Intra-articular morphine and bupivacaine analgesia after arthroscopic knee surgery

We assessed the effectiveness of intra-articular solutions of morphine, bupivacaine with adrenaline and a combination of both, compared with placebo in facilitating mobilisation and reducing postoperative pain and analgesic requirements for 24 h after operation. Forty patients undergoing arthroscopic knee surgery were studied in a double-blind, randomised, controlled trial. All treatments proved more effective than placebo in facilitating earlier mobilisation and in decreasing postoperative pain as measured by visual analogue scale. Morphine alone provided the best analgesia and significantly decreased analgesic consumption for 24 h after surgery. We conclude that 1 mg of intra-articular morphine provides effective pain relief following arthroscopic knee surgery and that the addition of bupivacaine is of no benefit.     

Postoperative analgesia for outpatient arthroscopic knee surgery with intraarticular clonidine and/or morphine

Both clonidine, an alpha(2) agonist, and morphine, an opioid agonist, provide enhanced patient analgesia after arthroscopic knee surgery when administered via the intraarticular (IA) route. Clonidine potentiates morphine analgesia in the animal model. We designed this study to determine whether clonidine or morphine results in better analgesia and whether their combination would provide superior analgesia to either drug alone. We evaluated 60 patients undergoing arthroscopic knee meniscus repair under local anesthesia with sedation. After surgery, patients were randomized into four IA groups: Group B received 30 mL 0.25% bupivacaine; Group BC received 30 mL 0.25% bupivacaine and clonidine 1 microg/kg; Group BM received 30 mL 0.25% bupivacaine and morphine 3 mg; and Group BCM received 30 mL 0.25% bupivacaine, clonidine 1 microg/kg, and morphine 3 mg. This study revealed a significant benefit from the individual IA administration of both clonidine and morphine. The combination of these drugs resulted in decreased postoperative pain and analgesic use, as well as an increased analgesic duration compared with either drug alone. We conclude that IA clonidine and morphine improved comfort compared with either drug alone in patients undergoing knee arthroscopy.     

A comparison of intra-articular magnesium and/or morphine with bupivacaine for postoperative analgesia after arthroscopic knee surgery

Purpose

Both magnesium and morphine provide enhanced patient analgesia after arthroscopic knee surgery when administered separately via the intra-articular route. Magnesium sulfate amplifies the analgesic effect of morphine. This study was designed to compare the analgesic effects of intra-articular magnesium and morphine, with bupivacaine, when used separately and in combination.

Methods

Eighty patients undergoing arthroscopic menisectomy were randomized blindly into four intra-articular groups: group B+Mor+Mg received 20 ml 0.25% bupivacaine, morphine 2 mg, and magnesium 150 mg; group B+Mor received 20 ml 0.25% bupivacaine and morphine 2 mg; group B+Mg received 20 ml 0.25% bupivacaine and magnesium 150 mg; and group B received 20 ml 0.25% bupivacaine. Pain scores at rest and during movement, analgesic duration, and total analgesic consumption were recorded.

Results

Group B+Mor and group B+Mg patients had equally effective postoperative analgesia. Group B+Mor+Mg patients had significantly reduced visual analogue scale (VAS) values both at rest and during movement and significantly increased time to first postoperative analgesic request, as well as significantly reduced total analgesic consumption, compared with the other groups.

Conclusion

Intra-articular administration of magnesium sulfate or morphine, with bupivacaine, had comparable analgesic effects in the doses used. Their combination provided more effective postoperative analgesia than either drug alone.     

The preemptive analgesic effect of intraarticular bupivacaine and morphine after ambulatory arthroscopic knee surgery

