关节腔内注射酮咯酸氨丁三醇用于老年患者膝关节镜术后镇痛

目的 观察关节腔内注射酮咯酸氨丁三醇或吗啡复合罗哌卡因对老年患者膝关节镜术后的镇痛效果.方法 48例腰一硬联合阻滞下行膝关节镜手术的老年患者,随机均分为关节腔内注射吗啡复合罗哌卡因组(RM组)、酮咯酸氨丁三醇复合罗哌卡因组(RK组)和生理盐水对照组(C组),记录术后2、4、8、12、24和48 h患者屈膝关节90°状态下的VAS评分、镇痛满意度及术后8 h内按需注射曲马多用量.结果 术后2、4、8、12、24和48 h患者屈膝90°VAS评分RM、RK组均显著低于C组(P<0.01);术后镇痛满意度RM、RK组较C组高,而RK组高于RM组(P<0.05);RM、RK组术后8 h曲马多平均使用量较C组明显减少(P<0.05).结论 关节腔内注射酮咯酸氨丁三醇复合罗哌卡因可有效缓解老年患者膝关节镜术后疼痛,患者满意程度优于吗啡复合罗哌卡因.     

Intra-articular morphine for pain relief after knee arthroscopy.

We performed a randomised double-blind controlled study in patients undergoing elective knee arthroscopy to assess the effect of intra-articular morphine on postoperative pain relief. Patients in the study group (n = 10) received 5 mg of morphine in a 25 ml dilution intra-articularly while those in the control group (n = 10) received 25 ml of saline. Postoperative pain was assessed at intervals by a visual analogue scale and the requirement for supplementary analgesia was recorded. Those in the study group had significantly lower pain scores and required less systemic analgesics than those in the control group. Plasma profiles for morphine and its metabolites were assayed and showed that they were too low to produce effective analgesia. Evidence suggests that analgesia was mediated by local action within the joint.     

Intra-articular tenoxicam improves postoperative analgesia in knee arthroscopy

PURPOSE: Non Steroidal Anti-inflammatory drugs have a well documented benefit in the relief of postoperative pain. This study was designed to compare the analgesic effect of intra-articular tenoxicam 20 mg with intravenous tenoxicam on postoperative pain in 88 patients undergoing day case knee arthroscopy. METHODS: A prospective, double blind, randomized trial was performed. All patients received a standard general anesthetic. Patients in group A received 20 mg tenoxicam made up to 40 ml with normal saline intra-articularly (ia) and 2 ml normal saline i.v. Patients in group B received 40 ml normal saline intra-articularly and 2 ml, 20 mg of tenoxicam, i.v. RESULTS: Both groups of patients were similar with respect to age, weight, sex and tourniquet inflation time. Patients receiving ia tenoxicam had lower pain scores (at rest and upon movement) at 30, 60, 120 and 180 min postoperatively (0.8+/-0.2 vs. 2.5+/-0.2 at rest and 1.24+/-0.2 vs. 3.4+/-0.2 at movement at 60 min; P< 0.0001). Fewer patients required additional analgesia in the first four hours postoperatively (33% vs. 84%; P<0.00001) and the time to first analgesia (23.7+/-11.2 vs. 9.4+/-0.6; P<0.02) was longer in those receiving ia tenoxicam. CONCLUSION: Intra-articular tenoxicam provides superior postoperative analgesia and reduces postoperative analgesic requirements compared with i.v. tenoxicam in patients undergoing day case knee arthroscopy.     

