Intraoperative small-dose ketamine enhances analgesia after outpatient knee arthroscopy

Ketamine may prevent postoperative hyperalgesia. In patients undergoing arthroscopic meniscectomy using general anesthesia, we tested whether a single intraoperative dose of ketamine enhanced postoperative analgesia and improved functional outcome compared with a typical multimodal analgesic regimen. After the induction of anesthesia, 50 patients were randomly assigned to ketamine (0.15 mg/kg IV just after the induction of anesthesia) or a vehicle placebo. Standardized general anesthesia included propofol, alfentanil, and nitrous oxide. Bupivacaine (0.5%) and morphine (5 mg) were given intraarticularly at the end of surgery. Postoperative analgesia was initially provided with morphine and subsequently with naproxen sodium (550 mg orally twice daily) and Di-Antalvic (400 mg acetaminophen and 30 mg dextropropoxyphene) as needed. Pain scores, analgesic requirements, side effects, and ability to walk were assessed in the ambulatory unit and at home for three postoperative days. Times to awakening and to discharge were similar in the two groups. However, the Ketamine group had significantly less postoperative pain at rest and during mobilization on Days 0, 1, and 2. Furthermore, they consumed significantly fewer Di-Antalvic tablets than the control group (13 [7-17] vs 27 [16-32], median [25%-75% interquartile range]). Patients given ketamine were also able to walk for longer periods of time on the first postoperative day. In conclusion, adding small-dose ketamine to a multimodal analgesic regimen improved postoperative analgesia and functional outcome after outpatient knee arthroscopy.     

The preoperative administration of ketoprofen improves analgesia after laparoscopic cholecystectomy in comparison with propacetamol or postoperative ketoprofen

Background. Non-opioid analgesics, paracetamol and non-steroidanti-inflammatory drugs (NSAIDs) are proposed for pain reliefafter laparoscopy. We compared perioperative propacetamol (P)and ketoprofen (K) to provide analgesia after laparoscopic cholecystectomy. Methods. After ethical committee approval, we included 104 ASAI–II patients, without preoperative analgesic drugs, whowere scheduled to undergo laparoscopic cholecystectomy. Anaesthesiawas standardized using propofol, fentanyl, atracurium, isofluraneand N₂O 50%. Ketoprofen 100 mg or propacetamol 2 g or a salinedrip (a 100-ml unit of saline in 10 min) was infused blindlyand randomly. Patients received either ketoprofen (group K1)or propacetamol (group P1) before induction of anaesthesia andsaline after surgery, or saline before surgery and ketoprofen(group K2) or propacetamol (group P2) after surgery. Postoperativevisual analogue pain scores (VAS 0–100 mm) were recordedduring 24 h. If VAS was >30, a second dose (placebo, ketoprofenor propacetamol) was infused. Nalbuphine 0.2 mg kg^–1 i.v.was given as rescue analgesic if VAS was 50. Results. Ninety-eight patients were studied The number of patientsnot requiring the second analgesic was greater in K1 (33.5%)than the others (K2 0%, P1 0%, P2 7.5%). VAS scores were significantlylower in K1 (P=0.001), with less nalbuphine consumption comparedwith P1. VAS and opioid request were similar in K2 and P2. Conclusion. Preoperative administration of ketoprofen improvespostoperative analgesia after laparoscopic cholecystectomy comparedwith its postoperative administration and pre- and postoperativepropacetamol.     

A comparison of three regional anaesthesia techniques for outpatient knee arthroscopy

Purpose

The purpose of this study was to compare intraoperative conditions and postoperative pain control of three penpheral regional anaesthesia techniques for outpatient knee arthroscopic procedures.

