Pain Management After Cardiac Surgery - Opioids or NSAID

Study Overview
=================
Brief Summary
-----------------
The aim of this randomized controlled study is to shed light on the analgesic properties and side-effect profile of an opiod-based regimen as opposed to an Ibuprofene based regimen.

Detailed Description
-----------------
Background: Postoperative pain following median sternotomy can represent a major postoperative problem as it can lead to reduced mobilization and shallow, restricted breathing and insufficient cough, which can lead to pulmonary complications. However, pain management with opioids has frequent side-effects such as confusion, respiratory depression, sedation, nausea and obstipation/ paralytic ilieus. Non-steroid anti-inflammatory drugs (NSAIDs) can been used as opiod-sparing analgesics following cardiac surgery. However, this remains controversial, as NSAIDs has been linked to an increased risk of myocardial infarction, especially in patients with ischaemic heart disease, renal failure, gastrointestinal bleeding, and possibly impaired sternal healing. The investigators wanted to investigate the analgesic properties of a opiod-based regimen with that of an ibuprofene-based, through randomization of patients to one of the two arms. Intervention: The participants were given analgesics in accordance to their randomization group upon return from the postoperative ICU stay. The opioid regimen relied on a basic dose of slow-release oxycodone (Oxycontin, Norpharma, Vedbaek, Denmark, 10mg two times daily) and paracetamol (Panodil, GlaxoSmithKline, Copenhagen, Denmark, 1g four times daily). For break-through pain extra oxycodone was administered as injections or capsules (5mg pr. dose). Furthermore laxatives were co-administered to prevent obstipation. In the ibuprofene regimen slow-release ibuprofen (Brufen Retard, Abbott, Copenhagen, Denmark, 800mg two times daily) replaced oxycodone as the basic analgesic. In the ibuprofene regimen lansoprazol (Lansoprazole, Actavis, Gentofte, Denmark, 30mg once daily) was co-administered to prevent development of gastric ulcers. These regimens were initiated the first postoperative day, when the patient was transferred from the ICU to the ward, and continued until the seventh postoperative day. Some patient Outcome: Please refer to the outcome chapter Statistics: Data are presented as number of patients, medians, and ranges. Patients are compared according to the ibuprofen or the oxycodone group, and statistics were done using intention-to-treat-design. Fischer's exact test, Mann-Whitney, and 95% confidence intervals were used as appropriate. Significance was defined as P-values below 0.05.

Official Title
-----------------
Pain Management After Cardiac Surgery - Opioids or NSAID? A Randomized Prospective Study

Conditions
-----------------
Postoperative Pain, Renal Insufficiency, Myocardial Infarction

Intervention / Treatment
-----------------
* Drug: Ibuprofene
* Drug: Oxycodone


Participation Criteria
=================
Eligibility Criteria
-----------------
Inclusion Criteria: Cardiac surgery through median sternotomy Written consent Age over 18 years Exclusion Criteria: Other forms of sternotomy (i.e. re-sternotomy or partial sternotomy) Preoperative creatinine over 110 µmol/L Preoperative use of opioids or NSAIDs in analgesic doses (aspirin in antithrombotic doses was accepted) Allergy to NSAIDs or opioids, and other contraindications to the used drugs The postoperative exclusion criteria were: Staying more than one night at the intensive care unit Unacceptable side effects Exclusion at the patients request

Ages Eligible for Study
-----------------
Minimum Age: 18 Years

Sexes Eligible for Study
-----------------
All

Accepts Healthy Volunteers
-----------------
No

Study Plan
=================
How is the study designed?
-----------------

Design Details

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


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Opioid group<br>If randomized to the opiod group, the patient was given the following regimen for 1 week, upon return from the intensive care unit, after surgery. Tbl. Oxycodone (slow-release) 10mg, Twice daily for 1 week Tbl. Paracetamol 1000mg, Four times daily for 1 week Tbl.oxycodone 5mg Max 4 times daily, as needed, until discharge. Inj, oxycodone 2.5 mg, Max 4 times daily, as needed, until discharge Tbl. Magnesia 1g, Twice daily, for 1 week Sol. Sodiumpicosulfate 7.5mg/ml 10 drops daily, for 1 week | Drug: Oxycodone<br>* The opioid group is given an oxycodone based analgesic regimen.<br>* Other names: Oxycontin;|
| Active Comparator: Ibuprofene group<br>If randomized to the ibuprofen group, the patient was given the following regimen for 1 week, upon return from the intensive care unit, after surgery. Tbl. Ibuprofen (slow-release) 800mg, Twice daily, for 1 week Tbl. Paracetamol 1000mg, Four times daily, for 1 week Tbl.oxycodone 5mg Max 4 times daily, as needed. Until discharge. Inj, oxycodone 2.5 mg Max 4 times daily, as needed. Until discharge. Tbl. Lanzoprazole 40 mg, Once daily, for 1 week Tbl. Magnesia 1g, Twice daily, for 1 week Sol. Sodiumpicosulfate 7.5mg/ml, 10 drops daily, for 1 week | Drug: Ibuprofene<br>* The Ibuprofene group is given an ibuprofen based analgesic regimen, to be compared with the standard opiod based regimen.<br>* Other names: Nurofen;|

What is the study measuring?
-----------------
Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Pain score - Visual Analouge Scale | Visual analouge scale from 0-10, recorded at noon every day. Given as average/minimum/maximum previous 24h by patient. Until discharge, average 5th postoperative day. | 5 days | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Bowel movement, hours until movement | Time is noted of first bowel movement. Registration until discharge, average 5th postoperative day. | 5 days | 
| Nausea, Hours | At noon, the total hours of nausea over the previous 24h is noted. Registration until discharge, average 5th postoperative day. | 5 days | 
| Vomiting, events pr. 24 hours | Number of themes the patient has vomitted is noted. Registration until discharge, average 5th postoperative day. | 5 days. | 
| Hallucination, events pr. 24 hours | At noon, it is recorded wether the patient has experienced hallucinations the previous 24h. Registration until discharge, average 5th postoperative day. | 5 days | 
| Confusion | At noon, it is recorded wether the patient can name the given time, physical location own social security number. Registration until discharge, average 5th postoperative day. | 5 days | 
| Opioid antidote | At noon, it is recorded if the patient is given opiod antagonists (such as Naloxone) the previous 24h. Registration until discharge, average 5th postoperative day. | 5 days | 
| Renal function as serum-creatinine (micromol/l) | Se-creatinine recorded on the morning of postoperative day 1, 2 and 4 and as out-patient at followup. | 36 months | 
| Myocardial Infarction, no. of cases | Postoperative myocardial infarction according to ESC/ACC/AHA/WHF consensus-report. Registration until discharge, average 5th postoperative day, and as outpatients until followup. | 36 months | 
| All cause mortality | All cause mortality until followup. | 36 months | 
| Sternal non-union, no of cases | Sternal non-union from 1 month after surgery until followup. | 36 months | 
| Gastro-intestinal bleeding, no. of cases | Bleeding verified through gastroscopi or colonoscopi from operation until followup. | 36 months | 
| Degree of mobilization, Mobilization scale | At noon, the degree of mobilization is noted on an scale from 0 (complete immobilization) - 4 (complete mobilization). Registration until discharge, average 5th postoperative day. | 5 days |