Intra-articular tenoxicam relieves post-arthroscopy pain

Background : Nonsteroidal anti-inflammatory drugs have been documented to be effective in the treatment of postoperative pain. The aim of this study was to evaluate the analgesic effect of local intra-articular injection of tenoxicam compared with intravenous injection on postoperative pain after arthroscopy. Methods : After day-case arthroscopy, 60 patients were randomized to receive either tenoxicam 20 mg in 20 ml of normal saline intra-articularly and 2 ml of normal saline i.v., or 20 ml of normal saline intra-articularly and 2 ml tenoxicam 20 mg i.v. Postoperative pain was assessed using a visual analogue scale and measuring analgesic requirements. Results : Pain scores were significantly lower in the intra-articular group at rest and during active flexion of the knee at 1,2 and 4 hours postoperatively and during walking at 6 hours postoperatively (P < 0.05). Significantly more patients in the intravenous group required supplemental opioid analgesia within the first 4 hours postoperatively (P < 0.05). Conclusion : Intra-articular tenoxicam 20 mg provided better analgesia and decreased the requirements for postoperative analgesic compared with i.v. tenoxicam 20 mg.     

Combination of intra-articular tenoxicam, lidocaine, and pethidine for outpatient knee arthroscopy

BACKGROUND: Studies of intra-articular non-steroidal anti-inflammatory drugs have revealed an analgesic effect equivalent to that of intra-articular local anaesthetic agents and morphine. The aim of this study was to evaluate the analgesic effect of intra-articular lidocaine, pethidine and tenoxicam compared with that of lidocaine and pethidine on postoperative pain after arthroscopy. METHODS: After day-case knee arthroscopy, 60 patients were randomly allocated to one of three groups to receive 20 ml of a solution containing 0.9% saline (group S), 2% lidocaine and 10 mg preservative-free pethidine (group LP) and 2% lidocaine, 10 mg preservative-free pethidine and 20 mg tenoxicam (group LPT). Postoperative pain was assessed using a visual analogue scale and measuring analgesic requirements. RESULTS: Pain scores were significantly lower in the LP group than in the S group at 1 and 2 h after surgery. From 4 h until the end of the first postoperative day, pain scores were significantly lower in the LPT group of patients at rest and on knee flexion than in the other two groups; these patients also used less oral analgesics (P<0.05). CONCLUSION: The combination of 20 ml lidocaine 2%, 10 mg pethidine and 20 mg tenoxicam given intra-articularly provided superior analgesia and reduced oral analgesic requirement during the first day after arthroscopy compared with lidocaine and pethidine alone.     

Efficacy of intra-articular bupivacaine, ropivacaine, or a combination of ropivacaine, morphine, and ketorolac on postoperative pain relief after ambulatory arthroscopic knee surgery: a randomized double-blind study

BACKGROUND: Effective pain relief is important after diagnostic and therapeutic arthroscopic knee surgery to permit early discharge and improve comfort and mobility at home. The aim of this study was to assess the efficacy of bupivacaine, ropivacaine, or a combination of ropivacaine, morphine, and ketorolac injected intra-articularly for postoperative pain relief after arthroscopic knee surgery. METHODS: Sixty-three healthy patients undergoing knee arthroscopy under local anesthesia (LA) were randomized to receive 1 of the following substances intra-articularly postoperatively: group B: 30 mL of bupivacaine (150 mg); group R: 30 mL of ropivacaine (150 mg); and group RMK: ropivacaine 150 mg, morphine 4 mg, and ketorolac 30 mg in normal saline (total volume 30 mL). Oral paracetamol 1g and tramadol 50 mg were used as rescue drugs. Postoperatively, pain was assessed at rest and movement, and side effects were recorded. The patients were asked to self-assess pain for 7 days and record analgesic consumption as well as activities of daily living (ADLs). Plasma concentration of LA was measured in another 8 patients. RESULTS: All groups had excellent analgesia at 0 and 4 hours postoperatively. Group RMK had significantly lower visual analog pain score at rest at 8 hours and during movement at 8 and 24 hours compared with the other groups (P<.05). Group RMK required less paracetamol and tramadol on day 1 (P<.05), had less sleep disturbances because of pain, more patients were ready to work on days 1 and 2 (P<.05), and were more satisfied on days 1 and 4 to 7. Postoperatively, plasma concentrations of ropivacaine and lidocaine were far below known systemic toxic concentrations in all patients. CONCLUSION: Addition of morphine and ketolorac to ropivacaine intra-articularly enhances analgesic efficacy of LA, reduces postdischarge analgesic consumption, and improves ADLs without increasing side effects after ambulatory arthroscopic knee surgery.     

右美托咪定对患者膝关节腔注射罗哌卡因镇痛ED_(50)的影响

目的观察右美托咪定对罗哌卡因膝关节腔注射用于老年患者膝关节镜术后镇痛ED_(50)的影响。方法选择择期行膝关节镜诊治术老年患者72例,男35例,女37例,年龄60~75岁,ASAⅠ或Ⅱ级。随机分为罗哌卡因组(R组)和右美托咪定复合罗哌卡因组(DR组),每组36例。R组患者膝关节腔内注射不同浓度罗哌卡因;DR组患者关节腔内注射不同浓度罗哌卡因和右美托咪定1μg/kg的混合液。术后2hVAS评分低于3分为镇痛有效。采用序贯法确定罗哌卡因浓度,初始浓度为0.15%,相邻浓度比值为1.1,镇痛有效则下一例采用低一级浓度,镇痛无效则下一例采用高一级浓度。采用Dixon-Massey法确定ED_(50)及其95%CI。记录术前5min(T_0)、术后1h(T_1)、2h(T_2)、3h(T_3)、6h(T_4)、12h(T_5)、24h(T_6)和48h(T_7)患者BP和HR,并对患者进行改良的OAA/S评分和VAS评分。结果术前和术后各时点两组患者BP、HR、VAS评分和OAA/S评分差异均无统计学意义。C组ED_(50)为0.31%(95%CI 0.30%~0.32%);DR组ED_(50)为0.14%(95%CI 0.14%~0.15%)。结论右美托咪定可增强罗哌卡因膝关节腔注射用于患者膝关节镜术后镇痛的效果,并可减少罗哌卡因的用药剂量。     

Effects of ketorolac and bupivacaine on recovery after outpatient arthroscopy.

The effects of intraarticular bupivacaine, systemic ketorolac, and a combination of both treatments on postoperative pain and mobilization were evaluated in 60 healthy outpatients undergoing arthroscopic knee surgery under general anesthesia. After induction of anesthesia, patients received 2 mL of either ketorolac (60 mg) or saline solution (1 mL IV and 1 mL IM). On completion of surgery, the patient's knee joint was injected with 30 mL of either 0.5% bupivacaine or saline solution, according to a randomized, double-blind protocol. Only one patient (6%) receiving both medications complained of pain on awakening, compared with seven patients receiving either bupivacaine (37%) or ketorolac (41%) alone. Postoperative fentanyl was required by significantly fewer patients receiving combined therapy (n = 4, 21%) than either bupivacaine (n = 13, 62%) or ketorolac (n = 12, 60%) alone; however, there were no significant differences among the three treatment groups in terms of perioperative pain, nausea, or sedation visual analogue scale scores. Similarly, there were no differences in the times to ambulation or discharge or in analgesic requirements at home. In conclusion, a combination of systemic ketorolac and intraarticular bupivacaine decreased analgesic requirements and pain on awakening after arthroscopic surgery. However, the use of ketorolac alone or in combination with bupivacaine offered no advantage over bupivacaine alone with respect to recovery times after outpatient arthroscopy.     

Comparisons of analgesic effects of different doses of morphine and morphine plus methylprednisolone after knee surgery

BACKGROUND: In this double-blind randomized study, the analgesic effects of morphine alone and with methylprednisolone were examined in 72 patients undergoing arthroscopic knee surgery. METHODS: At the end of arthroscopy, patients were allocated randomly to one of four groups to receive intra-articular administrations of saline, morphine 1 mg, morphine 5 mg or morphine 1 mg with methylprednisolone 40 mg. Preoperative and postoperative pain levels at rest and during movement (active flexion of the knee) were measured by a visual analogue scale (VAS). Postoperative analgesic requirements to alleviate pain were evaluated. RESULTS: Pain scores were significantly lower for the patients who received 5 mg morphine and 1 mg morphine with 40 mg methylprednisolone than for those who received saline or 1 mg morphine. This was accompanied by a decrease in the postoperative consumption of analgesics and prolongation of the duration of pain relief. CONCLUSIONS: This study confirms that the analgesic effect of morphine given intra-articularly is dose dependent and that combination of methylprednisolone with morphine has an additive effect on analgesia.     

