Introduction: Pain following hepatectomy may delay recovery and increase opioid use. We tested the primary hypothesis that combining lidocaine and low-dose esketamine would reduce movement-evoked pain 24 h after hepatic resection. We also evaluated whether this approach reduced opioid consumption and improved quality of recovery.
Methods: Patients having elective hepatic resections were allocated randomly to receive lidocaine-esketamine or placebo from induction of anaesthesia until the end of surgery. After surgery, patients allocated to lidocaine-esketamine were given a continuous infusion of lidocaine with esketamine for 72 h. All patients received transversus abdominis plane blocks with ropivacaine 2 mg.kg-1 after induction of anaesthesia. Postoperative analgesia was provided by patient-controlled intravenous analgesia with sufentanil.
Results: In total, 304 patients were included, of whom 145 (48%) had open surgery. Lidocaine-esketamine infusion reduced median (IQR [range]) pain scores with movement at 24 h (3 (2-4 [1-6]) vs. 4 (3-5 [1-9]), p < 0.001); 48 h (3 (2-4 [0-7]) vs. 4 (3-5 [0-8]), p < 0.001); and 72 h (2 (1-3 [0-6]) vs. 3 (2-4 [0-7]), p < 0.001), respectively. Moderate-to-severe movement-evoked pain at 24 h was evident in 52/152 (34%) patients who received lidocaine-esketamine vs. 85/152 (56%) who received placebo (p < 0.001). Cumulative sufentanil equivalents were significantly reduced at each measurement time and quality of recovery scores were significantly higher through the first 72 h for lidocaine-esketamine compared with placebo, but these changes were clinically modest.
Discussion: The combination of lidocaine with esketamine reduced movement-evoked pain and opioid consumption whilst improving quality of recovery during the initial 72 h after hepatic resection. However, treatment effects were modest and of limited clinical importance.
Keywords: anaesthesia; analgesics; esketamine; hepatectomy; lidocaine.
What we did: We studied 304 adults who had planned liver surgery. Patients were randomly put into two groups. One group received two medicines, lidocaine (a local anaesthetic/numbing medicine) and a low dose of esketamine (a strong painkiller). The other group received a placebo (a treatment with no active medicine). All patients still received normal pain care. The study medicines were given during surgery and continued for 3 days after surgery. We measured pain when patients moved, how many strong painkillers they used and how well they felt they were recovering.
Why we did it: After liver surgery, many people have pain when they try to move. This pain can make it hard to get out of bed, walk, breathe deeply and recover well. Doctors often use strong pain medicines called opioids, but these medicines can cause side effects and slow recovery. We wanted to find safer ways to reduce pain and help patients get better more easily.
What we found: We found that patients who received lidocaine and esketamine had less pain when moving during the first 3 days after surgery. Fewer patients had moderate or severe pain. They also used a little less opioid medicine. Recovery scores were slightly better. The treatment was safe and did not cause serious side effects. However, the improvements were small. This means the treatment may help a little with pain and recovery, but the overall benefit is limited and may not be strong enough for routine use in all patients after liver surgery.
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