Methods

Sixty patients were randomized to one of three groups. Group IA received portal injections (10 ml lidocaine 1%), intraarticular lidocaine (20 ml CO₂ lidocaine 2% with 1/200.000 adrenaline) and a placebo femoral nerve block (20 ml saline). Group FNB received a femoral 3-in-1 nerve block (20 ml chloroprocaine 2% with 1/200.000 adrenaline), placebo portal injections (10 ml saline) and placebo intraarticular saline (20 ml saline with 1/200.000 adrenaline). Group FNB + IA received a femoral 3-m-1 nerve block, intraarticular hdocaine and placebo portal injections. The following were assessed: intraoperative pain (10 cm VAS: 0 = no pain. 10 = extreme pain), surgical operating conditions (1 = excellent. 4 = unacceptable), intraoperative use of sedation and analgesia, time to discharge, patient satisfaction score (1= very satisfied, 5 very unsatisfied) and postoperative analgesia. Data were analyzed using ANOVA, Kruskal-Wallis, and Chi-square tests as appropriate. P< 0.05 was considered significant.

Results

There were no differences among the groups regarding any of the vanables tested. Considerable postoperative pain (VAS> 5) was expenenced by 20/54 (37%) patients.

Conclusion

Any of the three anaesthetic techniques tested provide reliable intraoperative patient and surgical conditions for outpatient knee arthroscopy. Patient discomfort postoperatively was considerable in all groups and requires further investigation.     

A comparison of two regional anesthetic techniques for outpatient knee arthroscopy

IMPLICATIONS: Small dose lidocaine spinal anesthesia and 3% 2-chloroprocaine epidural anesthesia provided comparable discharge times for outpatient knee arthroscopy. The incidence of transient neurologic symptoms with small-dose lidocaine spinal anesthesia was 12%.     

A comparison of spinal, epidural, and general anesthesia for outpatient knee arthroscopy

We compared general, epidural, and spinal anesthesia for outpatient knee arthroscopy (excluding anterior cruciate ligament repairs). Forty-eight patients (ASA physical status I-III) were randomized to receive either propofol-nitrous oxide general anesthesia with a laryngeal mask airway with anesthetic depth titrated to a bispectral index level of 40-60, 15-20 mL of 3% 2-chloroprocaine epidural, or 75 mg of subarachnoid procaine with 20 microg fentanyl. All patients were premedicated with <0.035 mg/kg midazolam and <1 microg/kg fentanyl and received intraarticular bupivacaine and 15-30 mg of IV ketorolac during the procedure. Recovery times, operating room turnover times, and patient satisfaction were recorded by an observer using an objective scale for recovery assessment and a verbal rating scale for satisfaction. Statistical analysis was performed with analysis of variance and chi(2). Postanesthesia care unit discharge times for the general and epidural groups were similar (general = 104+/-31 min, epidural = 92+/-18 min), whereas the spinal group had a longer recovery time (146+/-52 min) (P = 0.0003). Patient satisfaction was equally good in all three groups (P = 0.34). Room turnover times did not differ among groups (P = 0.16). There were no anesthetic failures or serious adverse events in any group. Pruritus was more frequent in the spinal group (7 of 16 required treatment) than in the general or epidural groups (no pruritus) (P<0.001). We conclude that epidural anesthesia with 2-chloroprocaine provides comparable recovery and discharge times to general anesthesia provided with propofol and nitrous oxide. Spinal anesthesia with procaine and fentanyl is an effective alternative and is associated with a longer discharge time and increased side effects. Implications: For outpatient knee arthroscopy, anesthesia can be provided adequately with regional or general anesthesia. Epidural and general anesthesia provide equal recovery times and patient satisfaction, whereas spinal anesthesia may prolong recovery and have increased side effects. The choice of anesthesia may depend primarily on the patient's interest in being alert or asleep during the procedure.     

Tramadol or fentanyl analgesia for ambulatory knee arthroscopy

In a double-blind, randomized, controlled study, 61 patients who received a standardized anaesthetic for day case arthroscopic knee surgery were studied. Group T (n = 31) received tramadol 1.5 mg kg-1, and group F (n = 30) received fentanyl 1.5 micrograms kg-1 at the induction of anaesthesia. All patients also received 20 mL of intra-articular bupivacaine 0.5% at the end of surgery. Assessments were made of pain at rest and on movement, analgesic requirements and side-effects at hourly intervals up to 6 h and by means of a postal questionnaire at 24 h and 48 h post-operatively. Group F had higher pain scores than group T at 4 h only [VAS 3.3 (1.6-5.5) vs. 2.4 (1-4), P = 0.039, respectively; median (interquartile range)]. There were no other significant differences between the groups in terms of pain scores, supplemental analgesic requirements or incidence of side-effects. We conclude that tramadol offers little benefit clinically compared with fentanyl when used at induction of anaesthesia for day case arthroscopic knee surgery. Further studies are indicated in patients with more severe pain to determine the role of tramadol in post-operative analgesia.     