Postoperative pain following knee arthroscopy: the effects of intra-articular ketorolac and/or morphine.

BACKGROUND AND OBJECTIVES: Morphine and nonsteroidal antiinflammatory drugs (NSAID) have been found to be effective in relieving postoperative pain. The goal of this study was to determine whether ketorolac alone or in combination with morphine provides superior pain relief following arthroscopy performed with local anesthesia (LA). METHODS: This was a randomized, double-blind, prospective, study in 100 healthy patients from 15 to 60 years of age. Knee arthroscopy was performed with LA using 40 mL prilocaine (5 mg/mL) with adrenaline (4 microg/mL). At the end of the operation, a catheter was inserted intra-articularly, and one of the following solutions diluted to a total volume of 40 mL was injected: group P (40 mL normal saline), group M (3 mg morphine), group K30 (30 mg ketorolac), group K60 (60 mg ketorolac), and group KM (3 mg morphine + 30 mg ketorolac). Visual analog scale (VAS) pain scores (0-100 mm) were measured preoperative and at 30, 60, 90, 120 minutes postoperative and thereafter 4, 8, 24, and 48 hours at rest and on movement of the knee. The total number of distalgesic tablets (325 mg paracetamol + 32.5 mg dextropropoxyphene) consumed during the 48 hours postoperative was recorded. RESULTS: Significant differences in VAS pain scores were seen between group P and group KM at 4, 8, and 24 hours (P < .05) and between group M and group KM at 4, 8, 24, and 48 hours (P < .01) after the operation at rest. During mobilization of the knee, a significant difference in VAS pain score was found between group P and group KM at 8, 24, and 48 hours (P < .05) and between group P and group K60 at 24 and 48 hours (P < .05). The total consumption of distalgesic tablets did not differ among the groups. CONCLUSIONS: The combination of 3 mg morphine plus 30 mg ketorolac provided significantly better analgesia than either placebo alone or morphine alone. This result could be a synergistic effect.     

Comparison of the analgesic efficacy and plasma concentrations of high-dose intra-articular and intramuscular morphine for knee arthroscopy

BACKGROUND AND OBJECTIVE: It is important to provide good postoperative analgesia after discharge from day case surgery. The usefulness of intra-articular morphine for analgesia after day case knee arthroscopy remains controversial. A large dose of morphine intra-articularly may provide a good long-lasting analgesia, but its efficacy and pharmacokinetics are not known and may be no better than intramuscular morphine. We compared the effect of 10 mg intra-articular and intramuscular morphine for 24 h post-injection in a randomized double-blind study. METHODS: Forty adults undergoing knee arthroscopy were recruited and received either 10mg morphine intra-articularly or intramuscularly. Our primary outcome was overall visual analogue assessment of pain (0-100 mm scale where 0 is no pain and 100 is worst possible pain) between 4 h (on discharge) and 24 h (post-operatively). Plasma morphine concentrations were measured at 15 min, and 1, 2, 4 and 24 h. The use of additional analgesia was noted. RESULTS: The assessment of pain experienced between discharge (4 h) and 24 h was significantly better in the intra-articular (n = 20; mean+/-SD: 18+/-19) than the intramuscular (n = 19; mean+/-SD: 34+/-20) group (P = 0.027). The number of patients consuming any additional analgesia between discharge and 24 h was significantly lower in the intra-articular morphine group (P = 0.038), with 4 (20%) patients in the intra-articular group and 11 (60%) patients in the intramuscular group consuming supplementary analgesia. There were no differences in plasma morphine concentrations between the groups. CONCLUSIONS: A large dose of intra-articular morphine provided better analgesia than the same dose of intramuscular morphine, low plasma morphine levels suggesting a peripheral mechanism.     