Intraarticular (IA) morphine provides effective postoperative analgesia after arthroscopic knee surgery. Some investigators have suggested that the preemptive administration of opioids may reduce postoperative analgesic requirements and hypersensitivity. We evaluated the analgesic effect of administering IA morphine either before or after surgical incision in patients undergoing arthroscopic knee surgery under local anesthesia. Forty patients undergoing arthroscopic meniscectomy were randomized into two groups. All patients received IA bupivacaine 0.25% before and after surgery together with IV sedation using midazolam and propofol. The Preemptive IA Morphine group received a single 3-mg dose of morphine with their preoperative bupivacaine. The Post-IA Morphine group received 3 mg of morphine at the completion of surgery with the postoperative bupivacaine. After surgery, pain scores, the time to first opioid use, and 24-h analgesic use were recorded. Analgesic duration, defined as the time from completion of surgery until first opioid use, was significantly longer in those patients receiving preoperative (953 +/- 209 min) versus postoperative (556 +/- 121 min) IA morphine. The 24-h acetaminophen and oxycodone use was less in the Preemptive group (2.2 +/- 1.2 pills) versus the Postoperative group (3.0 +/- 1.2 pills). We conclude that IA morphine provides a longer duration of postoperative analgesia with less 24-h opioid use when administered before surgery. Implications: The administration of intraarticular morphine 3 mg before arthroscopic knee surgery provides a longer duration of analgesia with less 24-h opioid use compared with the administration of the drug at the completion of surgery.     

Comparison of postoperative analgesic effects of intraarticular bupivacaine and morphine following arthroscopic knee surgery.

Recent studies have shown that, in the presence of inflammation, the local administration of opioids results in analgesia. The analgesic efficacy of local anesthetics and morphine administered intraarticularly was compared in patients undergoing arthroscopic knee surgery under epidural anesthesia. We compared postoperative pain scores (VAS) and opioid requirements among 47 patients receiving, in a randomized, double-blinded fashion, one of three intraarticular medications (20 ml): normal saline with 100 micrograms epinephrine (group 1, n = 16); 0.25% bupivacaine with 100 micrograms epinephrine (group 2, n = 15); and 3 mg morphine sulfate and 100 micrograms epinephrine in normal saline (group 3, n = 16). VAS scores were similar in the groups preoperatively and on arrival in the recovery room. At the end of the first postoperative hour, the residual sensory blockade was minimal in all three groups (mean = 3.8-4.1 segments) and almost total recovery occurred in all three groups before the second postoperative hour. The VAS in group 3 was not significantly different than group 1 at any time interval. Intraarticular bupivacaine (group 2) provided significantly better analgesia than did saline or morphine (group 1 or 3) in the first 2 postoperative hours (ANOVA, P < .05). Subsequent VAS scores were not significantly different in the three groups. While no patient in group 2 requested analgesics during the first postoperative hour, nine patients in group 3 required systemic analgesics (P < .01). We conclude that no evidence for a peripheral opiate-receptor mediated analgesia could be demonstrated in patients undergoing arthroscopic knee surgery under epidural anesthesia.     

Patient supplemented epidural analgesia after major abdominal surgery with bupivacaine/fentanyl or ropivacaine/fentanyl

PURPOSE: To compare analgesic efficacy and occurrence of motor block and other side effects during patient supplemented epidural analgesia (PSEA) with either ropivacaine/fentanyl or bupivacaine/fentanyl mixtures. METHODS: In a prospective, randomized, double-blind study, 32 ASAI-III patients undergoing major abdominal surgery received an epidural catheter at the T8- T10, followed by integrated general epidural anesthesia. Postoperative epidural analgesia was provided using a patient controlled pump with either ropivacaine 0.2%/2 microg x ml(-1) fentanyl (group Ropivacaine, n = 16) or bupivacaine 0.125%/2 microg x ml(-1) fentanyl (group Bupivacaine, n = 16) [background infusion 4-6 ml x hr(-1), 1.5 ml Incremental Doses and 20 min lock out]. Verbal pain rating score, number of incremental doses, consumption of epidural analgesic solution and rescue analgesics, sedation (four-point scale), and pulse oximetry were recorded by a blind observer for 48 hr after surgery. RESULTS: No differences in pain relief, motor block, degree of sedation, pulse oximetry and other side effects were observed between the two groups. The number of incremental doses and the volume of analgesic solution infused epidurally were higher in patients receiving the bupivacaine/fentanyl mixture (10 [0-52] I.D. and 236 [204-340] ml) than in patients receiving the ropivacaine/fentanyl solution (5 [0-50] I.D. and 208 [148-260] ml) (P = 0.03 and P = 0.05, respectively). CONCLUSION: Using a ropivacaine 0.2%/2 microg x ml(-1) fentanyl mixture for patient supplemented epidural analgesia after major abdominal surgery provided similar successful pain relief as bupivacaine 0.125%/2 microg x ml(-1) fentanyl, but patients receiving bupivacaine/fentanyl requested more supplemental.     

Analgesic effect of intraarticular bupivacaine or morphine after arthroscopic knee surgery: a randomized, prospective, double-blind study.

The effect of 20 mL of intraarticular bupivacaine (0.25%, with or without 1:200,000 epinephrine), morphine (0.03%, with or without 1:200,000 epinephrine), or normal saline on postoperative analgesia after arthroscopic knee surgery was studied in a randomized, prospective, double-blind trial in ASA I-III outpatients receiving general anesthesia (n = 112) or regional anesthesia (n = 27 [spinal (n = 25) or epidural (n = 2)]). The visual analogue pain scores in the postanesthesia care unit and 3, 6, 12, and 24 h after surgery, time to first analgesic use, and total 24-h analgesic requirements were recorded. In those who received general anesthesia, the visual analogue scores were significantly lower in the bupivacaine group compared with both the morphine- and placebo-treated patients (P less than 0.05). The time to first analgesic use was longer in both the bupivacaine and morphine groups when compared with the control group (P less than 0.05). No significant differences were detected in total 24-h analgesic requirements among the groups. Patients who had received regional anesthesia had lower visual analogue scores compared with patients who had received general anesthesia irrespective of the intraarticular treatment (P less than 0.05). Our results indicate that intraarticular injection of bupivacaine after arthroscopic knee surgery provides prolonged analgesia but that there is no significant prolonged analgesia provided by intraarticular morphine.     

Intrathecal bupivacaine with morphine or neostigmine for postoperative analgesia after total knee replacement surgery

PURPOSE: To compare the postoperative analgesic efficacy and safety of intrathecal (IT) neostigmine and IT morphine in patients undergoing total knee replacement under spinal anesthesia. METHODS: Sixty patients scheduled for elective total knee replacement under spinal anesthesia were randomly divided into three equal groups which received IT 0.5% hyperbaric bupivacaine 15 mg with either normal saline 0.5 mL, neostigmine 50 microg, or morphine 300 microg. The maximal level of sensory block, duration of analgesia, time to use of rescue analgesics, the overall 24-hr and four-hour interval visual analogue scale (VAS) pain score, and the incidence of adverse effects were recorded for 24 hr after administration. RESULTS: There was no significant difference in maximal level of sensory block among the three groups. The morphine group had a later onset of postsurgical pain and longer time to first rescue analgesics than the neostigmine group (P <0.05). Overall 24-hr VAS pain scores were significantly higher in the saline group vs the morphine and neostigmine groups (P <0.05). Motor block lasted significantly longer in the neostigmine group than in the morphine and saline groups (P <0.05). The incidence of adverse effects was similar in the neostigmine and morphine groups except for pruritus (70%) occurring more frequently in the morphine group than in the neostigmine and saline groups (0%; P <0.05). Overall satisfaction rates were better in the neostigmine group than in the morphine and saline groups (P <0.05). CONCLUSIONS: IT neostigmine 50 microg produced postoperative analgesia lasting about seven hours with fewer side effects and better satisfaction ratings than IT morphine 300 microg.     

Comparison between epidural infusion of fentanyl/bupivacaine and morphine/bupivacaine after orthopaedic surgery

Purpose

To compare epidural infusions of bupivacaine-fentanyl and bupivacaine-morphine mixtures for postoperative pain relief after total hip replacement.

Methods

In a prospective, randomized, double-blind study, 30 ASA physical status I–II patients undergoing total hip replacement were studied. Anaesthesia was provided by combined general/epidural anaesthesia without epidural opioids. Postoperative epidural analgesia was by continuous infusion of bupivacaine 0.125% (4 ml·hr^?1) with either 0.05 mg·ml^?1 morphine (morphine, n = 15) or 0.005 mg·ml^?1 fentanyl (fentanyl, n = 15). Visual analogue pain scale (VAS), sedation (fourpoint scale), respiratory rate, pulse oximetry, rescue analgesics and supplemental oxygen were recorded by a blind observer at 1,3, 6, 9, 12 and 24 hr after surgery.

