Effects of intravenous patient-controlled analgesia with morphine, continuous epidural analgesia, and continuous femoral nerve sheath block on rehabilitation after unilateral total-hip arthroplasty

BACKGROUND AND OBJECTIVES: Regional analgesic techniques allow better postoperative rehabilitation and shorter hospital stay after major knee surgery. The authors tested the hypothesis that similar results could be obtained after total-hip arthroplasty. METHODS: Forty-five patients scheduled for THA under general anesthesia were randomly divided into 3 groups. Postoperative analgesia was provided during the first 48 hours, with intravenous patient-controlled analgesia (IV PCA) induced by morphine (dose, 1.5 mg; lockout interval, 8 min) in group IV, continuous femoral nerve sheath block in group FNB, and continuous epidural analgesia in group EPI. The day after surgery, the 3 groups started identical physical therapy regimens. Pain scores at rest and on movement, supplemental analgesia, side effects, daily degree of maximal hip flexion and abduction, day of first walk, and duration of hospital stay were recorded. RESULTS: Population data, quality of pain relief, postoperative hip rehabilitation, and duration of hospital stay were comparable in the 3 groups. When compared with the two other techniques, continuous FNB was associated with a lower incidence of side effects (no nausea/vomiting, urinary retention, arterial hypotension, or catheter problem during the first 48 hours in 20%, 60%, and 13% of patients in groups IV, FNB, and EPI, respectively). CONCLUSIONS: This study suggests that IV PCA with morphine, continuous FNB, and continuous epidural analgesia provide similar pain relief and allow comparable hip rehabilitation and duration of hospital stay after total-hip arthroplasty (THA). As continuous FNB is associated with less side effects, it appears to offer the best option of the three.     

股神经阻滞用于全膝关节置换术患者术后镇痛的Meta分析

目的 采用Meta分析的方法评价股神经阻滞(femoral nerve block,FNB)对全膝关节置换术(total knee arthroplasty,TKA)患者术后镇痛的效果. 方法 检索PubMed、OVID、EMBASE、Cochrane图书馆,检索时间从建库至2014年11月.收集在TKA术后使用FNB与患者自控静脉镇痛(patient-controlled intravenous analgesia,PCIA)或患者自控硬膜外镇痛(patient-controlled epidural analgesia,PCEA)的临床随机对照实验(randomized controlled trial,RCT).采用Cochrane协作网系统评价法评价纳入文献的质量,采用RevMan5.2软件进行Meta分析评价. 结果 共纳入14项研究,包括1 157例患者,其中FNB组616例,PCIA组380例,PCEA组161例.与PCIA组比较,FNB有效减少了患者术后24 h[加权均数差(weighted mean difference,WMD)=-17.93,95％置信区间(confidence interval,CI)=-27.38～-8.49]及48 h(WMD=-25.70,95％CI:-41.67～-9.74)的吗啡累计消耗量,降低患者术后24 h活动时VAS(WMD=-1.99,95％CI:-3.14～-0.85)(P＜0.05);且FNB组患者术后恶心呕吐比值比(odds ratio,OR)(0.31,95％CI:0.22～0.44)、尿潴留(OR=0.24,95％CI:0.13～0.43,P＜0.05)及头晕的发生率(OR=0.27,95％CI:0.14～0.52)都较低(P＜0.05). 结论 比较PCIA及PCEA,FNB可能是TKA患者术后镇痛的一种更好的选择.     

Intraarticular, epidural, and intravenous analgesia after total knee arthroplasty

