Clinical trial NCT06521697: Effects of Minimal-Flow Sevoflurane and Multimodal Analgesia in Head and Neck Cancer Surgery
Official title: Anesthetic-sparing and Renal Protection Effects of Minimal-flow Sevoflurane Anesthesia and Multimodal Analgesia Using a Mixture of Dexmedetomidine-ketamine-lidocaine in Head and Neck Cancer Patients With Free Flap Microvascular Surgery
Study type: INTERVENTIONAL
Overall status: NOT_YET_RECRUITING
Phase: PHASE4
Conditions: Head and Neck Cancer
Anesthesia
Renal Protection
Acute Kidney Injury
Multimodal Analgesia
Keywords: Greenhouse gas
Carbon emissions
Acute kidney injury
Multimodal analgesia
Head and Neck Cancer
Lead sponsor: National Taiwan University Hospital
Sponsor class: OTHER
First posted: 2024-07-26
Enrollment: 60
Sex: ALL
Minimum age (years): 18
Maximum age (years): 99
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: RANDOMIZED
Intervention model: FACTORIAL
Intervention model description: This study is a single-center, prospective, 2x2 factorial randomized controlled trial designed to evaluate the anesthetic-sparing and renal protection effects of minimal-flow (intervention 1) sevoflurane anesthesia combined with multimodal analgesia (intervention 2) in head and neck cancer patients undergoing free flap microvascular surgery. Participants will be randomly assigned to one of four groups:

Fresh gas flow at 0.5 L/min with dexmedetomidine-ketamine-lidocaine mixture. Fresh gas flow at 0.5 L/min with normal saline. Fresh gas flow at 1.0 L/min with dexmedetomidine-ketamine-lidocaine mixture. Fresh gas flow at 1.0 L/min with normal saline.

The study uses triple blinding (participant, care provider, investigator) to ensure unbiased results. The primary purpose of the study is treatment, aiming to reduce anesthetic usage and assess renal protection.
Primary purpose: PREVENTION

Brief summary: This study evaluates the anesthetic-sparing and renal protection effects of minimal-flow sevoflurane anesthesia combined with multimodal analgesia using dexmedetomidine, ketamine, and lidocaine in head and neck cancer patients undergoing free flap microvascular surgery. The 2x2 factorial randomized controlled trial aims to compare sevoflurane usage and renal function changes with different fresh gas flow rates and multimodal analgesia.

Detailed description: This study investigates the anesthetic-sparing and renal protection effects of minimal-flow sevoflurane anesthesia combined with a multimodal analgesia strategy using dexmedetomidine, ketamine, and lidocaine in head and neck cancer patients undergoing free flap microvascular surgery. The trial employs a 2x2 factorial randomized controlled design to evaluate the effectiveness of different fresh gas flow rates and multimodal analgesia on sevoflurane usage and renal function.

Background and Significance:

Sevoflurane, a widely used anesthetic for prolonged surgeries, significantly contributes to healthcare-related greenhouse gas emissions. Reducing fresh gas flow during anesthesia effectively minimizes anesthetic usage, but concerns about potential renal damage hinder its clinical application. Recent studies show that sevoflurane enhances renal sympathetic nerve activity, leading to decreased renal blood flow and increased risks of acute kidney injury, particularly when coupled with factors like low blood pressure.

Multi-modal analgesia combining drugs like dexmedetomidine, ketamine, and lidocaine has emerged as a trend in anesthesiology. These drugs not only reduce sevoflurane usage but may also counteract its renal effects. This project aims to investigate the renal protective effects and anesthetic reduction potential of a multi-modal analgesia strategy in head and neck cancer surgeries.

Study Objectives:

To evaluate the anesthetic-sparing effect of minimal-flow sevoflurane anesthesia (0.5 L/min) combined with dexmedetomidine-ketamine-lidocaine multimodal analgesia.

To assess the renal protection effects of dexmedetomidine-ketamine-lidocaine multimodal analgesia during minimal-flow sevoflurane anesthesia.

To examine the safety and other potential effects (e.g., hemodynamic stability, postoperative cognitive function) of the combined anesthesia strategy.

