Lidocaine combined with low-dose esketamine for movement-evoked pain after hepatectomy: a double-blind randomised controlled trial.
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. 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 after induction of anaesthesia. Postoperative analgesia was provided by patient-controlled intravenous analgesia with sufentanil. 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. 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.