BACKGROUND: After total knee arthroplasty, patients regularly suffer from severe pain. It is unclear whether epidural or systemic pain therapy is superior in terms of postoperative pain relief, patients' comfort and side effects. A new therapeutic approach, intraarticular opioids, has been suggested with the detection of opioid receptors in inflamed tissue. This method has proven suitable for clinical use in small operations (e.g. knee arthroscopy). In this study, we compared epidural analgesia and intraarticular application of morphine plus "on-demand" intravenous analgesia to "on-demand" intravenous analgesia alone. METHODS: Thirty-seven patients, scheduled for total knee arthroplasty, were randomly assigned to three treatment groups: in group 1 (EPI) patients received bolus doses of morphine via an epidural catheter; in group 2 (IA) an intraarticular bolus of 1 mg of morphine was applied at the end of the operation with subsequent use of a patient-controlled analgesia (PCA) pump; group 3 (Control), in which only PCA was provided, served as control for both analgesic procedures. Main outcome measures included visual analogue pain scales, total morphine consumption, and stress hormones. RESULTS: No statistically significant differences in visual analogue pain scales could be detected between the three groups. Application of intraarticular morphine did not reduce the amount of analgesics required for postoperative analgesia as compared to intravenous analgesia alone. Application of epidural morphine significantly suppressed beta-endorphine release, but did not significantly influence other stress hormones as compared to the control group. CONCLUSION: Epidural and intravenous analgesia after total knee arthroplasty are equivalent methods of pain relief. In major orthopaedic procedures, application of intraarticular morphine does not reduce analgesic requirements.     

Comparison of patient-controlled analgesia (PCA) with tramadol or morphine

PURPOSE: To compared the clinical efficacy of tramadol and morphine using a patient-controlled analgesia (PCA) delivery system. METHODS: In a prospective, randomized, double blind study, we evaluated 80 adult patients scheduled for elective hip or knee arthroplasty with general inhalational anesthesia. When patients complained of pain in the recovery room, patients were randomized to receive either tramadol or morphine by titration in 30 min to achieve analgesia (VAS < or =4). Equivalent volumes containing either 30 mg x ml(-1) tramadol or 1 mg x ml(-1) morphine were used for PCA with a lockout interval of 10 min. The patients were followed six-hourly for 48 hr for VAS, satisfaction rate, analgesic dose, and side effects. RESULTS: Patients obtained adequate analgesia with either drug. More patients had very good satisfaction scores in the morphine group in the recovery room (43% vs. 23%, P<0.05) and at 24 hr (40% vs. 20%, P<0.05) than those in the tramadol group. More nausea was evident in the tramadol group (48% vs. 11% in recovery room and 28% vs. 12% in 24 hr, P<0.05) than in the morphine group. Vomiting was also more (28% vs. 5% in recovery room, 15% vs. 3% in 24 hr, P<0.05). Morphine produced more sleepiness (45% vs. 23% in recovery room, P<0.05 and 35% vs. 15% in 24 hr, P<0.05). CONCLUSION: Tramadol PCA can provide effective analgesia following major orthopedic surgery provided sufficiently high doses are given for loading and by patient demand. However, the incidence of nausea/vomiting is also higher causing decreased satisfaction.     

Postoperative extradural analgesia with morphine and ropivacaine. A double-blind comparison between placebo and ropivacaine 10 mg/h or 16 mg/h

BACKGROUND: Some controversy exists in the literature on the benefit of epidurals compared to patient-controlled intravenous analgesia (PCA). Also, the dose of ropivacaine for epidural analgesia when combined with morphine remains uncertain. The aim of this study was to compare the epidural vs. PCA technique and high-dose vs. low-dose ropivacaine combined with morphine during knee replacement surgery. METHODS: In this prospective, randomized, double-blind study, postoperative pain relief with a combination of epidural ropivacaine (Group L: 10 mg h-1, Group H: 16 mg h-1) and morphine (0.16 mg h-1) was evaluated in 30 patients. A placebo group (Group PL) of 15 patients having PCA morphine served as the control. Visual analog pain (VAS), morphine consumption, sensory and motor block and side-effects were recorded during 48 h. RESULTS: VAS scores at rest were significantly lower in Groups L and H compared to Group PL. On movement, Group H had lower VAS scores than Group PL during 3-27 h (P<0.05) and Group L during 4-9 h (P<0.05), while Group L had lower a VAS than Group PL during 9-18 h (P<0.05). Morphine consumption after 48 h was greater in Group PL (64.6+/-36.3 mg) vs. Group L (23.3+/-33.9 mg) (P<0.001) and Group H (4.3+/-9.6 mg) (P<0.0001). Mild motor block was seen in Group H in 20% and 14% patients at 24 h and 48 h, respectively, but time to mobilization was similar between the groups. Pruritus was more common in the ropivacaine groups (P<0.05). CONCLUSION: Lumbar epidural analgesia using a combination of ropivacaine (16 mg h-1) and morphine (0.16 mg h-1) provides superior analgesia compared to the PCA technique or ropivacaine (10 mg h-1) and morphine (0.16 mg h-1). Although this resulted in a mild motor block during the first 12 h, patient mobilization was similar in all groups.     

