitioned to an oral pain management regimen, an expected average of 3 days and up to 7 days | 
| Incidence of Major Postoperative Complication | Major surgical, infectious, respiratory, cardiac, and renal complications will be recorded for subjects in each arm of the study. | time to discharge after surgery, with an expected average of approximately 7-10 days, up to 6 weeks if complications arise | 
| Highest VAS Pain Scores With Coughing | Post-operative pain scores with coughing, as assessed by Pain Assessment Scales (Wong-Baker Faces Scale and Visual Analog Pain Scale (VAS) will be measured. Pain score is from 0 (no hurt) to 10 (hurts worst). | postoperatively until regional catheter removed, with an expected average of 3 days and up to 7 days | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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thoracic epidural, continuous paravertebral catheter, PCA, liver resection, pain management