Effect of the PIEB Versus CEI on the Quality of Postoperative Recovery in Patients Undergoing VATS Lobectomy

Study Overview
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Brief Summary
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In recent years, lobectomy under VATS(Video-assisted thoracic surgery,VATS) has gradually emerged, but there is still a proportion of patients with postoperative pain that affects their postoperative recovery. Epidural analgesia (EA) , the gold standard for postoperative analgesia in thoracic surgery, is currently administered in two ways: 1) continuous epidural infusion 2) programmed intermittent epidural bolus. The former is currently the commonly used method of anesthetic infusion, while the latter has been better studied in obstetrics and major abdominal surgery, but is still unclear in thoracic medicine. This paper aims to investigate the impact of both drug delivery methods on the quality of postoperative recovery in patients undergoing lobectomy by VATS.

Detailed Description
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In recent years, video-assisted thoracic surgery (VATS) has largely matured and gained widespread acceptance. Patients undergoing VATS have been reported to have less postoperative pain and a better quality of life. VATS has fewer overall post-operative complications, shorter hospital stays and lower rates of blood transfusion than conventional open surgery. However, about 38% of patients who underwent VATS were still reported to have severe postoperative pain. The placement of a thoracic drain increases the level of post-operative pain, especially when the patient breathes deeply, moves around or coughs, making the patient afraid to cooperate with deep breathing or coughing after surgery, thus increasing the chance of post-operative atelectasis and lung infection. Epidural analgesia (EA) is the 'gold standard' for postoperative analgesia in the thoracic surgery and is an important component of multimodal analgesia in thoracic surgery. Continuous epidural infusion (CEI) of local anesthetic combined with patient-controlled analgesia (PCA) is an effective method of post-operative analgesia in thoracic surgery. However, CEI has some disadvantages, such as increased consumption of local anesthetic and limited distribution area of anesthetic, which does not suppress pain during deep breathing or coughing in the postoperative period very well, resulting in poor appetite and reduced quality of recovery. Programmed intermittent epidural bolus (PIEB) is an epidural analgesia modality that has emerged in recent years and has been more comprehensively studied in the field of postoperative analgesia in obstetrics. PIEB mode has been shown to provide better analgesia and lower consumption of local anesthetic compared to the traditional CEI mode. The current study of PIEB in thoracic surgery under VATS is still unclear and we wanted to investigate the effect of procedural intermittent epidural bolus (PIEB) versus continuous epidural infusion (CEI) on the quality of recovery in patients undergoing lobectomy by VATS. The trial was divided into two groups, with the control group (CEI group) using a continuous epidural infusion and the trial group (PIEB group) using a programmed intermittent epidural infusion. All subjects received a standardised epidural solution containing 0.2% ropivacaine and 0.4（male）/0.3（famale）μg/ml sufentanil. The CEI group was infused continuously at a rate of 0.05*kg ml/h, while the PIEB group was programmed for intermittent infusion with 0.1*kg pumped every two hours. The PCEA is 4ml in both groups. The lockout time for both groups was 60 min. The maximum infusion dosage of the both groups is 10ml/h. Heart rate, ECG, pulse oximetry, invasive blood pressure, and end-expiratory carbon dioxide partial pressure (ETCO2) are routinely monitored on admission. Prior to induction of anaesthesia, ultrasound-assisted epidural puncture placement in the mid-thoracic segment (T5/6 or T6/7 or T7/8) is performed and the success of placement is judged using the disappearance of resistance method. The epidural catheter was placed 5 cm cephalad and 3 mL of 1.5% lidocaine was injected epidurally as a test dose to rule out inadvertent vessel entry and dural breach. This was followed by an epidural push of 10-20 mL of 0.2% ropivacaine with a test plane in the T1-T10 range. General anesthesia was induced with intravenous dexmedetomidine (0.5 ug/kg), propofol (2 mg/kg), sufentanil (0.2 ug/kg) and cis-atracurium (0.15 mg/kg). Anesthesia is maintained with 4ug/ml propofol in TCI model, with additional cis-atracurium as required, followed by additional epidural 0.2 % ropivacaine at the discretion of the anesthetist and recorded as appropriate. Vasoactive drugs may be used as appropriate to maintain blood pressure fluctuations within ±20% of basal blood pressure. The QoR15 rating scale (Quality of Recovery-15, QoR15) is one of the main methods currently used to evaluate postoperative recovery and is a valid, reliable and responsive patient-centred prognostic indicator that is highly acceptable to both patients and clinicians. Therefore, we used the 24h postoperative QoR15 score as the primary outcome.