Intrathecal clonidine added to a bupivacaine-morphine spinal anesthetic improves postoperative analgesia for total knee arthroplasty

Postoperative pain after total knee arthroplasty (TKA) is severe and can complicate early physical therapy. We tested the hypothesis that intrathecal clonidine would improve postoperative analgesia for TKA using a hyperbaric bupivacaine spinal anesthetic. In a double-blinded, placebo-controlled protocol, 81 ASA physical status I-III patients undergoing either a single or bilateral TKA were randomized into 4 groups with the following 2-mL solutions added to 15 mg of hyperbaric bupivacaine: 1) sterile saline, 2) morphine (250 microg), 3) morphine (250 microg) with clonidine (25 microg), and 4) morphine (250 microg) with clonidine (75 microg). At 1, 2, 4, 6, 12, and 24 h postoperatively, we measured visual analog scales (VAS), cumulative IV morphine consumption, hemodynamics, nausea, ancillary drugs, and side effects. Our primary comparison was between the clonidine with morphine groups versus the morphine group. We found that the combined administration of intrathecal clonidine and morphine decreased 24 h IV morphine consumption by 13 mg (P = 0.028) when compared with intrathecal morphine alone. This corresponded to a decrease in the VAS score of 1.3 cm at 24 h postoperatively (P = 0.047). Adverse side effects were similar among all groups with the exception of more relative hypotension in the clonidine groups through postoperative hour 6. We conclude that the coadministration of intrathecal clonidine and morphine decreases the 24-h IV morphine consumption and improves the 24-h VAS score when compared with intrathecal morphine alone. IMPLICATIONS: In this prospective, randomized, double-blinded, and placebo-controlled trial, we identify an effective postoperative analgesic approach in total knee replacement surgery. Intrathecal morphine (250 microg) combined with clonidine (25 or 75 microg) provided superior analgesia compared with intrathecal morphine alone.     

Fast-track coronary artery bypass grafting surgery under general anesthesia with remifentanil and spinal analgesia with morphine and clonidine

OBJECTIVE: Effective postoperative analgesia is a critical part of fast-track cardiac surgery. This study compared the postoperative analgesic effect of fast-track anesthesia with remifentanil and spinal morphine and clonidine with that of sufentanil anesthesia followed by patient-controlled administration of intravenous morphine. DESIGN: Prospective, blinded, randomized study. SETTING: Single private institution. PARTICIPANTS: Forty patients selected for coronary artery bypass graft surgery allocated randomly into 2 groups. INTERVENTIONS: General anesthesia was performed with etomidate, isoflurane, cisatracurium, and either remifentanil (0.10-0.25 microg/kg/min) or sufentanil (up to 3.5 microg/kg). In the remifentanil group, patients received spinal morphine (4 microg/kg) and clonidine (1 microg/kg) before induction. Postoperatively, patients in both groups were connected to an intravenous patient-controlled analgesia (PCA) morphine pump that delivered a 1-g bolus with a 7-minute lockout interval. MEASUREMENTS AND MAIN RESULTS: Patients were evaluated for pain on a visual analog scale (VAS), at rest and on deep breathing, and for intravenous PCA morphine consumption during 24 hours. The intravenous PCA morphine 24-hour cumulative dose was lower in the fast-track than in the control group (15.8+/-12.6 v 32.7+/-22.3 mg, p<0.05). Before extubation, VAS scores were higher in the fast-track group, but after they were lower both at rest and during deep breathing. Extubation delay was shorter in the fast-track group (156.5+/-46.1 v 272+/-116.4 minutes, p<0.05). CONCLUSION: The combination of anesthesia with remifentanil and spinal analgesia with morphine and clonidine produces effective analgesia after coronary artery surgery and a rapid extubation time.     

