Clinical trial NCT04964219: Analgesic Effects of Low-dose S-ketamine in Major Spine Fusion Surgery
Official title: Analgesic Effects of Low-dose S-ketamine in Patients Undergoing Major Spine Fusion Surgery: A Double-blinded, Randomized Controlled Trial
Study type: INTERVENTIONAL
Overall status: RECRUITING
Phase: PHASE4
Conditions: S-ketamine
Postoperative Analgesia
Spine Fusion
Keywords: S-ketamine
Postoperative Analgesia
Spine Fusion
Lead sponsor: Peking University First Hospital
Sponsor class: OTHER
First posted: 2021-07-16
Enrollment: 164
Sex: ALL
Minimum age (years): 18
Maximum age (years): 80
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: RANDOMIZED
Intervention model: PARALLEL
Primary purpose: TREATMENT

Brief summary: Despite opioid-based multimodal analgesia, moderate-to-severe pain remains a big problem in patients following multi-segment spinal fusion. As a N-methyl-D-aspartate receptor antagonist, S-ketamine has prominent analgesic effects through activating receptors both in the brain and in the spinal cord, inhibiting the excitatory postsynaptic potential, and thus blunting nociception transmission.

This randomized controlled trial is designed to investigate whether perioperative S-ketamine infusion can decrease pain intensity after major spine fusion surgery.

Detailed description: Multi-segment spinal fusion usually lasts long and produces significant trauma. Patients following this surgery are at high risk of developing moderate-to-severe pain. In a large sample size cohort study investigating pain severity following 179 kinds of surgical procedures, multi-segment spinal fusion ranked the third with a median pain score of 6.6 (assessed with an 11-point scale, where 0=no pain and 10= the worst pain) and a median morphine consumption of 27 mg during the first postoperative day.

High-dose opioids are associated with adverse effects including respiratory depression, sedation, nausea and vomiting, pruritus, and constipation, which are harmful for early postoperative recovery. A previous study showed that about 50% of patients are taking opioids for chronic pain at 3 months after spinal fusion surgery. Chronic pain is considered to be a result of poorly controlled acute postoperative pain. Thus, multimodal analgesia aiming at improving analgesia while decreasing opioid consumption is advocated to control acute postsurgical pain, in order to promote perioperative recovery and prevent chronic pain.

Racemic ketamine, a commonly used N-methyl-D-aspartate receptor antagonist, is a mixture of equal parts of two optical isomers including R-(-)-ketamine and S-(+)-ketamine. It has prominent analgesic effects through activating receptors both in the brain and in the spinal cord, inhibiting the excitatory postsynaptic potential, and thus blunting nociception transmission. Additionally, studies also showed that, when used within the appropriate time, ketamine reduces pain-related sensitization that aggravates postoperative pain. Thus, ketamine is recommended as a part of a multimodal analgesia regimen in clinical practice, especially for patients undergoing major orthopedic surgery. However, the reported psychotropic side effects limit the clinical use of racemic ketamine.

S-ketamine, an S-isomer of ketamine, is twice as potent as the racemic mixture in analgesia, and produces fewer side effects than the racemic ketamine. How, there are only a few studies exploring analgesic effect of S-ketamine in spine fusion surgery. In opioid-dependent patients, Nielsen et al. reported that intraoperative S-ketamine infusion reduced opioid consumption within 24 hours and relieved back pain intensity at 6 months, it also decreased the daily opioid use at 1 year after spinal surgery. On the other hand, the study of Brinck et al. did not found any superiority of intraoperative S-ketamine in reducing oxycodone consumption within 48 hours after lumbar fusion surgery in opioid-naive patients.

Considering these inconsistent results, the effects of S-ketamine in spinal surgery require further clarification. This trial is designed to investigate the analgesic effect of S-ketamine infused both intraoperatively and postoperatively in patients undergoing multi-segment spine infusion surgery.

Eligibility criteria: Inclusion Criteria:

* Patients aged between 18 and 80 years.
* Scheduled to undergo multi-segment (≥2) spine fusion surgery.
* Agreed to receive postoperative patient-controlled analgesia.

Exclusion Criteria:

* Refused to participant in this trial.
* Poor blood pressure control in those with hypertension (BP \>160/100 mmHg in the ward).
* Previous history of hyperthyroidism or pheochromocytoma.
* Previous history of schizophrenia, epilepsy or Parkinson disease.
* History of sick sinus syndrome, bradycardia (HR \<50 beat per min), or atrioventricular block of grade II or higher without pacemaker.
* Severe heart dysfunction (New York Heart Association functional classification 4), hepatic insufficiency (Child-Pugh grade C), renal insufficiency (serum creatinine of 442 μmol/L or above, or requirement of renal replacement therapy), or ASA classification IV or above.
* Unable to complete preoperative assessment due to severe dementia or language barrier.
* Any other conditions that were considered unsuitable for the study participation.

Primary outcomes:
measure: The percentage of patients with moderate-to-severe pain in the first 48 hours after surgery.
timeFrame: Up to 48 hours after surgery
Secondary outcomes:
measure: Opioid consumption during anesthesia
timeFrame: From induction to end of anesthesia
measure: Cumulative opioid consumption after surgery
timeFrame: From end of anesthesia to the 5th day after surgery
measure: NRS pain score at rest and with movement
timeFrame: Up to postoperative day 5
measure: The percentage of using rescue analgesics
timeFrame: Up to postoperative day 5
measure: Subjective sleep quality
timeFrame: Up to postoperative day 5
measure: Time to first ambulation
timeFrame: Up to 30 days after surgery
measure: Quality of recover after surgery
timeFrame: On the third day after surgery
measure: Length of hospital stay after surgery
timeFrame: Up to 30 days after surgery
measure: The percentage of taking oral analgesics
timeFrame: On the 30th day after surgery
measure: The severity of anxiety and depression
timeFrame: On the 30th day after surgery
measure: The incidence of postoperative complications and mortality
timeFrame: Up to 30 days after surgery
Other outcomes:
measure: Sedation or agitation level
timeFrame: Up to 5 days after surgery
measure: The incidence of postoperative nausea and vomiting
timeFrame: Up to 5 days after surgery
measure: The incidence of delirium
timeFrame: Up to 5 days after surgery
measure: The incidence of other adverse events (dizziness, nightmares, hallucination and etc.)
timeFrame: Up to 5 days after surgery
measure: The percentage of adverse events requiring therapeutic intervention
timeFrame: Up to 5 days after surgery
Locations:
city: Beijing
country: China
facility: Beijing University First Hospital
state: Beijing
Study officials:
affiliation: Peking University First Hospital
name: Dong-Xin Wang, MD, PhD
role: PRINCIPAL_INVESTIGATOR
References:
citation: Gerbershagen HJ, Aduckathil S, van Wijck AJ, Peelen LM, Kalkman CJ, Meissner W. Pain intensity on the first day after surgery: a prospective cohort study comparing 179 surgical procedures. Anesthesiology. 2013 Apr;118(4):934-44. doi: 10.1097/ALN.0b013e31828866b3.
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