The efficacy of intra-articular ketamine for postoperative analgesia in outpatient arthroscopic surgery

PurposeThe purpose of this study was to compare the postoperative analgesic effects of intra-articularly administered ketamine, neostigmine, and bupivacaine after outpatient arthroscopic surgery.Type of studyProspective, randomized, double-blind, clinical study.MethodsIn this study, 60 patients undergoing arthroscopic surgery other than ligament reconstruction were evaluated for postoperative pain. Ketamine, neostigmine, and bupivacaine were administered intra-articularly. The period of effective analgesia, recorded in minutes, was measured between time 0 and first usage of patient-controlled anesthesia (PCA) by the patients. The visual analog scale (VAS) was used to describe the pain level of the patient.ResultsVAS values were lower for the 3 medication groups compared with the placebo at rest and 90° knee flexion. Intra-articular administration of 0.5 mg/kg ketamine provided longer duration of analgesia as defined by the first PCA use time (P < .05). The total amount of pethidine and analgesia time were longer for the 3 medication groups.ConclusionsOur basic finding was reduction in postoperative pain and consumption of adequate analgesic drugs with intra-articular ketamine, bupivacaine, or neostigmine use. We have not seen any psychomimetic side effects, particularly as seen with higher doses or systemic use. This study may conclude that intra-articular administration of ketamine provides long-lasting and effective analgesia, similar to neostigmine but less effective than bupivacaine after knee arthroscopy without any adverse effects.Level of evidenceLevel I.     

Propacetamol versus ketorolac for treatment of acute postoperative pain after total hip or knee replacement

We assessed the analgesic efficacy of IV propacetamol and ketorolac in a double-blinded, placebo-controlled study involving patients undergoing total hip or knee replacement procedures. On the first morning after major joint replacement surgery, 164 patients experiencing moderate-to-severe pain were randomly assigned to receive an IV infusion of propacetamol (2 g), ketorolac (15 or 30 mg), or placebo (saline). Patient-controlled analgesia with morphine was made available as a "rescue" analgesic on patient's request during the 6-h postdosing evaluation period. The median time to onset of analgesia with propacetamol (8 [95% confidence interval 6,10] min) was shorter than ketorolac 15 mg (14 [7,16] min), and placebo (16 [8; not estimable] min) although the differences did not reach statistical significance. However, compared with ketorolac 30 mg, propacetamol had a shorter duration of analgesia (3.5 [2;5.4] vs 6 [3.3; not estimable] h). Analysis of pain intensity and pain relief scores demonstrated that propacetamol produced a significantly greater improvement in pain relief than saline from 45 min until 5 h after the injection. Propacetamol was not significantly different from ketorolac 15 mg and 30 mg with respect to the main analgesic efficacy variables during the 6-h assessment period. The most frequently reported adverse event with propacetamol was injection site pain (28% vs 19% for ketorolac 15 mg, 29% for ketorolac 30 mg, and 10% for placebo, respectively). In conclusion, propacetamol (2 g IV) possesses a similar analgesic efficacy to ketorolac (15 or 30 mg IV) after total hip or knee replacement surgery.     

Addition of morphine to intra-articular bupivacaine does not improve analgesia after day-case arthroscopy

We conducted a randomized, double-blind, controlled study inpatients undergoing day-case knee arthroscopy to evaluate theanalgesic effect, for 36 h after operation, of the additionof either 2 mg or 5 mg of morphine to intra-articular bupivacaine.Patients in group BM5 (n = 20) received 0.25% bupivacaine 40ml with morphine 5 mg; patients in group BM2 (n = 20) received0.25% bupivacaine 40 ml with morphine 2 mg and patients in groupB0 (n = 18) received 0.25% bupivacaine 40 ml only. The drugswere given by intra-articular injection by the surgeon at theend of the operation and the tourniquet released 70 min later.Preoperative and postoperative pain was assessed over the ensuing36 h, at rest and with movement, using a 100-mm visual analoguescale. There were no significant differences in pain scores,consumption of additional analgesia, or time to first requestfor analgesia between any of the groups. We conclude that, afterday-case knee arthroscopy, no additional analgesic effect wasafforded by the addition of morphine to intra-articular bupivacaine. Present addresses: Department of Anaesthesia, Leicester RoyalInfirmary, Leicester LE1 5WW     

