Clinical trial NCT03954379: IPACK Study in Total Knee Arthroplasty Patients
Official title: Opioid Sparing Analgesic Strategies for Enhanced Recovery After Total Knee Arthroplasty
Study type: INTERVENTIONAL
Overall status: COMPLETED
Phase: PHASE4
Conditions: Knee Replacement Arthroplasty
Lead sponsor: University Health Network, Toronto
Sponsor class: OTHER
First posted: 2019-05-17
Enrollment: 78
Sex: ALL
Minimum age (years): 18
Maximum age (years): 85
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: yes
Allocation: RANDOMIZED
Intervention model: PARALLEL
Primary purpose: TREATMENT

Brief summary: This study proposes to compare current multimodal analgesic treatment for TKA with a new multimodal analgesic regimen to demonstrate decreased opioid requirement, time to rehabilitation, and time to reach hospital discharge.

Detailed description: Total knee replacement surgery (TKA) causes severe pain and this procedure is the most common reason patients are prescribed strong opioid drugs in hospital. As a result they are slow to begin rehabilitation after surgery, and are late in hospital discharge. Ontario hospitals are constantly challenged to meet growing demands of TKA and in fact increased demand has overcome the health care system resulting in TKA wait time (Ontario actual: 286 days vs. target: 182 days).1 One strategy to accommodate expanding volume and reduce wait time is to reduce hospital length of stay (LOS) through an enhanced recovery program.2 One essential component is further improvement of postoperative pain treatment to expedite rehabilitation and hospital discharge.

Treatment of severe post TKA pain often requires potent opioids but their excessive and prolonged use has negative consequences e.g., increased perioperative adverse events and longer LOS.3 Approximately 8% of opioid naive TKA patients become chronic opioid users at 6 months and the duration of prescription is the strongest predictor of misuse.4 Knowing that the opioid crisis in Canada is steadily growing and prescription opioids play a significant role in dependence and misuse,5 an effective perioperative opioid minimization analgesic program is mandatory for TKA patients.

Current multimodal analgesic treatment for TKA consists of oral non opioid drugs e.g., acetaminophen and non steroidal anti-inflammatory agents (NSAIDs) and surgeon performed peri-articular local anesthesia infiltration, however this is only partially effective.6 The regional analgesic effect is often short lived (\< 8 hours). Failure to sustain effective analgesia necessitates continued heavy reliance on opioids.

Several new treatments have been recently described for post TKA pain. They are: IV dexamethasone (steroid),7 dexmedetomidine (alpha 2 agonist)8, ketamine (NMDA antagonist)9 and 2 novel nerve block procedures- adductor canal block10 and iPACK block (infiltration between popliteal artery and posterior capsule of the knee).11 While each individual intervention has demonstrable analgesic benefit, the impact of incorporating all new treatments into the current analgesic regimen remains unknown.

The investigators believe that the new multimodal analgesic regimen proposed in this study will significantly decrease opioid requirement, time to rehabilitation, and time to reach hospital discharge criteria. It may also decrease the duration of opioid prescription for pain relief after hospital discharge. Although investigator's preliminary experience with this new regimen in 10 patients is promising, robust evidence showing its sustained opioid sparing analgesic effect is lacking.

Eligibility criteria: Inclusion criteria:

* English-speaking;
* Age 18 - 85;
* BMI ≤ 38;
* Undergoing unilateral primary total knee arthroplasty surgery.

Exclusion criteria:

* inability to give informed consent
* patient refusal
* pregnancy, patients who are breastfeeding
* contraindication to nerve blocks or multimodal analgesia
* contraindication or hypersensitivity to any of the study drugs (celecoxib, acetaminophen, morphine, ropivacaine, bupivacaine, ketamine, dexmedetomidine, dexamethasone, ketorolac, epinephrine, sulfonamides)
* chronic pain disorders (\> 50 mg oral morphine equivalence per day at time of recruitment)
* medical or recreational use of marijuana and substance abuse (e.g., alcoholism),
* complications after surgery that result in discharge to a location other than home
* severe cardiovascular diseases e.g., heart failure, significant dysrhythmias; uncontrolled low blood pressure e.g., systolic blood pressure ≤ 100 mm Hg while on antihypertensive medication(s)
* respiratory diseases e.g., severe asthma, urticaria, or allergic-type reactions after taking acetylsalicylic acid (ASA) or other NSAIDs; severe acute or chronic respiratory disease and obstructive airway
* severe or active liver disease
* severe inflammatory bowel disease
* severe renal impairment (creatinine clearance \<30 mL/min)
* uncontrolled diabetes (type 1 or 2)
* active bleeding condition (e.g., postoperative or gastro-intestinal bleeding)
* severe psychiatric disorders and intake of monoamine oxidase inhibitors
* neurologic disorders (e.g., operative extremity neuropathy, delirium tremens, uncontrolled convulsive disorders, increased cerebrospinal or intracranial pressure)

Primary outcomes:
measure: postoperative opioid consumption in MG
timeFrame: 24 hours
Secondary outcomes:
measure: Pain scores at rest using numerical rating scale (NRS, 0 to 10)
timeFrame: 0-48 hours after surgery
measure: Opioid consumption in MG
timeFrame: 12 hours to 6 weeks after surgery
measure: Quality of Recovery (QoR) assessed using a validated QoR-15 tool ( Total score range- 0 to 150, higher values represent a better outcome)
timeFrame: Baseline, 24-hour, 48-hour and 2-weeks after surgery
measure: Time to reach physical therapy milestones in hours
timeFrame: 0-72 hours after surgery
measure: Time to reach hospital discharge criteria in hours
timeFrame: 24 to 72 hours after surgery until discharge
measure: Incidence of adverse events related to nerve block procedures
timeFrame: Post-op 24 to 72 hours
measure: Incidence of adverse events related to opioid consumption
timeFrame: Post-op 24 to 72 hours
Other outcomes:
Locations:
city: Toronto
country: Canada
facility: Toronto Western Hopspital
state: Ontario
Study officials:
affiliation: University Health Network, Toronto
name: Vincent Chan, MD
role: PRINCIPAL_INVESTIGATOR
References: