Lidocaine combined with low‐dose esketamine for movement‐evoked pain after hepatectomy: a double‐blind randomised controlled trial

Summary 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.