Chronic Pain Clinical Trial
Official title:
The Effect of Choice of Intraoperative Opioid on Postoperative Pain
The primary aim of this randomized, double-blind study is to examine the effect of a single intraoperative dose of methadone on postoperative pain and analgesic requirements in patients undergoing cardiac surgery with cardiopulmonary bypass. These patients will be compared to subjects receiving a standard dose of the "traditional" intraoperative opioid (fentanyl). Secondary outcome measures to be assessed will include standard recovery variables (such as length of postoperative intubation, ICU length of stay, incidence of nausea or vomiting, level of sedation). In addition, patients will be assessed for the development of chronic postoperative pain.
Patients will be randomized to receive either methadone or fentanyl on the basis of a
computer generated random number table. Patients in each group will receive standard
intraoperative doses of either methadone or fentanyl that will allow for early tracheal
extubation (within 4-8 hours of the conclusion of the surgical procedure). Study infusions
will be prepared by the pharmacy, and all clinicians will be blinded to group assignment
(methadone group-0.3 mg/kg-100 mL normal saline; fentanyl group-12 μg/kg-100 mL normal
saline).
Pain will be assessed by blinded observers using a 11-point verbal analogue scale (0=no pain,
10=worst pain imaginable). Assessment for pain will be performed 15 minutes post-extubation
and then 2, 4, 8, 12, 24, 48, and 72 hours after tracheal extubation. Pain will be determined
at rest, with coughing, and during movement. At the same time pain data is collected, several
other clinical assessments will be completed. The presence or absence of nausea and vomiting
will be determined, and severity quantified using a 4-point ordinal scale (0=none, 3=severe).
Level of sedation will be measured by observers using a 4-point sedation scale (0=fully
awake, 1=mildly sedated (seldom drowsy and easy to awake), 2=moderately sedated (often drowsy
and easy to awake), 3=severely sedated (somnolent, difficult to awake). Pruritis will also be
measured using a 4-point scale (0=none, 3=severe). Any episodes of hypoventilation
(respiratory rate < 8 breaths/min) or hypoxemia (oxygen saturation < 90%) during the study
period will be recorded. Patient satisfaction with overall pain management will be determined
using a 100-point verbal rating scale (1=highly dissatisfied (worst), 100=highly satisfied
(best)). Respiratory rate, oxygen saturation (in ICU), and mean arterial blood pressure at
the time of evaluation will be noted.
Postoperative pain will be managed according to standard institutional protocols. In the ICU,
intravenous morphine will be administered for initial pain management (1 mg for mild-moderate
pain, 2 mg for moderate-severe pain). Patients will be transitioned to oral pain medication
when oral intake is tolerated (Norco tablets). The amount of pain medication administered
during each study interval (listed above) will be recorded.
Other standard recovery variables will be recorded. These include time of initiation of
ventilator weaning, time of tracheal extubation, arterial blood gas following extubation,
time of ICU discharge, and time of hospital discharge. Time of first flatus and bowel
movement will be recorded. Any complications during the hospitalization will be recorded. In
a cohort of patients undergoing only coronary artery bypass graft surgery (n=75), serum
troponins will be measured postoperatively to determine whether methadone has a potential
cardioprotective effect.
Patients will be provided with a survey and self-addressed envelope following discharge from
the hospital to determine the presence or absence of chronic persistent surgical pain. These
data will be mailed by each patient 1, 3, 6, and 12 months postoperatively. The survey will
assess the nature and severity of pain related to the surgical procedure.
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