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CTRI Number  CTRI/2020/12/030076 [Registered on: 28/12/2020] Trial Registered Prospectively
Last Modified On: 08/08/2023
Post Graduate Thesis  No 
Type of Trial  Interventional 
Type of Study   Surgical/Anesthesia 
Study Design  Randomized, Parallel Group, Active Controlled Trial 
Public Title of Study   Epidural morphine versus epidural local anaesthetic as pain killer after abdominal gastrointestinal cancer surgery  
Scientific Title of Study   MOrphine-bupivacaine intermittent bolus versus Ropivacaine-Fentanyl INfusion through epidural route after gastrointestinal oncosurgery: a randomized clinical trial 
Trial Acronym  MORFIN 
Secondary IDs if Any  
Secondary ID  Identifier 
NIL  NIL 
 
Details of Principal Investigator or overall Trial Coordinator (multi-center study)  
Name  Rudranil Nandi 
Designation  Consultant 
Affiliation  Tata Medical Center, Kolkata 
Address  400 B, Block B, Rupasi Abasan
Naipukur, Rajarhat
North Twentyfour Parganas
WEST BENGAL
700135
India 
Phone  9564713195  
Fax    
Email  drrudranilnandi@gmail.com  
 
Details of Contact Person
Scientific Query
 
Name  Rudranil Nandi 
Designation  Consultant 
Affiliation  Tata Medical Center, Kolkata 
Address  400 B, Block B, Rupasi Abasan
Naipukur, Rajarhat
North Twentyfour Parganas
WEST BENGAL
700135
India 
Phone  9564713195  
Fax    
Email  drrudranilnandi@gmail.com  
 
Details of Contact Person
Public Query
 
Name  Rudranil Nandi 
Designation  Consultant 
Affiliation  Tata Medical Center, Kolkata 
Address  400 B, Block B, Rupasi Abasan
Naipukur, Rajarhat
North Twentyfour Parganas
WEST BENGAL
700135
India 
Phone  9564713195  
Fax    
Email  drrudranilnandi@gmail.com  
 
Source of Monetary or Material Support  
NA 
 
Primary Sponsor  
Name  Tata Medical Center 
Address  14 MAR, New Town, Kolkata- 700156 
Type of Sponsor  Research institution and hospital 
 
Details of Secondary Sponsor  
Name  Address 
NIL  NIL 
 
Countries of Recruitment     India  
Sites of Study  
No of Sites = 1  
Name of Principal Investigator  Name of Site  Site Address  Phone/Fax/Email 
Rudranil Nandi  Tata Medical Center  Anaesthesia Academic room,2nd Floor OT, Phase 1 Buiding, Tata Medical Center, 14 MAR, New Town, Kolkata- 700156
North Twentyfour Parganas
WEST BENGAL 
9564713195

drrudranilnandi@gmail.com 
 
Details of Ethics Committee  
No of Ethics Committees= 1  
Name of Committee  Approval Status 
Tata Medical Center-Institutional Review Board  Approved 
 
Regulatory Clearance Status from DCGI  
Status 
Not Applicable 
 
Health Condition / Problems Studied  
Health Type  Condition 
Patients  , (1) ICD-10 Condition: C184||Malignant neoplasm of transverse colon,  
 
Intervention / Comparator Agent  
Type  Name  Details 
Intervention  Epidural Morphine- Bupivacaine intermittent Bolus  Epidural analgesia will be provided by Morphine 0.05 mg/kg diluted to 10 ml with Bupivacaine 0.1% solution [3 mg Morphine (1 ml) + 2ml Bupivacaine 0.5%+ NS 8 ml] approximately 15 min before surgical incision. The dose will be repeated in every 8-24 hrs depending on optimal response during perioperative period till postoperative day 5. Initially drug will be given 12 hrly, if pain relief not adequate it can be given 8 hrly. If analgesia is adequate and patient become sedated, drug will be administered 24 hrly. 
Comparator Agent  Epidural Ropivacaine-Fentanyl infusion   Epidural analgesia will be provided by Ropivacaine 0.2% + Fentanyl 2 mcg/ml at 3-6 ml /hr during perioperative period till postoperative day 5. Infusion rate will be titrated depending on response. 
 