Femoral block provides superior analgesia compared with intra-articular ropivacaine after anterior cruciate ligament reconstruction

BACKGROUND AND OBJECTIVES: Arthroscopic anterior cruciate ligament (ACL) reconstruction of the knee is a painful procedure requiring intensive postoperative pain management. This prospective study investigates analgesic quality after a femoral block as compared with intra-articular injection of local anesthetic. METHODS: Eighty patients scheduled for elective ACL repair under general anesthesia were included in our study. Upon completion of surgery, the patients were randomly assigned into 1 of 2 groups: femoral group (n = 40) received a femoral block with 20 mL 1% ropivacaine; intra-articular group (n = 40) received 20 mL 1% ropivacaine injected intra-articularly. During the first 24 hours after surgery, all patients received 2 g propacetamol and 100 mg ketoprofen, intravenously. Additional postoperative analgesia was available with parenteral morphine if required. Analgesic duration was defined as the time from end of surgery to the first requirement for a supplemental analgesic. Data collection included patient demographics, visual analog scale (VAS) scores, analgesic duration, and morphine use. Analysis of variance (ANOVA) test was used to compare the 2 groups. RESULTS: VAS score in the recovery room and during rehabilitation was higher in the intra-articular group than in the femoral group (P <.001). Morphine use was lower in the femoral group than in the intra-articular group (P <.001). Similarly, analgesic duration was longer in the femoral group than the intra-articular group (P <.0001). CONCLUSIONS: Compared with intra-articular injection of local anesthetic, femoral nerve block (FNB) provides better analgesia and allows a significant morphine-sparing effect after ACL repair.     

A background infusion of morphine does not enhance postoperative analgesia after cardiac surgery

PURPOSE: To compare the effects of patient-controlled analgesia (PCA), with or without a background infusion of morphine on postoperative pain relief and stress response after cardiac anesthesia. METHODS: With University Ethics approval, 35 consenting adults undergoing elective open-heart surgery were randomly assigned preoperatively in a double-blind fashion to receive either morphine PCA alone (Group I, n = 15) or morphine PCA plus a continuous basal infusion (Group II, n = 14) for 44 hr postoperatively. Pain scores with visual analogue scale (VAS) at rest, deep inspiration and with cough, sedation scores, stress hormone levels [cortisol, adrenocorticotropin (ACTH) and growth hormone (GH)] and morphine consumption were assessed, and serum morphine levels were measured at four, 20, 28 and 44 hr after surgery. Adverse effects including nausea, vomiting, constipation, urinary retention and pruritus were noted. Total blood, fluid requirements, drainage and urinary output were recorded. RESULTS: Postoperative morphine consumption at 44 hr was less in Group I (29.43 +/- 12.57 mg) than in Group II (50.14 +/- 16.44 mg), P = 0.0006. There was no significant difference between groups in VAS scores, GH levels, blood levels of morphine and adverse effects. While VAS scores, ACTH and GH levels decreased significantly in both groups, plasma cortisol levels increased significantly in Group I only at four hours. In Group II, ACTH and cortisol were higher at four and 44 hr respectively. CONCLUSION: PCA with morphine effectively controlled postoperative pain after cardiac surgery. The addition of a background infusion of morphine did not enhance analgesia and increased morphine consumption.     

Methadone patient-controlled analgesia for postoperative pain: a randomized,controlled, double-blind study

Purpose

Postoperative pain is an important health-care issue. Patient-controlled analgesia (PCA) is considered the gold standard for systemic postoperative pain treatment. Methadone PCA is used for patients with chronic pain and those in the palliative care setting. However, its efficacy as a first-line drug for acute postoperative pain is unknown. This study evaluated the use of postoperative methadone PCA after total hip arthroplasty (THA) compared with morphine PCA.