Methods:

The study will be conducted at National Taiwan University Hospital and will involve adult patients (18-99 years) scheduled for head and neck cancer tumor resection and free flap reconstruction surgery. Patients will be randomized into four groups in a 2x2 factorial design:

Group 1 (HL + D): Fresh gas flow at 0.5 L/min with dexmedetomidine-ketamine-lidocaine mixture.

Group 2 (HL): Fresh gas flow at 0.5 L/min with normal saline. Group 3 (D): Fresh gas flow at 1.0 L/min with dexmedetomidine-ketamine-lidocaine mixture.

Group 4 (Control): Fresh gas flow at 1.0 L/min with normal saline. The dexmedetomidine-ketamine-lidocaine mixture will be continuously infused from the induction of anesthesia until the end of surgery. Fresh gas flow settings will be maintained using the EtControl function of the GE Aisys CS2 anesthesia machine. Anesthetic depth and hemodynamic parameters will be monitored throughout the procedure.

Data Collection:

Primary Outcome Measures: Sevoflurane usage (mL/h) and changes in renal function (serum renin, AVP levels, urine KIM-1, NGAL levels).

Secondary Outcome Measures: Incidence of acute kidney injury, hemodynamic stability, postoperative pain scores, length of hospital stay, and postoperative cognitive function.

Blood and urine samples will be collected at four time points: before anesthesia induction, upon arrival in the ICU, 24 hours post-surgery, and 48 hours post-surgery. Clinical data, including demographic information, surgical details, anesthetic drug usage, hemodynamic parameters, and postoperative outcomes, will also be recorded.

Statistical Analysis:

Data will be analyzed using appropriate statistical methods, including Student's t-test, Mann-Whitney U test, Chi-square test, Fisher's exact test, and multivariate analysis of variance (MANOVA). Statistical significance will be defined as p \< 0.05.

Potential Challenges and Solutions:

Potential challenges include patient recruitment and adherence to protocol. To mitigate these, the study will involve experienced anesthesiologists and research staff who will ensure proper patient selection and protocol compliance.

Expected Outcomes:

The study aims to propose a feasible strategy to mitigate sevoflurane's renal effects, crucial for patients at risk of acute kidney injury. It also seeks to validate that minimal fresh gas flow (0.5 L/min) during sevoflurane anesthesia, coupled with multimodal analgesia, reduces sevoflurane usage, saving costs and contributing to carbon reduction. Additionally, the study will explore the potential protective effects of the multimodal analgesia strategy on other organs during prolonged surgeries.

Eligibility criteria: Inclusion Criteria:

* Age 18-99 years
* Scheduled for head and neck cancer tumor resection and free flap reconstruction surgery

Exclusion Criteria:

* Preoperative tracheostomy
* History of previous head and neck cancer tumor resection
* Anemia (hematocrit \<30% or recent transfusion)
* Hypertension on ACEI/ARB medications
* Significant medical conditions (e.g., NYHA class 3 or 4 heart failure, eGFR \<60 ml/min/1.73 m², Child B or C liver failure, severe respiratory disorders, pre-existing cognitive impairment)
* ASA physical status 4 or 5
* Allergies to sevoflurane, dexmedetomidine, ketamine, or lidocaine

Primary outcomes:
measure: Sevoflurane usage (mL/h)
timeFrame: Intraoperative period
measure: Renal function
timeFrame: Perioperative period
Secondary outcomes:
measure: Acute kidney injury
timeFrame: Perioperative period
measure: Hemodynamic stability_1
timeFrame: Intraoperative period
measure: Hemodynamic stability_2
timeFrame: Intraoperative period
measure: Hemodynamic stability_3
timeFrame: Intraoperative period
measure: Postoperative analgesic effect_1
timeFrame: Perioperative period
measure: Postoperative analgesic effect_2
timeFrame: Perioperative period
measure: Length of hospital stay
timeFrame: Perioperative period
measure: Cognitive function
timeFrame: Perioperative period
Other outcomes:
Locations:
Study officials:
affiliation: National Taiwan University Hosital
name: Ming-Hui Hung, MD
role: PRINCIPAL_INVESTIGATOR
References: