Saddle Block With IT Morphine for Penile Inversion Vaginoplasty

Официальное название

The Addition of a Saddle Block With Intrathecal Morphine for Analgesia in Transgender Patients Undergoing Penile Inversion Vaginoplasty: A Randomized Double-blind Placebo-controlled Trial

Обзор

Penile Inversion Vaginoplasty (PIV) is a transition-related surgery (TRS) that is associated with severe postoperative pain. The optimal pain management strategies for this surgery remain unknown. We hypothesized that the addition of a saddle block with intrathecal morphine would yield clinically important analgesic benefits.

Подробное описание

PIV is a TRS offered for male-to-female transition associated with severe postoperative pain despite contemporary analgesic strategies, including opioid-based multimodal systemic analgesia and local anesthetic-based pudendal nerve block. Intrathecal opioids directly target the nociceptors in the spinal cord and can provide potent analgesia for abdominopelvic procedures, including PIV, but are associated with important dose-related adverse effects with rostral spread within the cerebrospinal fluid.

Motor-sparing saddle block using ultra-low dose hyperbaric spinal anesthesia has been successfully implemented as the standard of care for anesthesia in patients undergoing ambulatory perianal procedures at WCH. Saddle block produces reliable sensory anesthesia and long-lasting analgesia of the perineum ("saddle") as the hyperbaric local anesthetic preferentially blocks the small pain fibers of the sacral nerve roots with gravity when the patient is placed in the seated position. With the aim to directly target the opioid nociceptors in the sacral roots and limit rostral opioid spread (and associated opioid-related adverse effects), we recently began to offer a presurgical saddle block with a low dose of intrathecal morphine (100mcg) to patients undergoing PIV at WCH with excellent anecdotal results. Therefore, we are undertaking the present randomized placebo-controlled study to determine whether or not the addition of a saddle block with IT morphine to multimodal systemic analgesia and surgeon-administered pudendal nerve block provides superior analgesia to multimodal systemic analgesia and surgeon-administered pudendal nerve block alone.

Вмешательства

• Процедура Saddle block
  The injected solution will be comprised of 5mg of heavy Bupivacaine 0.75% plus 100mcg of Morphine will be injected into the intrathecal space.
• Процедура pudendal nerve block
  As part of the analgesic plan, all patients will receive a multimodal analgesic regimen with acetaminophen, NSAIDs and opioids plus a surgeon-administered pudendal nerve block by anatomical landmarks with a mixture of Local Anesthetic as follows: 50mL of Normal Saline, 30mL of 0.25% Bupivacaine with epinephrine 1:200.000 and 20mL Lidocaine 1%. A volume of 20 mL of this mixture is used for the pudendal nerve block, and infiltration of the surgical incision and bilateral spermatic cord block is pe

Первичные конечные точки

• Cumulative opioid (analgesic) consumption [Срок оценки: 48 hours]

Вторичные конечные точки (6)

• Time to first analgesic request [Срок оценки: 24 hours]
• Pain Assessment (VAS) [Срок оценки: Up to 48 hours post-operatively]
• Incidence of opioid-related side effects [Срок оценки: Up to 48 hours post-operatively]
• Presence of Block-related complications [Срок оценки: Up to 48 hours post-operatively]
• Quality of Life scores [Срок оценки: 48 hours post-operatively]
• Patient Satisfaction with Analgesic Technique and Pain management [Срок оценки: 24 hours post-operatively]

Критерии участия

Критерии включения

• ASA I-III patients
• Ages 18-70 years
• Penile Inversion Vaginoplasty

Критерии исключения

• Local infection
• History of use of over 30mg oxycodone or equivalent per day.
• Contraindication to a component of multi-modal analgesia
• Complications or adverse events unrelated to the local anesthetic that precludes evaluation of the primary and secondary outcome measures.
• Unable to speak or read English.
• Revision and Vulvaplasty surgeries

Критерии приведены из реестра в оригинале (на английском). Окончательную оценку соответствия проводит исследовательский центр.

Здоровые добровольцы: Нет

Дизайн исследования

Распределение

Рандомизированное

Модель

Параллельные группы

Маскирование

Тройное слепое

Основная цель

Лечение

Центры проведения

Канада · 1 центр

• Women's College Hospital — Toronto

Публикации

• Swisher MW, Dolendo IM, Sztain JF, Alexander BS, Tsuda PS, Anger JT, Said ET. Intrathecal Morphine Injection for Postoperative Analgesia Following Gender-Affirming Pelvic Surgery: A Retrospective Case-Control Study. Cureus. 2023 Mar 27;15(3):e36748. doi: 10.7759/cureus.36748. eCollection 2023 Mar. PMID 37123779
• Yung EM, Abdallah FW, Todaro C, Spence E, Grant A, Brull R. Optimal local anesthetic regimen for saddle block in ambulatory anorectal surgery: an evidence-based systematic review. Reg Anesth Pain Med. 2020 Sep;45(9):733-739. doi: 10.1136/rapm-2020-101603. Epub 2020 Jul 22. PMID 32699103
• Hein A, Rosblad P, Gillis-Haegerstrand C, Schedvins K, Jakobsson J, Dahlgren G. Low dose intrathecal morphine effects on post-hysterectomy pain: a randomized placebo-controlled study. Acta Anaesthesiol Scand. 2012 Jan;56(1):102-9. doi: 10.1111/j.1399-6576.2011.02574.x. PMID 22150410
• DI Filippo A, Capezzuoli T, Fambrini M, Cariti G, Orlandi G, Vannucci G, Borracci T, DI Nallo L, Mazzella M, Petraglia F. Enhanced recovery after gynecological surgery: comparison between intrathecal and intravenous morphine multimodal analgesia. Minerva Obstet Gynecol. 2023 Apr;75(2):145-149. doi: 10.23736/S2724-606X.21.04961-7. Epub 2021 Dec 1. PMID 34851074
• Shim JW, Cho YJ, Moon HW, Park J, Lee HM, Kim YS, Moon YE, Hong SH, Chae MS. Analgesic efficacy of intrathecal morphine and bupivacaine during the early postoperative period in patients who underwent robotic-assisted laparoscopic prostatectomy: a prospective randomized controlled study. BMC Urol. 2021 Feb 26;21(1):30. doi: 10.1186/s12894-021-00798-4. PMID 33637066
• Chin P, Yuan N, Zaliznyak M, Stelmar J, Garcia M. Effectiveness of Pudendal Nerve Blocks on Postoperative Pain Control and Reduction in Opioid Usage after Gender-affirming Vaginoplasty. The Journal of Sexual Medicine. 2022;19(4, Supplement 1):S79. doi:10.1016/j.jsxm.2022.01.166

Идентификаторы

NCT: NCT06556121 · 2024-0061-B

Первоисточники (государственные реестры)

• ClinicalTrials.gov (NIH, США)

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