Spinal anesthesia with hyperbaric levobupivacaine and ropivacaine for outpatient knee arthroscopy: a prospective, randomized, double-blind study

To compare unilateral spinal block produced with small doses of hyperbaric ropivacaine with that produced by 2 doses of hyperbaric levobupivacaine, we randomly allocated 91 ASA physical status I-II outpatients undergoing knee arthroscopy to receive unilateral spinal anesthesia with 7.5 mg of hyperbaric ropivacaine 0.5% (group Ropi-7.5, n = 31) or either 7.5 mg (group Levo-7.5, n = 30) or 5 mg (group Levo-5, n = 30) of hyperbaric levobupivacaine 0.5%. Spinal anesthesia was performed at the L3-4 interspace using a 25-gauge Whitacre spinal needle. The lateral decubitus position was maintained for 15 min after injection. Strictly unilateral sensory block was present in 73%, 50%, and 61% of cases in groups Ropi-7.5, Levo-7.5, and Levo-5, respectively, 30 min after injection (P = 0.40), and unilateral motor block was observed in 94%, 93%, and 83% in groups Ropi-7.5, Levo-7.5, and Levo-5, respectively (P = 0.31). One patient of group Ropi-7.5 required general anesthesia to complete surgery, and fentanyl supplementation was required in one patient of group Ropi-7.5 (3%) and one patient of group Levo-5 (3%) (P = 0.42). The median (range) time for spinal block resolution was shorter in group Ropi-7.5 (135 [126-154] min] than in group Levo-7.5 (162 [148-201] min) (P = 0.04); whereas home discharge was shorter in groups Ropi-7.5 (197 [177-218] min) and Levo-5 (197 [187-251] min) as compared with group Levo-7.5 (238 [219-277] min) (P = 0.02 and P = 0.04, respectively). We conclude that 7.5 mg of 0.5% hyperbaric ropivacaine and 5 mg of 0.5% hyperbaric levobupivacaine provide adequate spinal block for outpatient knee arthroscopy, with a faster home discharge as compared with 7.5 mg of 0.5% hyperbaric levobupivacaine.     

Regional anaesthesia for outpatient knee arthroscopy: a randomized clinical comparison of two different anaesthetic techniques

BACKGROUND: The purpose of this prospective, randomized study was to evaluate the time required to perform anaesthesia, achieve surgical block and fulfil standardized discharge criteria in outpatients receiving knee arthroscopy with either spinal anaesthesia or combined sciatic-femoral nerve block. METHODS: After a standard midazolam/ketoprofen premedication and baseline measurement of cardiovascular parameters, 50 ASA I-II patients scheduled for elective outpatient knee arthroscopy were randomized to receive spinal anaesthesia with 8 mg of 0.5% hyperbaric bupivacaine (group Spinal, n=25), or combined sciatic-femoral nerve block with 25 ml of mepivacaine 20 mg ml(-1) and a multiple injection technique (15 ml for femoral nerve block and 10 ml for sciatic nerve block). Times lasting from skin disinfection to the end of local anaesthetic injection (preparation time) and then to achieve surgical anaesthesia (readiness for surgery), as well as times required for block resolution, micturition, unassisted ambulation, and home discharge were recorded by a blinded observer. Occurrence of adverse events was also recorded. RESULTS: Preparation time (mean+/-SD) was longer with sciatic-femoral block (8+/-2.7 min) than spinal anaesthesia (5+/-2.1 min) (P=0.0002) while no differences were observed in the time required to achieve readiness for surgery (14+/-5 min and 15+/-6 min in the Spinal and Sciatic-femoral groups, respectively). No differences in haemodynamic side effects and need for intraoperative additional analgesia were observed. Patients receiving spinal anaesthesia showed a faster resolution of nerve block and longer time to micturition (137+/-49 min and 231+/-101 min) than patients receiving peripheral nerve blockade (206+/-51 min and 145+/-36 min) (P<0.0005 and P=0.002, respectively); however, no differences were observed in the time required to fulfil standardized discharge criteria (241+/-101 min in group Spinal and 209+/-70 min in group Sciatic-femoral; P=0.86). CONCLUSION: In patients receiving elective outpatient knee arthroscopy, using a combined sciatic-femoral nerve block with 25 ml of mepivacaine 20 mg ml(-1) and a multiple injection technique results in a slightly longer preoperative time but provides similarly effective anaesthesia with no differences in home discharge times as compared to spinal anaesthesia with 8 mg hyperbaric bupivacaine.     

