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CLoWI Versus PCA Morphine for Pain Control After Major Abdominal Surgery (CLoWI)

Primary Purpose

Surgical Wound, Post-Op Complication, Opioid Use

Status
Active
Phase
Not Applicable
Locations
Singapore
Study Type
Interventional
Intervention
CLoWI
PCA
Sponsored by
JurongHealth
About
Eligibility
Locations
Arms
Outcomes
Full info

About this trial

This is an interventional treatment trial for Surgical Wound focused on measuring continuous local wound infusion, opioids, post-operative pain, surgical incision

Eligibility Criteria

21 Years - 80 Years (Adult, Older Adult)All SexesDoes not accept healthy volunteers

Inclusion Criteria:

  • Planned for elective or urgent# open abdominal surgery

Abdominal Surgery may include the following procedures:

A) Urgent laparotomy for perforated viscus, intestinal obstruction. B) Elective abdominal surgery for upper and lower gastrointestinal surgery

  • Ability to provide informed consent. A signed and dated written informed consent prior to study participation.
  • Age 21 to 80 years for both males and females

Exclusion Criteria:

  • Female subject who is pregnant
  • Inability to comply with PCA instructions due to physical disabilities. For example, visual or hearing impairment, arthritis, peripheral neuropathy.
  • Known allergy to local anaesthetic or opioid drugs (Morphine).
  • Current or recent on opioid therapy. For example due to chronic pain illness, opioid (or other) drug abuse or recent surgery.
  • Severe comorbid diseases including liver cirrhosis, renal failure requiring dialysis, Grade 4 NYHA (New Yoke Heart Association) heart failure, respiratory illness requiring NIV (Non-Invasive Ventilation), etc.
  • Severe associated acute illness American Society of Anesthesiologists (ASA) Grade 4 or 5 where survival following surgery is not expected

Sites / Locations

  • National University Hospital
  • Ng Teng Fong General Hospital

Arms of the Study

Arm 1

Arm 2

Arm Type

Experimental

Active Comparator

Arm Label

CLoWI

PCA

Arm Description

CLoWI (ropivacaine) and PCA (normal saline) The local anaesthetic infusion will be administered via 2 catheters using a ON-Q® (Halyard) delivery system that will be placed under direct vision by the surgeon at the time of wound closure. 40 mls of 0.25% ropivacaine are infiltrated in the preperitoneal plane. 0.5% ropivacaine will be infused at a rate of 4mls/hour (2mls/hour in each catheter). The dosage 40 mls of 0.25% ropivacaine and 0.5% ropivacaine at 4mls/hr (20mg/hr) over 4 days will be less than the recommended toxic dose of 3-4 mg/kg.

PCA (Morphine) and CLoWI (normal saline) Morphine will be administered via the standard PCA protocol in accordance to the hospital's Acute Pain Service Programme: Concentration: 1mg/ml Bolus (Loading): 1mg Lockout Interval: 5 minutes Maximum hourly dose of 10mg

Outcomes

Primary Outcome Measures

To compare CLoWI and PCA (Morphine) in terms of post operative pain control
To determine if wither CLoWI or PCA will achieve better post-operative pain control based on a numerical rating score from 0 - 10

Secondary Outcome Measures

To compare CLoWI and PCA (Morphine) in terms of post operative complication rates associated with opioid usage
This includes the following complications - urinary retention, time to flatus, time to bowel opening, nausea and vomiting.
To compare CLoWI and PCA (Morphine) in terms of the length of postoperative hospital stay.
This takes into account the length of time the patient spends in the hospital between the two arms.

Full Information

First Posted
February 26, 2020
Last Updated
March 30, 2022
Sponsor
JurongHealth
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1. Study Identification

Unique Protocol Identification Number
NCT04503720
Brief Title
CLoWI Versus PCA Morphine for Pain Control After Major Abdominal Surgery
Acronym
CLoWI
Official Title
Continuous Local Anaesthetic Wound Infusion (CLoWI) Versus PCA Morphine for Pain Control After Major Abdominal Surgery:A Double Blinded, Randomized, Controlled, Non Inferiority Trial (CLoWI Trial)
Study Type
Interventional

2. Study Status

Record Verification Date
March 2022
Overall Recruitment Status
Active, not recruiting
Study Start Date
December 1, 2017 (Actual)
Primary Completion Date
June 2022 (Anticipated)
Study Completion Date
June 2022 (Anticipated)

3. Sponsor/Collaborators

Responsible Party, by Official Title
Sponsor
Name of the Sponsor
JurongHealth

4. Oversight

Studies a U.S. FDA-regulated Drug Product
No
Studies a U.S. FDA-regulated Device Product
No
Data Monitoring Committee
Yes