Methods

This was a randomized, double-blind, controlled, parallel-group study. Patients were randomized into two groups: group methadone—methadone PCA, and group morphine—morphine PCA, for postoperative analgesia. Drugs were delivered through PCA pumps throughout the first 24 h after surgery (T1:6, T2:12, T3:18, T4:24 h).

Results

Opioid consumption in 24 h was significantly lower for group methadone than for group morphine. Group methadone patients experienced significantly less pain than group morphine at rest. Pain after movement was significantly lower in group methadone at T1 and T3 and marginally lower at T2 and T4. Adverse events more frequently reported were sleepiness, nausea, and vomiting, but no statistical difference between groups was found.

Conclusion

This study demonstrated that methadone PCA prompted less opioid consumption and lower pain scores at rest and at motion in comparison with morphine PCA as postoperative analgesia after THA.     

Multimodal periarticular injection vs continuous femoral nerve block after total knee arthroplasty: a prospective, crossover, randomized clinical trial

This study compares the efficacy of pain control using continuous femoral nerve block (FNB) and multimodal periarticular soft tissue injection. This is a randomized, crossover, clinical trial. Sixteen patients having bilateral osteoarthritis of the knee scheduled for staged total knee arthroplasty were randomized to receive either FNB (0.2% ropivacaine), via indwelling catheter for 72 hours, or multimodal periarticular soft tissue injection in the first stage. In the second stage, they received the opposite treatment. The primary outcome measure was morphine consumption by patient-controlled analgesia in the first 72 hours postoperatively. Cumulative morphine consumption as well as rest pain and motion pain in the first 72 hours was comparable between the 2 groups. The functional outcomes did not differ significantly. We conclude that multimodal periarticular soft tissue injection provides comparable analgesia to continuous FNB after total knee arthroplasty.     

Peroperative titration of morphine improves immediate postoperative analgesia after total hip arthroplasty

PURPOSE: To determine the Influence of peroperative titrated morphine on postoperative pain control. METHODS: Forty patients received general anesthesia for total hip arthroplasty (THA) and were divided into two groups of 20. In the Peroperative group (Perop group;) morphine was titrated at the end of surgery (3 mg i.v. every 5 or 10 min) in spontaneously breathing intubated patients, until the respiratory rate (RR) decreased. No morphine was administered to Postop group. In the Post Anesthesia Care Unit (PACU) patients in Perop and Postop groups received morphine until adequate pain relief VAS < or = 30 mm. Patients used patient-controlled analgesia (PCA) for the next 24 hr. In the PACU, the delay for analgesia, doses of morphine used and incidence of side effects were recorded. RESULTS: In the Perop group, patients received 10.3 +/- 1.3 mg (2-20 mg) as peroperative titration and had achieved adequate analgesia more rapidly than in the Postop group (42 +/- 7 min vs 76 +/- 7 min); P = 0.0026). Analgesia in the PACU in the Postop group required larger doses of morphine (15.4 +/- 1.5 mg;) than in the Perop group (7.3 +/- 1.3 mg; P = 0.0004). The respiratory rate decrease during peroperative morphine titration was correlated to the morphine dose needed in the PACU (P = 0.035). Respiratory depression in the PACU was more common in the Postop group than in the Perop group (five patients vs no patient P = 0.017). CONCLUSION: This study demonstrated that the peroperative administration of morphine can facilitate immediate postoperative pain management.     

Postoperative analgesia with morphine with or without diclofenac after shoulder surgery