Inclusion Criteria  
Age From  18.00 Year(s)
Age To  75.00 Year(s)
Gender  Both 
Details  1. Patients who will undergo elective GI oncosurgery
2. American Society of Anaesthesiology (ASA-PS) score of 1 to 3 
 
ExclusionCriteria 
Details  1.Hepatobiliary and pancreatic surgery
2.Thoracic surgery
3.Patients with life threatening arrhythmias
4.Patients with left ventricular ejection fraction (LVEF) <30%
5.Acute myocardial infarction (within 30 days)
6.Acute pulmonary oedema (within 7 days)
7.Chronic obstructive pulmonary disease with a forced expiratory volume (FEV1) in the first second of expiration of less than 50%
8.Emergency surgery
9.Coagulopathy (platelet <50000/μL, aPTT> x2 control, INR >1.5)
10.Significant liver dysfunction (liver enzymes >x3 times normal)
11.Significant renal dysfunction (creatinine >x2 times normal)
12.Psychiatric disorders
13.Sepsis before surgery.
14.Patients who have known hypersensitivity to any of the drugs used during the procedure
15.Patients who are not willing to sign the informed consent form
16.History of any significant condition which the investigator feels would interfere with study evaluations and study participation
17.Patients who are on transdermal opioids or long acting analgesics < 3days before procedure
18.Patients who have previously participated in this study and to undergo a second surgery
 
 
Method of Generating Random Sequence   Computer generated randomization 
Method of Concealment   Sequentially numbered, sealed, opaque envelopes 
Blinding/Masking   Not Applicable 
Primary Outcome  
Outcome  TimePoints 
Intravenous fentanyl requirement as rescue analgesia  In 1st 24 hrs Post surgery 
 
Secondary Outcome  
Outcome  TimePoints 
Postoperative pain score  Pain score of the patient on rest and during spirometry in visual analog scale will be asked after shifting the patient to PACU and 1,6, 12, 24 hrs in 1st postoperative day and after that two times every day till POD 5 
Requirement of vasopressors  If there is hemodynamic compromise [hypotension (SBP 90mm of Hg), urine output 0.5ml/kg/hr] intravenous fluid bolus with 5ml/kg will be infused. If hypotension persists even after fluid bolus, vasopressors will be given as per institutional protocol. Maximum Noradrenalin dose required to maintain normal haemodynamics will be noted during intraoperative period and every postoperative day. 
Postoperative fluid administration  Hourly fluid intake and urine output will be measured during intraoperative and postoperative period 
Time to enteric resumption  Postoperative day when patient tolerated 500 ml enteric liquid will be documented. 
Length of hospital stay  Length of hospital stay from the day of surgery to fitness to discharge will be noted. 
 
Target Sample Size   Total Sample Size="86"
Sample Size from India="86" 
Final Enrollment numbers achieved (Total)= "0"
Final Enrollment numbers achieved (India)="86" 
Phase of Trial   Phase 4 
Date of First Enrollment (India)   01/01/2021 
Date of Study Completion (India) 07/08/2023 
Date of First Enrollment (Global)  Date Missing 
Date of Study Completion (Global) Date Missing 
Estimated Duration of Trial   Years="1"
Months="0"
Days="0" 
Recruitment Status of Trial (Global)
Modification(s)  
Not Applicable 
Recruitment Status of Trial (India)  Completed 
Publication Details
Modification(s)  
Nil 
Individual Participant Data (IPD) Sharing Statement

Will individual participant data (IPD) be shared publicly (including data dictionaries)?  

Response - NO
Brief Summary
Modification(s)  