5. Study Description

Brief Summary
Major abdominal surgery is associated with significant complications which may lead to morbidity and mortality. Pain experienced after surgery affects the recovery from surgery. Our study aims to evaluate the current gold standard of PCA morphine infusion against a continuous wound infusion (CLoWI). The use of CLoWI negates the side-effects of opioids, and will be the first randomised controlled trial to compare PCA (Morphine) with CLoWI-LA (Ropivacaine).
Detailed Description
Major intra-abdominal surgery represents one of the commonest groups of surgical procedures performed both worldwide and within Singapore. Common general surgical conditions requiring major intra-abdominal surgery include intestinal pathologies such as cancer, ischaemia, infection, haemorrhage and perforation. Major surgery within the abdominal cavity is associated with significant complications which may be life threatening with an associated hospital mortality rate of as high as 20% for emergency surgery. Importantly, the recovery from this type of major surgery often entails significant pain and discomfort for the patient during healing of the abdominal wound and internal organs from tissue trauma associated with these surgical procedures. Recent developments in major intra-abdominal surgery have demonstrated the importance of the early surgical recovery period where common postoperative complications including pain, chest infection, intestinal ileus and delerium are not only associated with prolonged hospital stay but are harbingers of poor long term surgical outcomes. Current recommendations for perioperative management of patients undergoing major intra-abdominal surgery stress the importance of high quality perioperative care to minimise these sequelae. Key features of these recommendations are to provide a pain free postoperative surgical recovery with minimal nausea and vomiting to facilitate early mobilisation and functional recovery from surgery. Patient controlled analgesia (PCA) with opioids is the first line analgesia therapy currently used in the immediate post-operative period following major abdominal surgery. PCA with opioids has some inherent disadvantages that include side-effects of opioids such as nausea, vomiting, prolonged ileus, dizziness, hallucination and respiratory depression with the need for supplementary oxygen. This is most pertinent in elderly patients who are more prone to these side-effects in addition to being more likely to have difficulties in understanding how to use the PCA and so are more vulnerable to inadequate pain control. Consequently, there may be a delay in resuming mobility and discharge from hospital. Continuous local wound infusion (CLoWI) with Ropivacaine that is delivered into the extraperitoneal plane via an ON-Q® (Halyard) infusion pump has been shown to be an effective analgesia post-operatively. The use of CLoWI negates the side-effects of opioids and furthermore, the small portable pump allows early ambulation with no requirement for supplementary oxygen. Previous published research has demonstrated the benefits of continuous local wound infusion with local anaesthesia in terms of postoperative analgesia and surgical recovery However, there are no randomized controlled trials comparing PCA versus continuous local wound infusion alone; this study will be the first randomised controlled trial to compare PCA (Morphine) with CLoWI-LA (Ropivacaine). The local anaesthetic drug to be used for the wound infiltration system is Ropivacaine. Its mechanism of action involves inhibiting sodium influx through sodium-specific ion channels in the peripheral nerve axonal cell membrane, in particular, the voltage gated sodium channels. When the influx of sodium is interrupted, an action potential cannot arise and the conduction of a pain signal is inhibited. The local anaesthetic will be administered via 2 catheters that will be placed under direct vision by the surgeon at the time of wound closure. Ropivacaine 0.5% will be infused at a rate of 4mls/hour (2mls/hour in each catheter) for a total of 4 days. It is currently in clinical use within our hospital as a routine method of providing postoperative analgesia following major abdominal surgery.

6. Conditions and Keywords

Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
Surgical Wound, Post-Op Complication, Opioid Use
Keywords
continuous local wound infusion, opioids, post-operative pain, surgical incision

7. Study Design

Primary Purpose
Treatment
Study Phase
Not Applicable
Interventional Study Model
Single Group Assignment
Masking
ParticipantCare ProviderInvestigatorOutcomes Assessor
Allocation
Randomized
Enrollment
140 (Anticipated)

8. Arms, Groups, and Interventions

Arm Title
CLoWI
Arm Type
Experimental
Arm Description
CLoWI (ropivacaine) and PCA (normal saline) The local anaesthetic infusion will be administered via 2 catheters using a ON-Q® (Halyard) delivery system that will be placed under direct vision by the surgeon at the time of wound closure. 40 mls of 0.25% ropivacaine are infiltrated in the preperitoneal plane. 0.5% ropivacaine will be infused at a rate of 4mls/hour (2mls/hour in each catheter). The dosage 40 mls of 0.25% ropivacaine and 0.5% ropivacaine at 4mls/hr (20mg/hr) over 4 days will be less than the recommended toxic dose of 3-4 mg/kg.
Arm Title
PCA
Arm Type
Active Comparator
Arm Description
PCA (Morphine) and CLoWI (normal saline) Morphine will be administered via the standard PCA protocol in accordance to the hospital's Acute Pain Service Programme: Concentration: 1mg/ml Bolus (Loading): 1mg Lockout Interval: 5 minutes Maximum hourly dose of 10mg
Intervention Type
Device
Intervention Name(s)
CLoWI
Intervention Description
Patients will receive a continuous wound infusion with ropivacaine and normal saline in the PCA pump.
Intervention Type
Device
Intervention Name(s)
PCA
Intervention Description
Patients will receive a continuous wound infusion with normal saline and morphine in the PCA pump.
Primary Outcome Measure Information:
Title
To compare CLoWI and PCA (Morphine) in terms of post operative pain control
Description
To determine if wither CLoWI or PCA will achieve better post-operative pain control based on a numerical rating score from 0 - 10
Time Frame
5 days
Secondary Outcome Measure Information:
Title
To compare CLoWI and PCA (Morphine) in terms of post operative complication rates associated with opioid usage
Description
This includes the following complications - urinary retention, time to flatus, time to bowel opening, nausea and vomiting.
Time Frame
5 days
Title
To compare CLoWI and PCA (Morphine) in terms of the length of postoperative hospital stay.
Description
This takes into account the length of time the patient spends in the hospital between the two arms.
Time Frame
from the time of surgery till discharge, an average of 5 days

10. Eligibility

Sex
All
Minimum Age & Unit of Time
21 Years
Maximum Age & Unit of Time
80 Years
Accepts Healthy Volunteers
No
Eligibility Criteria
Inclusion Criteria: Planned for elective or urgent# open abdominal surgery Abdominal Surgery may include the following procedures: A) Urgent laparotomy for perforated viscus, intestinal obstruction. B) Elective abdominal surgery for upper and lower gastrointestinal surgery Ability to provide informed consent. A signed and dated written informed consent prior to study participation. Age 21 to 80 years for both males and females Exclusion Criteria: Female subject who is pregnant Inability to comply with PCA instructions due to physical disabilities. For example, visual or hearing impairment, arthritis, peripheral neuropathy. Known allergy to local anaesthetic or opioid drugs (Morphine). Current or recent on opioid therapy. For example due to chronic pain illness, opioid (or other) drug abuse or recent surgery. Severe comorbid diseases including liver cirrhosis, renal failure requiring dialysis, Grade 4 NYHA (New Yoke Heart Association) heart failure, respiratory illness requiring NIV (Non-Invasive Ventilation), etc. Severe associated acute illness American Society of Anesthesiologists (ASA) Grade 4 or 5 where survival following surgery is not expected
Overall Study Officials:
First Name & Middle Initial & Last Name & Degree
Christopher Keh, FRCS
Organizational Affiliation
Ng Teng Fong General Hospital
Official's Role
Principal Investigator
Facility Information:
Facility Name
National University Hospital
City
Singapore
ZIP/Postal Code
119074
Country
Singapore
Facility Name
Ng Teng Fong General Hospital
City
Singapore
ZIP/Postal Code
609606
Country
Singapore

12. IPD Sharing Statement

Plan to Share IPD
No
Citations:
PubMed Identifier
31627242
Citation
Liang SS, Ying AJ, Affan ET, Kakala BF, Strippoli GF, Bullingham A, Currow H, Dunn DW, Yeh ZY. Continuous local anaesthetic wound infusion for postoperative pain after midline laparotomy for colorectal resection in adults. Cochrane Database Syst Rev. 2019 Oct 19;10(10):CD012310. doi: 10.1002/14651858.CD012310.pub2.
Results Reference
background
PubMed Identifier
31698911
Citation
Prochazka V, Svoboda M, Svaton R, Grolich T, Farkasova M, Kala Z. Use of preperitoneal wound catheter for continuous local anaesthesia after laparoscopic colorectal surgery. Rozhl Chir. 2019 Summer;98(9):356-361. doi: 10.33699/PIS.2019.98.9.356-361.
Results Reference
background
PubMed Identifier
28958651
Citation
Dalmau A, Fustran N, Camprubi I, Sanzol R, Redondo S, Ramos E, Torras J, Sabate A. Analgesia with continuous wound infusion of local anesthetic versus saline: Double-blind randomized, controlled trial in hepatectomy. Am J Surg. 2018 Jan;215(1):138-143. doi: 10.1016/j.amjsurg.2017.09.007. Epub 2017 Sep 20.
Results Reference
background

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CLoWI Versus PCA Morphine for Pain Control After Major Abdominal Surgery

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