Intrathecal diamorphine vs. fentanyl-lidocaine-ketamine infusion for laparoscopic bowel resection

Published Date: 22nd September 2021

Publication Authors: Lightburn T, Little R, Raftery S, Dixit T

Background
Departmentally, fentanyl-lidocaine-ketamine (FKC) infusion (10 mug.ml-1 fentanyl, 1 mg.ml-1 ketamine, 10 mg.ml-1 lidocaine) at a rate of 1-2 mg.kg-1.h-1 of lidocaine [1] is being used for bowel resections. We sought to compare patient outcomes between peri-operative FKC infusion versus intrathecal diamorphine (ITD).

Methods
This is a retrospective review of two anaesthetic techniques for planned laparoscopic bowel resection in a district general hospital between 01/2018 and 01/2021. The ITD group contained 49 patients and the FKC group contained 89 patients. Both groups received general anaesthesia. Exclusions were planned open procedures or if they received a different method of anaesthesia. Variables recorded were recovery time, length of inpatient stay, highest daily pain score, ileus and other complication rates.

Results
Patients in the ITD group were discharged earlier from recovery. Median time to discharge was 1.5 h with FKC (95%CI 1.3-1.6) and 1 h in ITD group (95%CI 0.85-1.14). Inspection of the Kaplan-Meier plot suggests no difference in hospital stay attributed to the anaesthetic type with median length of stay for both 6 days. The FKC group had an aggregate pain score of 25.8 (95%CI 22.7-28.8), while ITD group had an aggregate pain score of 21 (95%CI 16.2-25.8). There was a significant difference in ileus (p = 0.0149), which was seen in 7.9% (95%CI 3.9-15.4%) in the FKC group and in 22.4% (95%CI 13-35.9%) in ITD group. The estimated number needed to treat to prevent one case of ileus was 6.8 (95%CI 3.4-39). Chi-squared analysis showed no evidence of a difference in prevalence of other complication rates.

Discussion
Pain scores were low overall in both groups. Lower aggregate scores in the spinal group may be explained through the absence of a standardised enhanced recovery analgesia regime. The significant difference in ileus rates is attributed to lidocaine [2]. Further prospective analysis of this technique is warranted after the implementation of standardised enhanced recovery pathway. FKC infusion significantly reduces the risk of postoperative ileus without a significant increase in pain and length of stay.

Lightburn, T; Little, R; Raftery, S; Dixit, T. (2021). Intrathecal diamorphine vs. fentanyl-lidocaine-ketamine infusion for laparoscopic bowel resection. Anaesthesia. 76 (S6), 48

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