Balanced analgesia using a narcotic and a nonsteroidal anti-inflammatory drug has been successfully tested for postoperative analgesia. This study was designed to examine the efficacy of such combination therapy after shoulder surgeries. Twenty ASA physical status I or II patients, scheduled for shoulder surgeries under general anesthesia, were randomly assigned to either morphine (M) group (n = 10), who received IV morphine patient-controlled analgesia (PCA) alone (2 mg as a bolus, lock-out interval of 10-minutes, and 10 mg as 1-hour limit for 48 hours), or morphine + diclofenac (M + D) group (n = 10), who received, in addition to morphine PCA, diclofenac suppositories 50 mg.8 h-1 starting immediately before surgical incision for 48 hours. Postoperative analgesic profiles, such as visual analog scale (VAS) at rest and on movement, and cumulative morphine consumption, the incidence and extent of side effects (nausea, vomiting, and time till the first bowel movement), and other complications were recorded. The two groups were similar demographically. Patients in the M + D group required 15.1 +/- 9.0 mg of morphine within 48 hours after surgery, while those in the M group required 30.5 +/- 21.0 mg of morphine (P < 0.05). No significant differences in VAS at rest and on movement were observed between the two groups. The time till the first bowel movement was significantly shorter in the M + D group. Our data suggest that diclofenac suppositories 50 mg.8 h-1 starting immediately before surgery for 48 h are effective adjuvant in reducing post-shoulder surgery morphine requirement and retardation of bowel movement.     

A comparison of morphine, meperidine, and oxymorphone as utilized in patient-controlled analgesia following cesarean delivery

Seventy-five patients (n = 75) undergoing elective cesarean delivery during epidural anesthesia were randomly assigned to receive one of three opioid analgesics via patient-controlled analgesia (PCA) when they first complained of pain in the recovery room. Following administration of an analgesic loading dose, patients were allowed to self-administer morphine 1.8 mg, meperidine 18 mg, or oxymorphone 0.3 mg iv every 8 min as required. Data collected during the 24-h observation period included visual analog scale (VAS) pain scores at rest and during movement, VAS patient satisfaction scores, total drug administered, the ratio of attempts/injections, and the incidence of nausea/vomiting, sedation, and pruritus. After adjusting for narcotic potency, no differences in 24-h dose requirements were noted between treatment groups (NS). All patients achieved an excellent level of analgesia at rest (NS); however, onset was most rapid with oxymorphone (P less than 0.05). The percentage of patients reporting severe pain during movement was highest in the meperidine group (P less than 0.05). Oxymorphone was associated with the highest incidence of nausea and vomiting (P less than 0.05), whereas increased sedation and pruritus were noted with morphine. Patient satisfaction with drug effect demonstrated significant negative correlations with resting pain scores and degree of sedation. Whereas morphine is a more commonly utilized PCA analgesic, the excellent analgesia, low incidence of sedation, and high patient satisfaction provided by meperidine and oxymorphone suggested useful alternatives.     

Intrathecal morphine for postoperative analgesia: a randomized, controlled, dose-ranging study after hip and knee arthroplasty

In this series, we examined analgesia and side effects of intrathecal morphine sulfate (ITMS) after hip and knee arthroplasty over a dose range of 0.0-0.3 mg. Eighty patients undergoing hip (n = 40) or knee (n = 40) arthroplasty were randomized to receive ITMS (0.0, 0.1, 0.2, or 0.3 mg). A patient-controlled analgesia (PCA) device provided free access to additional analgesics. Morphine use, pain relief, and side effects were recorded for 24 h. Data were analyzed with analysis of variance and linear regression. After hip arthroplasty, morphine use was less in patients receiving 0.1, 0.2, or 0.3 mg of ITMS than in control patients (P < 0.05). After knee arthroplasty, ITMS did not reduce postoperative morphine requirements. Nausea and vomiting and the incidence of oxygen saturation <93% were similar in all groups. Pruritus was more common after ITMS. Patients receiving 0.2 or 0.3 mg of ITMS were more satisfied with their pain control than those receiving 0.0 or 0.1 mg after both hip and knee arthroplasty. Analgesic needs are greater after knee arthroplasty than after hip arthroplasty. We conclude that combining small-dose (0.2 mg) ITMS with PCA morphine provides good to excellent pain control in most patients after total hip or knee arthroplasty. However, PCA morphine use was reduced by the addition of ITMS only after hip arthroplasty. IMPLICATIONS: This series examined the need for supplemental analgesics, the quality of analgesia, and the incidence of side effects with intrathecal morphine sulfate (ITMS) for analgesia after hip and knee arthroplasty. Analgesic needs are greater after knee arthroplasty than hip arthroplasty. Combining small-dose (0.2 mg) ITMS with standard doses of PCA morphine provided good to excellent pain control in most patients and reduced patient-controlled analgesia morphine use after hip, but not knee, arthroplasty.     

