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Analgesic effects of intraarticular bupivacaine after day-case arthroscopy
Arthroscopy: The Journal of Arthroscopic and Related Surgery 10(3):299-300 Published by Raven Press, Ltd. © 1994 Arthroscopy Association of North America
Analgesic Effects of Intraarticular Bupivacaine After Day-Case Arthroscopy G. Geutjens, M.D., F.R.C.S., F.R.C.S. Ed. and J. E. Hambidge, F.R.C.S. Ed. Orth.
Summary: A blind, prospective, randomized, controlled trial was conducted to assess the analgesic properties of intraarticular bupivacaine after day-case arthroscopy. Forty-eight patients undergoing routine arthroscopy were randomly allocated to receive l0 ml of 0.5% bupivacaine or 0.9% saline into the joint at the end of the procedure. The analgesic effects were assessed by visual analogue scales at discharge, on going to bed, and the following morning. Significant reduction in reported pain was found in the treatment groups on leaving the hospital and later the same evening, although no benefit was found the following day. Key Words: Analgesia--Day case.
Arthroscopy under local anaesthetic, as a combination of subcutaneous and intraarticular administration, has been widely used and reported (1-3). The postoperative analgesic effects of intraarticular local anaesthetic after arthroscopy performed with patients under general anaesthetic have also been investigated. These studies have centered on subjective pain control. Milligan et al. in 1988 (4) and Hughes in 1985 (5) both report n o evidence of analgesic effect provided by intraarticular bupivacaine. White et al. in 1990 (6) found some early pain r e l i e f f r o m s u b c u t a n e o u s and i n t r a a r t i c u l a r prilocaine with adrenaline but still concluded that there was no significant analgesic effect. The present study is a prospective, randomized, controlled trial of the analgesic effects of intraarticular bupivacaine in which arthroscopy has been performed as a day case.
study. Patients who underwent an additional e x traarticular procedure such as open meniscectomy or lateral release procedures were excluded. All arthroscopies were performed by the same surgeon (G.G.) during an afternoon list, the patients being discharged from the hospital at 18:00 h on the day of surgery. On admission to the hospital the patients were instructed in the use of a linear visual analogue scale---"no pain" scoring 0 at one end of the scale and "worst pain imaginable" scoring 20 at the other. Patients were asked to complete these visual analogue scales at three different times after arthroscopy on a trial form and to return these at clinic review 1 week after surgery. The patient was instructed to complete the first score on leaving the hospital, the second on the evening after surgery before going to bed, and the third the following morning. They were also asked to record the time after surgery that they needed their first oral analgesic drugs. None of the patients received premedication, and a standardised general anaesthetic was administered by the same anaesthetist. No narcotic drugs were administered in the peri- or postoperative period. Patients were randomly allocated into two groups. At the end of arthroscopy the first group received
PATIENTS AND METHOD Forty-eight patients undergoing elective or semiurgent knee arthroscopy at University Hospital Nottingham on a day-case basis were enrolled in the From the UniversityHospital--QueensMedicalCentre, Nottingham, England. Address correspondence and reprint requests to J. E. Hambidge,F.R.C.S. Ed. Orth., HarlowWoodOrthopaedicHospital, Mansfield,NottinghamNGI8 4TH, England. 299
300
G. GEUTJENS A N D J. E. HAMBIDGE
10 ml of 0.5% bupivacaine introduced through the fluid channel of the scope after residual saline had been evacuated from the knee joint. The tourniquet was left inflated for 5 min after administration of the bupivacaine to allow tissue binding to occur. The second group had 10 ml of 0.9% saline introduced via the scope in an identical manner. Four patients failed to complete the visual analogue scales and were excluded from the study. Twenty-three patients who had received bupivacaine and 21 who had received saline completed the trial. RESULTS The mean pain scores and ranges for each of the three recording times and the mean times to first analgesic use and range are shown in Table I. The pain scores were compared statistically using the Mann-Whitney large sample case. Pain scores were significantly reduced in the group receiving bupivacaine compared with those receiving saline on discharge from the hospital (p < 0.05) and on the same evening (p < 0.02). There was no significant difference the following morning. The times to first analgesic dose were compared by Mann-Whitney small sample case and those reporting no analgesic use were compared using a X2 test for association. There were no significant differences in analgesic use between the two groups. DISCUSSION This is the first prospective randomized trial of intraarticular bupivacaine after day case arthrosTABLE 1. Pain scores and analgesic use after arthroscopy
Pain score on discharge Pain score on going to bed Pain score next morning Time to first analgesic No. taking no analgesic drugs
Bupivacaine mean (range) (23 patients)
Saline mean (range) (21 patients)
3.57 (0-18)
5.57 (0-13)
3.10 (0-11)
6.29 (0-18)
3.83 (0-13)
4.90 (0-17)
11 h 53 min (2 h 30 min-24 h) 12
10 h 38 rain (3 h 30 rain--48h) 8
Arthroscopy, Vol. 10, No. 3, 1994
copy. Unlike previous studies, which have assessed local anaesthetic in the knee after arthroscopy, we were able to demonstrate a lasting analgesic effect from intraarticular bupivacaine, longer than the short-term effect suggested by White and coworkers. The period of analgesia provided is in keeping with the 8-h duration of action of bupivacaine used as a nerve block. Pain was recorded at standard times rather than standard intervals for patient convenience. It was thought that leaving the hospital, going to bed, and getting up the following morning were important psychological times when the patient's perception of his or her pain would be of particular significance. The time of discharge represents - 3 h (with a range 2--4 h), going to bed 8 h (range 6--10 h) and rising from bed 16 h (range 15-19 h) after surgery. A standard 8 h after surgery would have led to some patients having to rise from sleep to complete pain scores. There was no significant difference in the time that arthroscopy for the two groups had been undertaken. This study has demonstrated a significant analgesic property of intraarticular bupivacaine used in day case arthroscopy. Maintaining the patient free from pain until the morning after arthroscopy of the knee has an important influence on postoperative management. Acknowledgment: We thank Mr. Ian Forster, consultant orthopaedic surgeon, for permission to use his patients in this study and Dr. Zak Hussein for giving the standard anaesthetic regimen.
