Esketamine vs. Ketorolac for Prevention of Postoperative Pain and Cognitive Dysfunction After Total Knee Arthroplasty

Study Overview
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Brief Summary
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Purpose: To compare esketamine and ketorolac separately and in combination to prevent postoperative pain and cognitive dysfunction after total knee arthroplasty

Detailed Description
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With the increase in human life span, orthopedic injuries and subsequent repair surgery have become a major health problem which impairs the life quality of patients and burdens healthcare systems worldwide. Poor post-surgical pain control is a leading factor that hinders the physical rehabilitation and musculoskeletal functional recovery, and causes acute cognitive impairment and chronic pain syndrome. Therefore, prophylaxis of postoperative pain is indispensable to postoperative comfort and satisfaction. There is no denying the fact that pathologic pain is related to central glutaminergic system and N-methyl-d-aspartate (NMDA) receptor activation induced central sensitization. Also, it is previously reported that neuroinflammation is associated with pain development and cognitive dysfunction. Ketamine, a NMDA receptor antagonist, is effective in reversing NMDA receptor activation underlying pain states. But the side effects of ketamine limit its clinical application, such as gibberish and agitation. It is clarified that esketamine has lower side effects than ketamine and that antinociception of esketamine is stronger than ketamine. The following study is carried out to evaluate whether esketamine and ketorolac can prevent postoperative pain and cognitive impairment after total knee arthroplasty in patients.

Official Title
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Esketamine vs. Ketorolac for Prevention of Postoperative Pain and Cognitive Dysfunction After Total Knee Arthroplasty in Patients: a Randomized Double-blind Controlled Trial

Conditions
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Postoperative Pain, Postoperative Cognitive Dysfunction, Total Knee Arthroplasty

Intervention / Treatment
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* Drug: Normal saline
* Drug: Esketamine at high dose
* Drug: Esketamine at low dose
* Drug: Ketorolac at high dose
* Drug: Ketorolac at low dose


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Subject is scheduled to undergo total knee arthroplasty under a short general anesthesia of less than 2 hours Subject's American Society of Anesthesiologists physical status is I-II. The subject's parent/legally authorized guardian has given written informed consent to participate. Exclusion Criteria: Subject has a diagnosis of bronchial asthma, coronary heart disease, severe hypertension, renal failure or liver failure. Subject has a diagnosis of Insulin dependent diabetes. Subject is allergy and contraindication to esketamine or ketorolac. Subject has a history of chronic pain, a history of alcohol or opioid abuse, pre- existing therapy with opioids. Subject has any contraindication for the use of patient-controlled analgesia (PCA). Subject is pregnant or breast-feeding. Subject is obese (body mass index >30kg/m^2). Subject is incapacity to comprehend pain assessment and cognitive assessment.