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.     

超声引导下不同入路连续隐神经阻滞在膝关节镜术后镇痛效果中的比较

目的评价超声引导下不同入路连续隐神经阻滞在膝关节镜术后镇痛中的应用效果和对运动能力的影响。方法选择择期行全身麻醉膝关节镜手术患者48例,男42例,女6例,年龄25～33岁,体重65～81 kg,BMI 18.1～26.4 kg/m~2,ASAⅠ或Ⅱ级。采用随机数字表法分为收肌管阻滞组(MG组)和大腿远端阻滞组(DG组),每组24例。患者麻醉诱导前均行超声引导下隐神经阻滞。MG组将导管置入收肌管间隙;DG组将导管置入隐神经周围约3 cm。两组均用超声定位导管位置,连接电子自控镇痛泵,镇痛泵设置两组相同。单次给药0.5%罗哌卡因+1%利多卡因20 ml,连接镇痛泵持续输入0.2%罗哌卡因。记录两组患者神经阻滞成功率,阿片类(舒芬太尼、瑞芬太尼)药用量,术后辅助镇痛情况,术后6、12、24 h静息时VAS评分和timed-up-and-go测试时间,记录术后24 h穿刺部位血肿、周围神经损伤、局麻药中毒、穿刺部位感染发生情况。结果两组患者神经阻滞成功率,阿片类(舒芬太尼、瑞芬太尼)药用量,辅助镇痛情况差异无统计学意义。术后6、12、24 h两组患者静息时VAS评分差异无统计学意义。术后6、12、24 h MG组timed-up-and-go测试时间明显长于DG组(P0.05)。两组患者均未出现穿刺部位血肿、周围神经损伤、局部麻醉药中毒、穿刺部位感染等不良反应。结论与收肌管处阻滞比较,超声引导下经大腿远端1/3处行连续隐神经阻滞可为膝关节镜手术提供相同的术后镇痛效果,并对运动能力影响更小,值得推广。     

A comparison of 0.2 and 0.5 mg intrathecal morphine for postoperative analgesia after total knee replacement

The optimal dose of intrathecal morphine for postoperative analgesia after major surgery is a matter of debate, with some uncertainty concerning the therapeutic potential and safety of intrathecal morphine in the dose range 0.3-1.0 mg. This randomised double-blind study compared the efficacy and side-effect profile of 0.2 mg and 0.5 mg intrathecal morphine in 70 patients undergoing knee replacement surgery. The primary endpoint was the number of patients requiring rescue analgesia (tramadol) during the first 24 h postoperatively. Secondary endpoints included consumption of tramadol and the incidence of adverse effects. Fewer patients in the 0.5-mg group required rescue analgesia in the first 24 h than in the 0.2-mg group (16 (48%) vs 28 (85%), respectively; p = 0.003). Median (IQR [range]) tramadol consumption was lower in the 0.5-mg group than in the 0.2-mg group (0 (0-100 [0-350]) mg vs 100 (50-100 [0-350]) mg, respectively; p = 0.02). The incidence of adverse effects was similar in both groups. This study has demonstrated that 0.5 mg intrathecal morphine produces better analgesia than 0.2 mg after knee replacement without any increase in side-effects.     

