Dentofacial Deformities Clinical Trial
Official title:
Does it Worth to Reinforce With Additional Anesthesia to Improve Postoperative Course After Orthognathic Surgery?
Bimaxillary osteotomy is a surgery procedure of the orthognathic surgery field for correction of dental and facial abnormalities, for both functional and aesthetic cases. The incidence of this abnormality is 5-10% of the population, and the etiology is unknown, with genetic, environmental and embryonic factors related. The surgery technic is complex, and requires osteotomy of the maxilla and jaw, which allows toward, forward, impact and rotation of these bones to fix the edges of the face. The anesthetic management of these patients is a challenge because of the difficult airway management and the perioperative pain control. Multimodal approach for pain control is a fact, and the use of local anesthesia is mandatory. The investigators propose the infiltration of local anesthesia in two different times, first pre-incision and second before awaking the patient, for a proper control of postoperative pain
Bimaxillary osteotomy is a surgical procedure in the field of orthognathic surgery (from
Latin, "ortho" straight and "gnatho" jaw) for the correction of dentofacial deformities, both
for functional and aesthetic reasons. The incidence of this deformity is estimated to be
around the 5-10% of the population. Genetic, environmental and embryonic factors are
postulated to be the origin of such deformity, though its origin is still unknown. The
surgical technique is complex, with the performance of mandibular and upper jaw osteotomies
that allow to advance, retrude, impact and rotate these bones, to align the facial axes. For
all these reasons, the anesthetic management of these patients is a challenge. First, the
foreseeable difficulty of managing the patient's airway; and second, the control of the
patient's pain in the perioperative period.
Therefore, bimaxillary osteotomy is a frequent surgery and potentially painful in adults.
Bimaxillary surgery under general anesthesia is the common practice. And peripheral
non-ultrasound-guided peripheral nerve blocks are widely used by surgeons. These minor
blockades are used to avoid the undesired effects of anesthetics and analgesics; mainly the
adverse respiratory effects of opioids. The practice of loco-regional anesthesia provides a
control of perioperative pain in a multimodal way showing effective postoperative analgesia
and minimizing the respiratory depression caused by the excess use of opioids.
In general, during bimaxillary surgery the surgeon performs the infiltrations with local
anesthetic (LA) in a pre-incisional manner for the blockade of the terminal branches of the
maxillary and mandibular nerve intranasally and intraorally. The choice of LA is influenced
by considerations such as the start of action, duration and toxicity. A wide range of LA has
been used in maxillofacial surgery, such as lidocaine and ropivacaine among others. Both LA
produce a reversible blockade of the sodium channel of the neuronal membrane, and are
synthetic derivatives of cocaine. Both possess three essential functional units (hydrophilic
tertiary amide chain, linked by an intermediate amide chain, to another lipophilic aromatic
ring-portion). This means, both LA are amide type; but even if they belong to the same group
of LA there is still great differences in the beginning of action, duration of action and
toxicity. Lidocaine has a faster start of action (short latency) than ropivacaine, and has an
antiarrhythmic effect. Ropivacaine is more potent, the action last longer than lidocaine, has
vasoconstrictor effect by itself and is less cardiotoxic than other equipotent LA such as
bupivacaine and levobupivacaine.
The investigators avoid the use of a combination of LA for maxillary and mandibular nerve
block. The combination of several local anesthetics in the same nerve block is sometimes used
in perioperative anesthesia with the intention of compensating the short duration of action
of some agents whose start of action is fast, such as lidocaine, and the high latency of the
agents that present a more lasting action, such as ropivacaine. The combination of lidocaine
and ropivacaine offers clinical advantages (rapid onset, long duration). However, to date,
indications for combining LA are scarce because of the use of catheters in many forms of
regional anesthesia that allow to prolong the duration of the block. This is nevertheless not
an extended practice among anesthesiologists in maxillofacial surgery. On the other hand, it
is important to also remember avoiding the use of maximum doses of two LA combined, which is
based on the erroneous belief that their toxicities are independent; on the contrary, the
toxicities have an additive character.
Multiple drugs have been used to increase the time of action of LA, such as adrenaline,
clonidine, dexamethasone, ketamine and dexmedetomidine, among others. In the investigator's
patients, adrenaline is always administered along with physiological serum pre-incision by
the surgeon at the local level to improve the surgical field. The use of clonidine is ruled
out because it is not supplied in the hospital center where the researchers will carry out
the study. The use of dexamethasone and ketamine is ruled out, because they will be
administered intravenously in the patient's perioperative period as anti-inflammatory agents
and anesthetic adjuvant, respectively. And the use of dexmedetomidine is also ruled out in
order to prolong the effect of the nerve blockade as this indication is not in the technical
file.
Thus, the investigators propose to use firstly lidocaine and adrenaline pre-incision
(antiarrhythmic effect and short duration of action). And secondly, they propose to use
ropivacaine without adjuvant before extubation (vasoconstrictor effect and longer duration of
action).
The control of postoperative pain is a primary factor to achieve greater patient
satisfaction, better rehabilitation and shorter hospital stay. The current clinical
guidelines recommend the management of postoperative pain control in a multimodal manner; and
this includes the use of local anesthetics.
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