Results

No differences in pain relief, sedation, or non-respiratory side effects were observed between the two groups. Rescue analgesics were required in three patients in the fentanyl group (20%) and in two receiving morphine (13.3%) (P:NS). Two patients in the fentanyl group and three in the morphine group required oxygen due to SpO₂ < 90% (P:NS). Both opioid/bupivacaine mixtures decreased haemoglobin oxygen saturation compared with preoperative values. The mean ± SD SpO₂ values measured at 3,6, 12 and 24 hr were 94.4 ± 1, 92.6 ± 0.9, 92 ± 0.8, and 92.8 ± 1 in the morphine group, 95.3 ± 0.5, 95 ± 0.5, 94.6 ± 1.2, and 95.6 ± 1 in the fentanyl group (P < 0.05).

Conclusion

Continuous epidural infusion of bupivacaine-morphine or bupivacaine-fentanyl mixtures provided similar pain relief. Patients receiving morphine showed a more marked decrease in SpO₂ than those receiving fentanyl. However, the average SpO₂ remained > 90% in both groups.     

Postoperative analgesia for outpatient arthroscopic knee surgery with intraarticular clonidine

Intraarticular (i.a.) local anesthetics are often used for the management and prevention of pain after arthroscopic knee surgery. Clonidine prolongs the duration of local anesthetics. We designed this study to determine whether clonidine added to an i.a. injection would result in an analgesic benefit. Fifty patients were randomly assigned to one of five groups that received clonidine (either via the subcutaneous or i.a. route) or saline placebo with or without i.a. bupivacaine, as follows: Group 1 received 30 mL of 0.25% bupivacaine i.a.; Group 2 received 30 mL of 0.25% bupivacaine with clonidine (1 microg/kg) i.a.; Group 3 received 30 mL of 0.25% bupivacaine i.a. and subcutaneous clonidine (1 microg/kg); Group 4 received 30 mL of 0.25% bupivacaine with epinephrine (5 microg/mL) i.a.; and Group 5 received clonidine (1 microg/kg) in 30 mL of saline i.a.. The results of this study revealed a significant difference in analgesia from the i.a. administration of clonidine. The group who received a combination of i.a. bupivacaine and clonidine had a significantly decreased need for oral postoperative analgesics and an increased analgesic duration (P < 0.0001). We conclude that i.a. clonidine improved comfort in patients undergoing knee arthroscopy. Implications: The intraarticular administration of clonidine along with bupivacaine results in a significant improvement in analgesia compared with either drug alone. There was an increased time to first analgesic request and a decreased need for postoperative analgesics.     

Comparison of bupivacaine and fentanyl as an adjuvant of epidural morphine for postoperative analgesia

We conducted a retrospective study to determine whether bupivacaine or fentanyl is a better adjuvant to epidural morphine for postoperative analgesia using 108 patients. Following epidural lidocaine anesthesia with or without light general anesthesia for major gynecological surgeries, 59 patients received epidural morphine (EPM) 2 mg (group M), 21 patients received morphine 2 mg plus 0.25% plain bupivacaine 6–10 ml epidurally (group B), and 28 patients received morphine 2 mg plus fentanyl 100 μg epidurally (group F). The analgesic interval, defined as the duration from EPM injection to the first request of analgesics for incisional pain, was significantly longer in group F than in group M (29±11vs 19±17 h,P<0.05), but similar to group B (22±14 h). Group F patients required the least amount of analgesics for incisional pain of the three groups during the first 24 h postoperatively (P<0.01). The incidence of adverse effects was similar among all three groups. In conclusion, fentanyl appears to be a better adjuvant to epidural morphine than bupivacaine.     