A comparison of psoas compartment block and spinal and general anesthesia for outpatient knee arthroscopy

The optimal anesthetic technique for outpatient knee arthroscopy remains controversial. In this study, we evaluated surgical operating conditions, patient satisfaction, recovery times, and postoperative analgesic requirements associated with psoas compartment block, general anesthetic, or spinal anesthetic techniques. Sixty patients were randomized to receive a propofol/nitrous oxide/fentanyl general anesthetic, spinal anesthesia with 6 mg of bupivacaine and 15 micro g of fentanyl, or psoas compartment block with 40 mL of 1.5% mepivacaine. All patients received IV ketorolac and intraarticular bupivacaine. The frequency of postanesthesia recovery room admission was 13 (65%) of 20 for patients receiving general anesthesia, compared with 0 of 21 for patients receiving spinal anesthesia and 1 (5%) of 19 for patients receiving psoas block (P < 0.001). The median time from the end of surgery to meeting hospital discharge criteria did not differ across groups (131, 129, and 110 min for general, spinal, and psoas groups, respectively). In the hospital, 45% of general anesthesia patients received opioid analgesics, compared with 14% of spinal anesthesia and 21% of psoas block patients (P = 0.087). There was no difference among groups with respect to the time of first analgesic use or the number of patients requiring opioid analgesia. Pain scores were highest in patients receiving general anesthesia at 30 min (P = 0.032) and at 60, 90, and 120 min (P < 0.001). Patient satisfaction with anesthetic technique (P = 0.025) and pain management (P = 0.009) differed significantly across groups; patients receiving general anesthesia reported lower satisfaction ratings. We conclude that spinal anesthesia or psoas block is superior to general anesthesia for knee arthroscopy when considering resource utilization, patient satisfaction, and postoperative analgesic management. IMPLICATIONS: Outpatient knee arthroscopy may be performed using a variety of anesthetic techniques. We report that spinal anesthesia and psoas compartment block are superior to general anesthesia when considering resource utilization, patient satisfaction, and postoperative analgesic management.     

Continuous femoral nerve blockade or epidural analgesia after total knee replacement: a prospective randomized controlled trial

Because postoperative pain after total knee replacement (TKR) can be severe, we compared the analgesic efficacy of continuous femoral nerve blockade (CFNB) and continuous epidural analgesia (CEA) after TKR in this prospective randomized trial. Patients undergoing TKR under spinal anesthesia were randomized to receive either a femoral infusion of bupivacaine 0.2% (median infusion rate 9.3 mL/h) (n = 53) or an epidural infusion of ropivacaine 0.2% with fentanyl 4 microg/mL (median infusion rate 7.6 mL/h) (n = 55). Adjuvant analgesics were oral rofecoxib and oxycodone and IV morphine. Pain, nausea and vomiting, hypotensive episodes, motor block, range of knee movement, and rehabilitation milestones were assessed postoperatively. There were equivalent pain scores, range of movement, and rehabilitation in both groups. There was significantly less nausea and vomiting in the CFNB group (P < 0.002). The CFNB group received more rofecoxib (P < 0.04) and oxycodone (P < 0.005) than the CEA group. The operative limb displayed more motor block than the nonoperative limb in both groups at the level of the hip and knee for up to 48 h (P < 0.05, Mann-Whitney U-test), but there was no difference between groups in the nonoperative limb. CFNB is an effective regional component of a multimodal analgesic strategy after TKR.     

Postoperative analgesia after arthroscopic knee surgery: a randomized, prospective, double-blind study of intravenous regional analgesia versus intra-articular analgesia.

SUMMARY: The aim of this study was to determine the quality of postoperative analgesia in patients undergoing arthroscopic knee surgery using preoperative intravenous regional analgesia. After initial consultation with a statistician, we allocated 36 patients randomly and double-blind to 1 of 3 groups. Group A received intravenous regional analgesia preoperatively, group B received standard postperative intra-articular analgesia, and group C received saline and acted as the placebo. Our results showed no statistically significant difference in pain levels between the groups. However, there was a significantly larger amount of morphine administered by patient-controlled pumps in the placebo group when compared with the 2 treatment groups. There was no such difference between the 2 treatment groups. We concluded that preoperative regional analgesia in this setting is as good as but no better than intra-articular analgesia and that neither technique has any advantages over diclofenac plus patient-controlled analgesia.