REFERENCES 1. Alpen N, Axera G, Hirchberge C, Agasi M. Arthroscopy of the knee under local anaesthesia and controlled pressure irrigation. Clin Orthop 1979;134:176-9. 2. Johnson LL. Arthroscopy of the knee using local anaesthesia: a review of 400 patients. J Bone Joint Surg [Am] 1976; 58:736. 3. McGinty JB, Matza RA. Arthroscopy of the knee: evaluation of an outpatient procedure under local anaesthetic. J Bone Joint Surg [Am] 1978;60:787-9. 4. Milfigan KA, Mowbray MJ, Mulrooney L, Standen PJ. Intraarticular bupivacainefor pain refief after arthroscopic surgery of the knee joint in day case patients. Anaesthesia 1988; 43:563--4. 5. Hughes DG. Intra-articular bupivaeaine for pain relief in arthroscopic surgery. Anaesthesia 1985;40:821. 6. White AP, Lanrent S, Wilkinson DJ. Intraarticular and subcutaneous pfilocaine with adrenaline for pain relief in day case arthroscopy of the knee joint. Ann R Coil Surg Engl 1990;72:350-2.
Analgesic Effects of Intraarticular Bupivacaine After Day-Case Arthroscopy G. Geutjens, M.D., F.R.C.S., F.R.C.S. Ed. and J. E. Hambidge, F.R.C.S. Ed. Orth.
Summary: A blind, prospective, randomized, controlled trial was conducted to assess the analgesic properties of intraarticular bupivacaine after day-case arthroscopy. Forty-eight patients undergoing routine arthroscopy were randomly allocated to receive l0 ml of 0.5% bupivacaine or 0.9% saline into the joint at the end of the procedure. The analgesic effects were assessed by visual analogue scales at discharge, on going to bed, and the following morning. Significant reduction in reported pain was found in the treatment groups on leaving the hospital and later the same evening, although no benefit was found the following day. Key Words: Analgesia--Day case.
Arthroscopy under local anaesthetic, as a combination of subcutaneous and intraarticular administration, has been widely used and reported (1-3). The postoperative analgesic effects of intraarticular local anaesthetic after arthroscopy performed with patients under general anaesthetic have also been investigated. These studies have centered on subjective pain control. Milligan et al. in 1988 (4) and Hughes in 1985 (5) both report n o evidence of analgesic effect provided by intraarticular bupivacaine. White et al. in 1990 (6) found some early pain r e l i e f f r o m s u b c u t a n e o u s and i n t r a a r t i c u l a r prilocaine with adrenaline but still concluded that there was no significant analgesic effect. The present study is a prospective, randomized, controlled trial of the analgesic effects of intraarticular bupivacaine in which arthroscopy has been performed as a day case.