Non-narcotic adjuvants may improve the duration and quality of analgesia after knee arthroscopy: a brief review

PURPOSE: We have evaluated randomized controlled trials of the administration of clonidine, neostigmine, steroids and non-steroidal anti-inflammatory agents intra-articularly as adjuvants to local anesthetic drugs after arthroscopic knee surgery. METHODS: Twenty-five studies were reviewed using specific inclusion criteria and, accordingly, included in the final assessment. These studies were assessed for pain scores, total analgesic consumption and time to first analgesic request to determine a possible peripheral effect, as opposed to possible systemic effects of an adjuvant administered intra-articularly. RESULTS: A total of 16 studies, met the inclusion criteria. These studies considered the use of non-steroidal anti-inflammatory drugs, steroids, neostigmine and clonidine. Ketorolac was used in four studies (for a total of 230 patients) and showed a significant improvement in analgesia. Clonidine has shown considerable analgesic effect, with minimal adverse effects. All seven studies assessed in this review were supportive (a total of 424 patients). Furthermore the addition of clonidine to bupivacaine or morphine was found to increase duration and quality of postoperative analgesia. CONCLUSIONS: Current evidence indicates that a variety of agents have synergistic effects when added to local anesthetics and there is evidence that the improvement in analgesia is, at least partially, through a local rather than a central mechanism. The results of this review suggest that clonidine and ketorolac, when administered intra-articulary after arthroscopic knee surgery, may reduce postoperative pain.     

Intra-articular injection of ketorolac in the rat knee joint: effect on articular cartilage and synovium

We have investigated the effects of intra-articular (i.a.) administration of ketorolac in the rat knee joint. Thirty Sprague- Dawley rats were given 0.25 ml of a standard preparation of ketorolac trometamol (10 mg ml-1) by injection into the right knee joint and 0.25 ml of 0.9% physiological saline solution by injection into the left knee as a control. Ten rats were killed at 24 h, 10 at 48 h and 10 at 5 days after injection. The joints were prepared and sectioned for histological examination. There was significantly more inflammation in those knees that had received i.a. ketorolac at all times of examination, with the most severe changes occurring 5 days after injection. A further group of 10 rats were given 0.25 ml of 10% w/v ethanol in physiological saline (similar to the vehicle for parenteral ketorolac) injected into the knee joint, with a 0.9% saline control injected in the other knee. These rats were then killed at 5 days (as this was the time interval after which we found the maximum inflammatory response in the earlier phase of our study). The joints were prepared and examined histologically. We feel that the absence of inflammatory changes in these joints make it unlikely that ethanol was responsible for the inflammation produced by ketorolac injection.      

A double-blind study of the speed of onset of analgesia following intramuscular administration of ketorolac tromethamine in comparison to intramuscular morphine and placebo

A double-blind, randomised, parallel group, placebo-controlled study was performed in 85 patients to compare the speed of onset of analgesia following the intramuscular administration of a single dose of 30 mg of ketorolac tromethamine, 10 mg of morphine or placebo. A new, sensitive, method was used to measure the latency of analgesia. The onset of analgesia was defined by the time taken for the pain intensity score to reach a specified percentage of the baseline value. Twenty-five percent of patients achieving a 50% reduction in baseline pain intensity score appears to be the most appropriate parameter to assess the speed of onset of analgesia of ketorolac and morphine in the postoperative setting. Paired comparison demonstrated that ketorolac had a significantly faster onset of analgesia (p = 0.03) when compared to placebo, whilst comparison of morphine to placebo analgesic latency (p = 0.06) just failed to reach significance. There was no significant difference between the analgesic onset time of ketorolac and morphine (p = 0.73). Intramuscular ketorolac and intramuscular morphine have comparable analgesic onset times in the postoperative pain context. However, the sensitive method of measuring onset of analgesia described, highlights the slow onset of analgesia when analgesics of known efficacy are given by the intramuscular route in the postoperative period. More attention should be given to the speed of onset of analgesia in future assessments of analgesics.     

