Intrathecal Morphine for Recovery and Outcomes After VATS

This is a single-center, prospective, randomized, double-blind clinical trial evaluating the efficacy of intrathecal morphine in combination with serratus anterior plane block (SAPB) and dexmedetomidine infusion for postoperative analgesia in patients undergoing elective video-assisted thoracoscopic surgery (VATS). Eligible patients are ASA I-II, aged 18-70 years, with BMI < 35 kg/m². Patients will be randomized into two groups using a computer-generated sequence. The intervention group will receive intrathecal morphine (200 µg) in addition to SAPB and dexmedetomidine, while the control group will receive SAPB and dexmedetomidine alone. The primary outcome is postoperative pain scores (VAS) within the first 24 hours. Secondary outcomes include opioid consumption, quality of recovery, and incidence of side effects.

• Intrathecal Morphine (Drug): 200 µg morphine sulfate, single-dose via L3-L4, 27G Sprotte spinal needle, prior to induction.
• Serratus Anterior Plane Block (SAPB) group (Procedure): Ultrasound-guided unilateral SAPB at end of surgery with 30 mL 0.25% bupivacaine.
• Dexmedetomidine (Drug): Loading dose 0.5 µg/kg over 15 minutes, then 0.5 µg/kg/h continuous infusion intraoperatively.

Primary outcomes

• Quality of Recovery-15 (QoR-15) Score [Measured 24 hours after surgery]: The Quality of Recovery-15 (QoR-15) questionnaire is a validated 15-item instrument that assesses patient-centered postoperative recovery, including pain, physical comfort, emotional state, and overall wellbeing. The total score ranges from 0 to 150, with higher scores indicating better recovery.

Secondary outcomes

• Time to First Rescue Opioid [Within 24 hours postoperatively]: Duration (in hours) from the end of surgery to the first administration of rescue opioid (intravenous tramadol) when the Visual Analog Scale (VAS) pain score exceeds 4.
• Postoperative Pain Scores (VAS) [From postoperative hour 2 to hour 24.]: Postoperative pain intensity will be evaluated using the Visual Analog Scale (VAS), a 10-cm line ranging from 0 (no pain) to 10 (worst imaginable pain). Both active (movement) and passive (rest) VAS scores will be recorded at 2, 4, 6, 8, 10, 12, 14, 16, 18, 20, 22, and 24 hours after surgery. Higher scores indicate more severe pain.
• Total Opioid Consumption [24 hours postoperatively]: Cumulative opioid consumption (including PCA tramadol, subcutaneous morphine, and rescue IV tramadol) within 24 hours postoperatively, reported in mg.
• Intraoperative Complications [During surgery]: Occurrence of bradycardia, hypotension, or other anesthesia-related intraoperative adverse events.
• Postoperative Adverse Effects [24 hours postoperatively]: Incidence of nausea, vomiting, pruritus, respiratory depression, or other opioid-related side effects during the first 24 hours postoperatively.
• Serum Interleukin-6 (IL-6) Level [Preoperatively and at 24 hours postoperatively]: Serum IL-6 levels (pg/mL) will be measured to evaluate the systemic inflammatory response associated with surgical stress.
• Neutrophil-to-Lymphocyte Ratio (NLR) [Preoperatively and at 24 hours postoperatively]: The neutrophil-to-lymphocyte ratio (NLR) will be calculated to evaluate postoperative inflammatory status and its correlation with pain intensity and functional recovery.
• Serum C-reactive Protein (CRP) Level [Preoperatively and at 24 hours postoperatively.]: Serum CRP levels (mg/L) will be measured to assess postoperative systemic inflammation.
• Platelet-to-Lymphocyte Ratio (PLR) [Preoperatively and at 24 hours postoperatively.]: The platelet-to-lymphocyte ratio (PLR) will be calculated as a marker of postoperative inflammation and its correlation with pain level and recovery quality.
• Lymphocyte-to-Monocyte Ratio (LMR) [Preoperatively and at 24 hours postoperatively.]: The lymphocyte-to-monocyte ratio (LMR) will be calculated to assess systemic immune response in relation to postoperative recovery.
• Systemic Immune-Inflammation Index (SII) [Preoperatively and at 24 hours postoperatively.]: The systemic immune-inflammation index (SII) will be calculated as platelet × neutrophil / lymphocyte, providing an integrated indicator of postoperative inflammatory and immune status.

Sex: All, ages: 18 Years to 70 Years

Inclusion Criteria:

* Elective video-assisted thoracoscopic surgery (VATS) planned
* Age 18-70 years
* ASA physical status I-III
* Body mass index (BMI) <35 kg/m²

Exclusion Criteria:

* Coagulopathy
* Opioid dependence or intolerance
* Allergy to local anesthetics
* Contraindications to neuraxial blockade
* Chronic pain history
* Renal or hepatic failure

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• İREM ATEŞ, Principal investigator, Ataturk University
• Nuray Uzun, Principal investigator, Ataturk University