Ages Eligible for Study
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Minimum Age: 65 Years
Maximum Age: 85 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: Prevention
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Triple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Placebo Comparator: Normal saline in patients<br>After the induction of anesthesia, normal saline is intravenously injected in a volume of 2ml, and then a continuous infusion of 20 ml/h normal saline until starting skin suture. | Drug: Normal saline<br>* After the induction of anesthesia, normal saline is intravenously injected in a volume of 2ml, and then a continuous infusion of 20ml/h normal saline until starting skin suture.<br>* Other names: 0. 9% Sodium Chloride Injection;|
| Active Comparator: Esketamine in patients<br>After the induction of anesthesia, esketamine is intravenously injected at 0.4mg/kg, and then a continuous infusion of 0.4mg/kg/h esketamine until starting skin suture. | Drug: Esketamine at high dose<br>* After the induction of anesthesia, esketamine is intravenously injected at 0.4mg/kg, and then a continuous infusion of 0.4mg/kg/h esketamine until starting skin suture.<br>* Other names: Esketamine Hydrochloride Injection;|
| Active Comparator: Ketorolac in patients<br>After the induction of anesthesia, ketorolac is intravenously injected at 0.4mg/kg, and then a continuous infusion of 0.4mg/kg/h ketorolac until starting skin suture. | Drug: Ketorolac at high dose<br>* After the induction of anesthesia, Ketorolac is intravenously injected at 0.4mg/kg, and then a continuous infusion of 0.4mg/kg/h Ketorolac until starting skin suture.<br>* Other names: Ketorolac Tromethamine;|
| Active Comparator: Esketamine and Ketorolac in patients<br>After the induction of anesthesia, 0.2mg/kg esketamine and 0.2mg/kg ketorolac are intravenously injected, and then a continuous infusion of 0.2mg/kg/h esketamine and 0.2mg/kg/h ketorolac until starting skin suture. | Drug: Esketamine at low dose<br>* After the induction of anesthesia, esketamine is intravenously injected at 0.2mg/kg, and then a continuous infusion of 0.2mg/kg/h esketamine until starting skin suture.<br>* Other names: Esketamine Hydrochloride Injection;Drug: Ketorolac at low dose<br>* After the induction of anesthesia, Ketorolac is intravenously injected at 0.2mg/kg, and then a continuous infusion of 0.2mg/kg/h Ketorolac until starting skin suture.<br>* Other names: Ketorolac Tromethamine;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Cumulative opioid Consumption | Each patient was administered analgesics using a PCA (Patient-controlled analgesia) pump containing sufentanil in normal saline after leaving PACU (Postanesthesia care unit). Sufentanyl cumulative consumption is recorded 72 hours postoperatively | 72 hours after surgery | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Pain Score (NRS) after movement | The pain score after movement was evaluated by pain 11-point numerical rating scale (NRS): 0 = no pain, 10 = greatest imaginable pain. | 72 hours after surgery | 
| Time of First Postoperative Analgesic Requirement | First postoperative pain (NRS≥5) is initially controlled by titration of sufentanyl. | 1 hour after surgery | 
| Total Dose of First Postoperative Analgesic Requirement | First postoperative pain (NRS≥5) is initially controlled by titration of sufentanyl. | 1 hour after surgery | 
| Mini-Mental State Examination (MMSE) | Cognitive performance was assessed with 0-30 points Mini-Mental State Examination (MMSE) scale. Greater scores means better outcome. | 72 hours after surgery | 
| The incidence of Side Effects | The number of patients with post-operative side effects including nausea, vomiting, dizziness, headache, shivering, and pruritus was recorded 72 hours after surgery. | 72 hours after surgery | 
| The levels of TNF-a in blood | Blood samples are collected to measure the levels of cytokine TNF-a using ELISA kits. | 72 hours after surgery | 
| The levels of chemokine CXCL1 in blood | Blood samples are collected to measure the levels of chemokine CXCL1 using ELISA kits. | 72 hours after surgery | 
| The levels of neuron specific enolase (NSE) in blood | Blood samples are collected to measure the levels of neuron specific enolase (NSE) using electrochemilumiscence kit. | 72 hours after surgery | 
| The levels of S-100 calcium-binding protein B in blood | Blood samples are collected to measure the levels of S-100 calcium-binding protein B using electrochemilumiscence kit. | 72 hours after surgery | 
| The levels of cortisol in blood | Blood samples are collected to measure the levels of cortisol using electrochemilumiscence kit. | 72 hours after surgery | 
| Pain Score (NRS) at rest | The pain score at rest was evaluated by pain 11-point numerical rating scale (NRS): 0 = no pain, 10 = greatest imaginable pain. | 72 hours after surgery | 
| The levels of chemokine CCL7 in blood | Blood samples are collected to measure the levels of chemokine CCL7 using ELISA kits. | 72 hours after surgery | 
| The levels of IL-18 in blood | Blood samples are collected to measure the levels of cytokine IL-18 using ELISA kits. | 72 hours after surgery | 
| The levels of IL-23 in blood | Blood samples are collected to measure the levels of cytokine IL-23 using ELISA kits. | 72 hours after surgery | 
| The levels of IL-17 in blood | Blood samples are collected to measure the levels of cytokine IL-17 using ELISA kits. | 72 hours after surgery | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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esketamine, ketorolac