Adequate dynamic pain control is a keystone of an enhanced recovery after surgery (ERAS) pathway. Evidence indicates that pain management in the postoperative period can affect the outcome of the surgery reducing cardiac, pulmonary and metabolic complications. The analgesic efficacy of thoracic epidural analgesia (TEA) for open colorectal surgeries has been shown to be superior to intravenous opioids. TEA also improves the postoperative pulmonary function due to reduced sedation and improved analgesia.Gastrointestinal function was reported in several studies to return 48 to 72 hours earlier in patients receiving thoracic epidural analgesiacompared topatients receiving intravenous analgesics.Ropivacaine has less toxicity on the cardiovascular and central nervous system. However, continuous infusion of epidural ropivacainemay cause motor block and hypotension, increasing the fluid requirement which may lead to fluid imbalance, anastomotic leakage, bowel edema etc. An alternative strategy is the use of intermittent bolus of epidural Morphine, which is a potent opioid analgesic that provides effective and long-lasting postoperative analgesia. Bupivacaine as an additive to morphine has been shown to reduce the incidence of postoperative nausea, vomiting and quality of analgesia. Moreover, requirement of morphine is much less when it is given through epidural route than intravenous route. More importantly, a chance of hypotension is much less when intermittent epidural bolus of morphine with low concentration bupivacaine is used as postoperative analgesic. No previous study has been conducted comparing the efficacy of intermittent bolus of epidural bupivacaine-morphine versus epidural infusion of ropivacaine- fentanyl.Therefore this study was designed to compare the analgesic efficacy and side effects of Buipvacaine-Morphine intermittent bolus versus Ropivacaine- Fentanyl infusion through epidural route after gastrointestinal (GI)oncosurgery. Our hypothesis is epidural bupivacaine morphine intermittent bolus will provide equivalent analgesia like epidural ropivacaine fentanyl infusion.Patients will be randomized either in the epidural bupivacaine-morphine group (group MOR) or epidural ropivacaine-fentanyl group (Group ROP). Epidural catheter will be placed as per incision congruent technique before induction in all patients. Placement of the catheter will be checked by 3 ml of 2% lignocaine with adrenaline (1:200000).

In group MOR, epidural analgesia will be provided by Morphine 0.05 mg/kg diluted to 10 ml with Bupivacaine 0.1% solution [3 mg Morphine (1 ml) + 2ml Bupivacaine 0.5%+ NS 8 ml] approximately 15 min before surgical incision. The dose will be repeated in every 8-24 hrs depending on optimal response during perioperative period till postoperative day 5. Initially drug will be given 12 hrly, if pain relief not adequate it can be given 8 hrly. If analgesia is adequate and patient become sedated, drug will be administered 24 hrly.

In group ROP epidural analgesia will be provided by Ropivacaine 0.2% + Fentanyl 2 mcg/ml at 3-6 ml /hr during perioperative period till postoperative day 5. Infusion rate will be titrated depending on response.

All patients will receive GA after placement of epidural catheter. In both the groups anaesthesia will be induced with propofol 2 mg/kg, fentanyl 2 mcg/kg and rocuronium 0.6 mg/kg. During intraoperative period, even after highest dose of epidural analgesia as per group allocation, if the patient’s heart rate or BP increases above 20% and that rise is clinically judged to be due to inadequate analgesiarescue analgesia will be administered with fentanyl 25 mcg. Anesthesia will be maintained with sevoflurane in a mixture of medical air 60% and O2 40%. End-tidal concentration of sevoflurane will be adjusted depending upon the vital parameters. Systolic blood pressure(SBP) will be maintained within 20% of baseline values, and hypotension (SBP<90 mmof Hg) will be treated with fluid bolus and/or vasopressors as per institutional protocol. A thermal blanket will be positioned over the exposed parts of the body to maintain perioperative normothermia. All patients will receive IV infusion of balanced salt solution (BSS) at a rate of 4 ml/kg/hour. Thirty minutes before termination of anesthesia intravenous paracetamol at the dose of 15mg/kg will be administered.In the postoperative period, if patient’s NRS becomes greater than 3 even after highest dose of epidural analgesia, IV fentanyl bolus 25 mcg will be given. If fentanyl consumption exceeds 100 mcg (4 bolus) in 4 hr, IV fentanyl infusion will be started with 20 mcg/hr. Adequate pain relief will be achieved by increasing fentanyl infusion by 5mcg/hr in every 30 min. If rescue fentanyl consumption exceeds 50 mcg/hr, IV Diclofenac 75 mg, will be administered 12 hourly as multimodal analgesia. If patient becomes sedated fentanyl infusion will be stopped. In the postoperative period all patients will receive maintenance intravenous fluid with balanced salt solution (BSS) at the rate of 1.5 ml/kg/hr. If there is hemodynamic compromise [hypotension (SBP< 90mm of Hg), urine output < 0.5ml/kg/hr] intravenous fluid bolus with 5ml/kg will be infused. If hypotension persists even after fluid bolus, vasopressors will be given as per institutional protocol. In both groups multimodal analgesia included intravenousparacetamol 15mg/kg, 3 times a day. 
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