Pre-emptive analgesia with epidural morphine or morphine and bupivacaine

Studies of preemptive analgesia in humans have shown conflicting results. The study design, patient population and the duration of assessment of postoperative pain are important in the evaluation of preemptive analgesia. We carried out a prospective, randomized, double-blind controlled study in 80 patients of physical status ASA 1-3 undergoing upper abdominal and thoracic surgery. Patients received two epidural injections, one 20 minutes before induction and the other at the end of surgery. Study solution was either morphine (50 micrograms/kg), with or without 0.1% bupivacaine in 10 ml of normal saline, or normal saline alone. The study groups (Pre M, Pre MB) were given either morphine or morphine-bupivacaine before induction and saline at the end of surgery. The control groups (Post M, Post MB) were given saline before induction and morphine or morphine-bupivacaine at the end of surgery. Postoperative pain was assessed with a Visual Analogue Scale (VAS) during coughing and deep breathing at six-hourly intervals for five days. Epidural morphine was given if the VAS exceeded 4. Pre MB compared to Post MB had a significantly increased interval between the analgesic top-ups (P < 0.01) and decreased total postoperative morphine requirements (P < 0.0001) and number of top-ups (P < 0.001). Pre M and Post M were comparable. Pre MB compared to Pre M had significantly decreased total postoperative morphine requirements (P < 0.0001) and number of top-ups (P < 0.0001). Epidural morphine plus bupivacaine is effective as a preemptive analgesic. Morphine plus bupivacaine has better efficacy than morphine given alone before the induction of anaesthesia.     

Intraarticular fentanyl compared with morphine for pain relief following arthroscopic knee surgery

PURPOSE: To compare the analgesia produced by comparable doses of intra-articular (IA) morphine and fentanyl. METHODS: Sixty-nine healthy patients undergoing arthroscopic surgery received a standardized general anesthetic of 4 mg x kg(-1) thiopental and 2 microg x kg(-1) fentanyl followed by 2 mg x kg(-1) succinylcholine prior to tracheal intubation and controlled ventilation. Maintenance of anesthesia was achieved with N2O/O2 and isoflurane. At the conclusion of surgery intra-articular injection was: Group I (n=23) 50 microg fentanyl in 20 ml saline; Group II (n=24) 3 mg morphine in 20 ml saline; Group III (n=22) 20 ml saline. Pain scores at rest using a visual analogue scale were recorded by a separate blinded observer at one, two, four, and eight hours postoperatively. RESULTS: Pain scores at one, two, four, and eight hours were 36, 26.3, 20.9, and 12.8 vs 35.8, 33.8, 28.8, and 21.9 vs 70.5, 57.7, 58.4, and 53.6 for the IA-fentanyl, IA-morphine, and control groups respectively. Pain scores were greater at all times for Group III. Pain scores for Groups I and II were similar at one hour, but thereafter were less (P < 0.001) for the IA-fentanyl group. CONCLUSION: Better postoperative analgesia was achieved with 50 microg intraarticular fentanyl than with 3 mg intraarticular morphine.     

Effect of intra-articular injection of midazolam and/or bupivacaine on postoperative analgesia after arthroscopic knee surgery

BackgroundA variety of analgesic techniques have been used to manage postoperative pain after arthroscopic knee surgery. We investigated the hypothesis that intra-articular midazolam would result in lower pain score and reduced analgesic requirements.MethodsOne-hundred patients undergoing arthroscopic meniscectomy were allocated randomly to receive intra-articular 20 mL of isotonic saline containing 50 μg/kg midazolam (midazolam group (group M),the bupivacaine group (group B) received 0.25% (20 mL) bupivacaine, and the midazolam with bupivacaine group (group MB) received bupivacaine 0.25% and 50 μg/kg of midazolam in 20 mL. The postoperative analgesia was assessed using visual analog score at rest and during movement at 1/2 h, 1 h, 2 h, 6 h, 12 h, and 24 h.ResultsPatients in group MB showed significantly lower visual analog scores, both at rest and during movement, long time to first postoperative analgesic request, as well as reduced total analgesic consumption than the other two groups.ConclusionIntraarticular administration of midazolam in combination with bupivacaine improves the quality of postoperative analgesia after arthroscopic meniscectomy.     

Comparison of analgesic effects of morphine, fentanyl, and remifentanil with intravenous patient-controlled analgesia after cardiac surgery