Analgesie durch intraartikuläres Morphin nach Kniegelenksarthroskopien? Eine doppelblinde,randomisierte Studie mit patientenkontrollierter Analgesie*

Previous studies investigating the peripheral action of locally instilled morphine after arthroscopic knee surgery found evidence for an analgesic effect. Follow-up studies have lead to conflicting results.We used patient-controlled analgesia (PCA) to test the analgesic potency of intraarticular morphine. Methods. Patients undergoing arthroscopic knee surgery under general anaesthesia received, after written informed consent and in double-blind and randomised manner, 1?mg morphine diluted in 10?ml saline either intraarticularly or intravenously at the end of the surgical procedure. A control injection of 10?ml saline was given at the other site. The pain intensity on a visual analogue scale (VAS) and the cumulative morphine consumption were recorded at 1, 2, 3, 4, 6, 8 and 24?h after the end of general anaesthesia. Statistics: Wilcoxon rank sum test with P<0.05. Results. A total of 59?patients were included in the study; 29 received morphine intraarticularly (verum group), 30 intravenously (control group). There was no difference in gender, age, duration of arthroscopy or anaesthesia. There were more than 60% diagnostic arthroscopies in both groups; other types of surgery were comparable, with the exception of cruciate band repair procedures only in the control group. We found no difference in morphine consumption or pain intensity between the two groups throughout the study period. Median overall consumption of morphine after 24?h was 14?mg in the verum group and 15?mg in the control group, with wide interindividual variation. Pain intensities were remarkably low. The peak pain intensity of both groups was found at 1?h postoperatively, with median 16/100 on the VAS in both groups. Blinding was robust. Conclusion. We found no reduction in postoperative morphine supplementation after 1?mg morphine intraarticularly compared to 1?mg intravenously given at the end of knee arthroscopies. There were also no differences in pain intensities on a VAS. We conclude that titration of postoperative pain with a morphine-filled PCA pump was unable to show a difference in analgesic potency between intraarticular and intravenous morphine.     

Intrathecal morphine provides better postoperative analgesia than psoas compartment block after primary hip arthroplasty

PURPOSE: Intrathecal morphine and psoas compartment block represent two accepted techniques to provide postoperative analgesia after hip arthroplasty. We designed a prospective, randomized, single-blinded study to compare these two techniques. METHODS: Patients scheduled for primary hip arthroplasty under general anesthesia were randomized to receive either an intrathecal administration of 0.1 mg morphine (Group I, n = 27) or a psoas compartment block with ropivacaine 0.475% 25 mL (Group II, n = 26). Pain scores, morphine consumption, associated side-effects were assessed for 48 hr postoperatively. In addition, patient's acceptance and satisfaction of the postoperative analgesic technique were also recorded. RESULTS: During the first 24 hr, pain scores (3.3 +/- 9.6 mm vs 22.8 +/- 27.1 at H+6, 3.3 +/- 8.3 mm vs 25 +/- 26.7 mm at H+12, 7 +/- 14.9 mm vs 21.9 +/- 29 mm at H+18) and morphine consumption (0.56 +/- 2.12 mg vs 9.42 +/- 10.13 mg) were lower in Group I than in Group II. Urinary retention was the more frequent side-effect occurring in 37% of cases in Group I vs 11.5% in Group II (P < 0.05). No major complication occurred. Despite better analgesia provided by the use of intrathecal morphine, there was no difference in the satisfaction scores between groups. CONCLUSION: 0.1 mg intrathecal morphine administration provides better postoperative analgesia than single-shot psoas compartment block after primary hip arthroplasty.     