An evaluation of the analgesic efficacy of intravenous regional anesthesia with lidocaine and ketorolac using a forearm versus upper arm tourniquet

Intravenous regional anesthesia (IVRA) using a forearm tourniquet may be a potentially safer technique compared with using an upper arm tourniquet. Ketorolac is a useful adjuvant to lidocaine for IVRA. In this study, we assessed the analgesic efficacy of administering IVRA lidocaine and ketorolac with either a forearm or upper arm tourniquet for outpatient hand surgery. Upper arm IVRA was established using 40 mL of a solution containing 200 mg of lidocaine and ketorolac 20 mg (0.5 mg/mL). Forearm IVRA was established using 20 mL of a solution containing 100 mg of lidocaine and ketorolac 10 mg (0.5 mg/mL). Onset and duration of sensory block as well as postoperative pain and analgesic use were recorded. The patients who received forearm IVRA had a significantly longer period during which they required no analgesics (701 +/- 133 min) compared with 624 +/- 80 min for the upper arm IVRA ketorolac patients (P = 0.032). Onset of sensory block was similar between the two groups; however, recovery of sensation was significantly longer in the Forearm IVRA (22 +/- 5 min) group compared with the Upper Arm IVRA (13 +/- 3 min) group (P < 0.05). There were no differences in postoperative analgesic use or pain scores between the two groups. We conclude that forearm IVRA with lidocaine and ketorolac provides safe and effective perioperative analgesia for patients undergoing ambulatory hand surgery. This technique results in a longer duration of sensory block and prolonged postoperative analgesia compared with upper arm IVRA while using one-half the doses of both lidocaine and ketorolac. IMPLICATIONS: Forearm tourniquet intravenous regional anesthesia (IVRA) with 50% less lidocaine and ketorolac provides for both a longer duration of sensory block and prolonged postoperative analgesia compared with upper arm IVRA.     

Combined pre- and post-surgical bupivacaine would infiltrations decrease opioid requirements after knee ligament reconstruction

PURPOSE: To test the efficacy of a combination of selective pre- and post-surgical local anesthetic infiltrations of the knee, compared with standard intra-articular injection at the end of surgery alone, to reduce postoperative opioid requirements following arthroscopic cruciate ligament reconstruction (ACLR). METHODS: In a double-blind, randomized, controlled trial, we studied 23 patients (ASA I or II) scheduled for elective ACLR under general anesthesia. The treatment group (n = 12) received infiltrations with bupivacaine 0.25% with epinephrine 1:200,000 presurgically (10 ml into the portals, 10 ml at the medial tibial incision site, 10 ml at the lateral femoral incision site, and 10 ml intra-articularly) and postsurgically (5 ml at the medial tibial incision and 10 ml at the lateral femoral incision). The control group (n = 11) received infiltrations with saline 0.9% in the same manner. All patients received a standard intra-articular local anesthetic instillation of the knee (25 ml of bupivacaine 0.25% with epinephrine 1:200,000) at the completion of surgery. RESULTS: Postoperative opioid requirements were lower in the treatment group (5.8 +/- 2.9 mg morphine equivalent) than in the control group ( 13.7 +/- 5.8 mg; P = 0.008). Treatment patients were ready for discharge approximately 30 min earlier than control patients (P = 0.046). There were no adverse events in the treatment group. In the control group, 2/11 patients vomited and a third experienced transient postoperative diaphoresis, dizziness and pallor. CONCLUSION: We conclude that a combination of selective pre- and post-surgical wound infiltration with bupivacaine 0.25% provides superior analgesia compared with a standard post-surgical intra-articular injection alone.