OBJECTIVE: The purpose of this study was to compare the analgesic effects of remifentanil with 2 other opioid agents, morphine and fentanyl, after cardiac surgery. DESIGN: Prospective, randomized, and double-blinded study. SETTINGS: This study was performed at Uludag University hospital. PARTICIPANTS: Seventy-five patients undergoing off-pump coronary artery bypass surgery were included in the study. INTERVENTIONS: Anesthesia was standardized. Cases were randomized into 3 groups consisting of 25 patients in each. Groups M, F, and R were given morphine HCl (1 mg/mL) with an infusion rate of 0.3 mg/h and 1-mg bolus doses; fentanyl (50 microg/mL) with an infusion rate of 1 microg/kg/h and 10-microg bolus; and, remifentanil (50 microg/mL) with an infusion rate of 0.05 microg/kg/min and 0.5-microg/kg bolus, respectively. Continuous infusion was started immediately after the completion of the surgery. MEASUREMENTS AND MAIN RESULTS: Pain was assessed by using a visual analog scale (0-10), and sedation was assessed with the Ramsey sedation score (1-6) 30 minutes, 1, 2, 4, 12, and 24 hours after extubation. The number of boluses and demands, time to extubation, and side effects were analyzed. Visual analog scale, sedation scores, and mean extubation times were similar in all groups. Total number of boluses and demands were statistically more in the remifentanil group. Regarding the side effects, nausea and vomiting was higher in group M (p < 0.05), whereas itching was prominent in group F (p < 0.05). CONCLUSIONS: Despite the different durations of these 3 opioid agents, the infusion dose of remifentanil was as effective as morphine and fentanyl after OPCAB surgery with fewer side effects.     

吗啡、芬太尼、曲马多术后镇痛对病人白细胞介素-2的影响

目的 观察吗啡、芬太尼、曲马多用于术后病人静脉自控镇痛(PCIA)时对血清白细胞介素-2(IL-2)分泌的影响。方法 150例择期行上腹部手术的病人，随机分成三组：M组(吗啡组)；F组(芬太尼组)；T组(曲马多组)。分别于麻醉前、术后1、3、24h采血，应用酶联免疫吸附试验(ELISA)检测血清IL-2水平。结果 与麻醉前比较，M组病人术后各时点血清IL-2水平明显降低(P＜0．05)，F组在各时点明显升高(P＜0．05)，T组术后1h与麻醉前比较差异无显著性(P＞0．05)，术后3h明显升高(P＜0．05)，术后24h达到更高水平(P＜0．01)。结论 吗啡、芬太尼、曲马多均可有效减轻术后疼痛。与吗啡抑制IL-2分泌相反，芬太尼和曲马多可明显增强上腹部手术病人术后IL-2的分泌。     

Epidural analgesia in total gastrectomy--combination of bupivacaine with ketamine or fentanyl

The effects of intraoperative epidural administration of ketamine added to bupivacaine were compared with fentanyl added to bupivacaine in patients undergoing total gastrectomy. Prospective, randomized, double blind study was designed to compare: group F: 20 patients (pts) receiving 20 ml of 0.125% bupivacaine and 50 ug of fentanyl and group K: 20 pts in whom 20 ml of 0.125% bupivacaine was combined with 50 mg of ketamine. Pts received an epidural injection through peridural catheter introduced through either T7-8 or T8-9 interspinous space. Non invasive arterial blood pressure, heart rate and ECG were recorded every 5 mins. We measured supplementary fentanyl requirement, ephedrine consumption, first postoperative complain on pain, tracheal extubation time. The groups were comparable with regard to patients characteristics, operation and anaesthesia related factors. There were no difference between groups in mean intraoperative fentanyl requirements (F vs. K = 118.5 (122.5) ug vs. 122.5(122.5)ug) (p n > 0.05), in the duration of epidural pain relief (F vs. K = 393.72 (98.75)min vs.403.63 (111.41)min, in the tracheal extubation time (F vs.K = 52.31 (50.4) vs.46.75 (48.35) min), postoperative sedation score (F vs.K = 1.26 (0.73) vs.1.11 (0.32)) (p > 0.05). Significantly higher systolic blood pressure was measured in group K comparing with group F in 20, 75, 105, 120, 150 min (p > 0.05). Statistically significant more ephedrine was applied in F group (F vs.K = 0.88(1.76)ml vs.0.05(0.23)ml) (p > 0.05). There were no statistically significant differences between groups in heart rate during the operation. None of the pts complained of bad dreams or awakeness during operation. Both fentanyl and ketamine added to bupivacaine and given as a bolus provided good intraoperative analgesia in combination with general anaesthesia, minimal sensorimotor disturbance and early tracheal extubation. In our study fentanyl added to bupivacaine caused higher incidence of hypotension than ketamine added to bupivacaine.