study. Patients who underwent an additional e x traarticular procedure such as open meniscectomy or lateral release procedures were excluded. All arthroscopies were performed by the same surgeon (G.G.) during an afternoon list, the patients being discharged from the hospital at 18:00 h on the day of surgery. On admission to the hospital the patients were instructed in the use of a linear visual analogue scale---"no pain" scoring 0 at one end of the scale and "worst pain imaginable" scoring 20 at the other. Patients were asked to complete these visual analogue scales at three different times after arthroscopy on a trial form and to return these at clinic review 1 week after surgery. The patient was instructed to complete the first score on leaving the hospital, the second on the evening after surgery before going to bed, and the third the following morning. They were also asked to record the time after surgery that they needed their first oral analgesic drugs. None of the patients received premedication, and a standardised general anaesthetic was administered by the same anaesthetist. No narcotic drugs were administered in the peri- or postoperative period. Patients were randomly allocated into two groups. At the end of arthroscopy the first group received
PATIENTS AND METHOD Forty-eight patients undergoing elective or semiurgent knee arthroscopy at University Hospital Nottingham on a day-case basis were enrolled in the From the UniversityHospital--QueensMedicalCentre, Nottingham, England. Address correspondence and reprint requests to J. E. Hambidge,F.R.C.S. Ed. Orth., HarlowWoodOrthopaedicHospital, Mansfield,NottinghamNGI8 4TH, England. 299
300
G. GEUTJENS A N D J. E. HAMBIDGE
10 ml of 0.5% bupivacaine introduced through the fluid channel of the scope after residual saline had been evacuated from the knee joint. The tourniquet was left inflated for 5 min after administration of the bupivacaine to allow tissue binding to occur. The second group had 10 ml of 0.9% saline introduced via the scope in an identical manner. Four patients failed to complete the visual analogue scales and were excluded from the study. Twenty-three patients who had received bupivacaine and 21 who had received saline completed the trial. RESULTS The mean pain scores and ranges for each of the three recording times and the mean times to first analgesic use and range are shown in Table I. The pain scores were compared statistically using the Mann-Whitney large sample case. Pain scores were significantly reduced in the group receiving bupivacaine compared with those receiving saline on discharge from the hospital (p < 0.05) and on the same evening (p < 0.02). There was no significant difference the following morning. The times to first analgesic dose were compared by Mann-Whitney small sample case and those reporting no analgesic use were compared using a X2 test for association. There were no significant differences in analgesic use between the two groups. DISCUSSION This is the first prospective randomized trial of intraarticular bupivacaine after day case arthrosTABLE 1. Pain scores and analgesic use after arthroscopy
Pain score on discharge Pain score on going to bed Pain score next morning Time to first analgesic No. taking no analgesic drugs
Bupivacaine mean (range) (23 patients)
Saline mean (range) (21 patients)
3.57 (0-18)
5.57 (0-13)
3.10 (0-11)
6.29 (0-18)
3.83 (0-13)
4.90 (0-17)
11 h 53 min (2 h 30 min-24 h) 12
10 h 38 rain (3 h 30 rain--48h) 8
Arthroscopy, Vol. 10, No. 3, 1994
copy. Unlike previous studies, which have assessed local anaesthetic in the knee after arthroscopy, we were able to demonstrate a lasting analgesic effect from intraarticular bupivacaine, longer than the short-term effect suggested by White and coworkers. The period of analgesia provided is in keeping with the 8-h duration of action of bupivacaine used as a nerve block. Pain was recorded at standard times rather than standard intervals for patient convenience. It was thought that leaving the hospital, going to bed, and getting up the following morning were important psychological times when the patient's perception of his or her pain would be of particular significance. The time of discharge represents - 3 h (with a range 2--4 h), going to bed 8 h (range 6--10 h) and rising from bed 16 h (range 15-19 h) after surgery. A standard 8 h after surgery would have led to some patients having to rise from sleep to complete pain scores. There was no significant difference in the time that arthroscopy for the two groups had been undertaken. This study has demonstrated a significant analgesic property of intraarticular bupivacaine used in day case arthroscopy. Maintaining the patient free from pain until the morning after arthroscopy of the knee has an important influence on postoperative management. Acknowledgment: We thank Mr. Ian Forster, consultant orthopaedic surgeon, for permission to use his patients in this study and Dr. Zak Hussein for giving the standard anaesthetic regimen.
REFERENCES 1. Alpen N, Axera G, Hirchberge C, Agasi M. Arthroscopy of the knee under local anaesthesia and controlled pressure irrigation. Clin Orthop 1979;134:176-9. 2. Johnson LL. Arthroscopy of the knee using local anaesthesia: a review of 400 patients. J Bone Joint Surg [Am] 1976; 58:736. 3. McGinty JB, Matza RA. Arthroscopy of the knee: evaluation of an outpatient procedure under local anaesthetic. J Bone Joint Surg [Am] 1978;60:787-9. 4. Milfigan KA, Mowbray MJ, Mulrooney L, Standen PJ. Intraarticular bupivacainefor pain refief after arthroscopic surgery of the knee joint in day case patients. Anaesthesia 1988; 43:563--4. 5. Hughes DG. Intra-articular bupivaeaine for pain relief in arthroscopic surgery. Anaesthesia 1985;40:821. 6. White AP, Lanrent S, Wilkinson DJ. Intraarticular and subcutaneous pfilocaine with adrenaline for pain relief in day case arthroscopy of the knee joint. Ann R Coil Surg Engl 1990;72:350-2.