Efficacy of 0.1 mg of subarachnoid morphine combined with bupivacaine on postoperative analgesia in total hip arthroplasty

OBJECTIVES: To analyze the analgesic efficacy, safety and side effects of subarachnoid morphine (0.1 mg) with bupivacaine in patients undergoing total hip arthroplasty. PATIENTS AND METHODS: Thirty patients scheduled for total hip replacement under spinal anesthesia with bupivacaine were randomly assigned to two groups according to whether local anesthetic with 0.1 mg subarachnoid morphine was also provided or not (group M [n = 15] and group S ? = 15[, respectively). Top-up analgesia with morphine was available through a patient-controlled device. Postoperative pain was assessed on a visual analogue scale (VAS) and consumption of intravenous morphine in the first 48 hours after surgery was recorded. RESULTS: VAS scores (mean +/- SD) were significantly lower in the first six hours in group M, but no differences between the two groups were observed thereafter. Total consumption of morphine at 48 hours was much lower in group M (6.80 +/- 7.74 mg) than in group S (31.38 +/- 13.17 mg). The incidence of nausea was high in both groups (46%). Slight pruritus affected 26.6% of patients in group M. Urinary retention necessitating temporary placement of a catheter was observed only in group M, where the incidence was 35.7%. No cases of respiratory depression occurred. Drowsiness was observed in 26.6% of patients in group S in comparison with 6.6% in group M. CONCLUSIONS: Combining 0.1 mg morphine and bupivacaine for total spinal anesthesia during hip arthroplasty significantly decreased the consumption of intravenous morphine during the first 48 hours after surgery. No respiratory depression occurred and the only side effects were urinary retention and mild pruritus and drowsiness.     

Postoperative analgesia after total hip arthroplasty: patient-controlled analgesia versus transdermal fentanyl patch

STUDY OBJECTIVE: To determine whether a new transdermal fentanyl patch (TFP) is a good choice for the postoperative pain management of patients undergoing primary total hip arthroplasty compared with patient-controlled analgesia (PCA). DESIGN: Randomized, prospective study. SETTING: University hospital. PATIENTS: 30 patients undergoing primary total hip arthroplasty. INTERVENTIONS: Patients received either a TFP (group T; Duragesic 50 microg/h, matrix fentanyl patch, Janssen-Cilag) applied approximately 10 hours before induction of general anesthesia and PCA programmed in the postanesthesia care unit (PACU), or PCA programmed in the PACU (group P). MEASUREMENTS: Intraoperative sufentanil and additional postoperative morphine administration were recorded, as well as visual analog scores and routine vital signs at predetermined intervals during the first 48 hours. MAIN RESULTS: Morphine consumption on arrival in the PACU was 3.5+/-3 mg in group T versus 13+/-5 mg in group P (P<0.0001). Visual analog scores on arrival in the PACU were 37+/-22 mm in group T versus 73+/-13 mm in group P (P<0.0001). Cumulative morphine consumption at the 24th hour was 43+/-16 mg in group P and 4+/-3 mg in group T (P<0.0001). Cumulative morphine consumption at the 48th hour was 54+/-26 mg in group P and 5+/-4 mg in group T (P<0.0001). Intraoperative sufentanil consumption was 38+/-15 microg in group T versus 30+/-5 microg in group P (not significant). The sedation score was 0 in both groups during the first 48 postoperative hours. CONCLUSIONS: Preoperative TFP application decreases pain scores and morphine consumption in the PACU and appears to have prolonged effects spanning the first 48 postoperative hours.     

Use of femoral nerve blocks in adolescents undergoing patellar realignment surgery

The purpose of this study was to analyze the efficacy of femoral nerve blocks (FNBs) in decreasing postoperative narcotic use in adolescents undergoing patellar realignment surgery (PRS). All patients who underwent PRS at 2 children's hospitals between 1998 and 2002 were included in the study. Patients were grouped according to postoperative analgesia: FNB (n = 14), as-needed intravenous morphine (PRN-IV; n = 16), or patient-controlled analgesia using morphine (PCA; n = 13). Total postoperative i.v. morphine use was statistically significantly different among the 3 groups: 9.0 mg for FNB, 26.43 mg for PRN-IV, and 64.7 mg for PCA. FNB use was effective in significantly decreasing postoperative i.v. narcotic use.