Official Title
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Effect of the Programmed Intermittent Epidural Bolus Versus Continuous Epidural Infusion on the Quality of Postoperative Recovery in Patients Undergoing VATS Lobectomy

Conditions
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Video-assisted Thoracic Surgery

Intervention / Treatment
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* Procedure: programmed intermittent epidural bolus
* Procedure: continuous epidural infusion
* Drug: ropivacaine and sufentanil


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Proposed lobectomy under VATS under general anesthesia with tracheal intubation Agree to use epidural analgesia after surgery ASA Ⅰ- Ⅲ grade BMI 18.5-30 kg/m2 Age 18-65 years old Exclusion Criteria: Preoperative refusal of surgery due to accident or subjective Neurological dysfunction contraindications to intralesional anesthesia history of preoperative opioid use Patients with abnormal preoperative pain and pain score (NRS) > 3 Patients taking sedative hypnosis, anti-anxiety, and antidepressant drugs for a long time before surgery

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 65 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: Parallel Assignment
Masking: Quadruple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: programmed intermittent epidural bolus group<br>All subjects received a standardised epidural solution containing 0.2% ropivacaine and 0.4（male）/0.3（famale）μg/ml sufentanil. The PIEB group is programmed for intermittent infusion with （0.1*kg）ml pumped every two hours. The lockout time for both groups is 60 min. | Procedure: programmed intermittent epidural bolus<br>* Bolus a certain amount of liquid at fixed intervals according to a predetermined procedure<br>Drug: ropivacaine and sufentanil<br>* 0.15% ropivacaine and 0.4μg/ml sufentanil<br>|
| Active Comparator: continuous epidural infusion group<br>All subjects received a standardised epidural solution containing 0.2% ropivacaine and 0.4（male）/0.3（famale）μg/ml sufentanil. The CEI group was infused continuously at a rate of （0.05*kg）ml/h. The lockout time for both groups was 60 min. | Procedure: continuous epidural infusion<br>* continuous epidural infusion<br>Drug: ropivacaine and sufentanil<br>* 0.15% ropivacaine and 0.4μg/ml sufentanil<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| QoR15 score at 24 hours after surgery | QoR15 score at 24 hours after surgery | Day 1 after surgery | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| QoR15 score at 48 and 72 hours after surgery | QoR15 score at 48 and 72 hours after surgery | 3 days after surgery | 
| Total amount of local anesthetics at 24,48and 72 hours after surgery | Total amount of local anesthetics at 24,48and 72 hours after surgery | 3 days after surgery | 
| NRS scores at rest, deep breathing, activity and cough at 24, 48 and 72 hours after surgery | NRS scores at rest, deep breathing, activity and cough at 24, 48 and 72 hours after surgery | 3 days after surgery | 
| Number of nocturnal PCEA at 24, 48 and 72 hours after surgery | Number of nocturnal PCEA at 24, 48 and 72 hours after surgery | 3 days after surgery | 
| Total number of PCEAs at 24, 48 and 72 hours after surgery | Total number of PCEAs at 24, 48 and 72 hours after surgery | 3 days after surgery | 
| Supplemental analgesic drug rates after 24, 48 and 72 hours after surgery | Supplemental analgesic drug rates after 24, 48 and 72 hours after surgery | 3 days after surgery | 
| Adverse event(Dizziness, nausea, vomiting, pruritus,hypotension ) rates at 24,48and 72 hours after surgery | Adverse event(Dizziness, nausea, vomiting, pruritus,hypotension ) rates at 24,48and 72 hours after surgery | 3 days after surgery | 
| Postoperative Nausea and Vomiting Intensity Score after 24, 48 and 72 hours after surgery | This score is assessed by Postoperative Nausea and Vomiting Intensity Scale .The minimum is 0 and the maximum is 2400.The higher score , the more intense Nausea and Vomiting. | 3 days after surgery | 
| patient satisfaction | patient satisfaction score is from 0 to 100 points. The higher scores, the more satisfaction. | 1 week after surgery | 
| Length of hospital stay | Length of hospital stay | 1 month after surgery | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Programmed intermittent epidural bolus, Continuous epidural infusion, QoR-15, Epidural anesthesia