- Email: [email protected]
Intra-Articular Morphine for Postoperative Analgesia in Knee Arthroscopy
Personal Practice
INTRA-ARTICULAR MORPHINE FOR POSTOPERATIVE ANALGESIA IN KNEE ARTHROSCOPY MEERA KHARBANDA* and VIKAS MAHESHWARI** *Senior Consultant Anaesthesiologist, **Senior Resident, Department of Anaesthesiology, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi 110 076, India. Correspondence to: Dr. Meera Kharbanda, Senior Consultant Anaesthesiologist, Department of Anaesthesiology, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi 110 076, India.
INTRODUCTION THERE exists evidence that in addition to their central effects opioids can produce potent antinociceptive effects by interacting with opioid receptors in peripheral tissue. The recent growth in outpatient surgery has presented new challenges in the field of postoperative pain management. The search continues for an ideal analgesic technique that is site specific, long-lasting easily administered and has a high therapeutic safety index. Arthroscopic surgery of the knee is a common outpatient procedure. Although intra-articular injection of bupivacaine following arthroscopy has been demonstrated to be safe and effective in providing postoperative analgesia, the mean duration of analgesia is only two hour. More recently longer lasting analgesia has been achieved using intra-articular morphine, although the onset of analgesia may be delayed. OUR STUDY Eighty patients were enrolled in the study conducted at our hospital we evaluated the response of 5 mg of morphine injected into the knee joint after arthroscopy alone and in combination with 0.25% bupivacaine. Patients were randomly divided into four groups for intra-articular injection at the end of surgery when knee was sealed. Patients in control Group C (n = 20) normal saline. Patients in Group M (n = 20) morphine 5mg in normal saline. Patients in Group B (n = 20) bupivacaine (0.25%). Twenty patients received a combination of 5 mg morphine and 20 mL 0.25% bupivacaine. The volume of solution was 20 mL and all solutions contained 1:2,00,000 adrenaline (Epinephrine). Rescue analgesia was provided by Injection Tramadol 50 mg given intravenously. The results showed that in patients undergoing arthroscopic knee surgery, intra-articular bupivacaine results in good analgesia in the immediate 43
post-operative period (i.e., 0 hr). In contrast, intraarticular Morphine failed to provide significant analgesia during the same period. Delayed analgesic effect was poor in the bupivacaine group as compared to group morphine and (bupivacaine + morphine). In (bupivacaine + morphine) group analgesia lasted up to 24 hours after the knee arthroscopy. The combination of (bupivacaine + morphine) had the best results with both early and delayed analgesia. DISCUSSION We found a decrease in the pain scores in all the active treatment group patients (morphine, bupivacaine and morphine + bupivacaine) when compared with placebo and no systemic side effects were detected. In patients undergoing arthroscopic knee surgery intra-articular bupivacaine results in good analgesia in the immediate post-operative period (i.e., 0-1 hr). In contrast intraarticular morphine failed to provide significant analgesia during the initial period as measured by VAS [1,2] scores and the demand of rescue analgesia. A combination of (bupivacain + morphine) behaves like bupivacaine in early post-operative period and like morphine in the late post-operative period. To discuss these time courses of action, one has to consider that local anaesthetics exert their effects through an action upon peripheral nerves. In studies done on humans, intra-articular morphine can significantly inhibit post-operative pain by activation of peripheral opioid receptors within the joint. Lawrence, et al. have identified opioid binding site in synovial tissue, indicating that analgesia is locally mediated. It has also been studied that morphine may diminish local post-traumatic inflammation through actions on leukocyte inhibition of bradykinin formation. Apollo Medicine, Vol. 5, No. 1, March 2008
Personal Practice
and beyond that its action is poor and intra-articular morphine injection at the end of procedure has minimal or no analgesic effect in the first 6 hours.It has a delayed onset of action (4-6 hr) and prolonged duration of action of 24 hr. Therfore, a combination of bupivacaine + morphine is suitable for use in day care knee arthroscopy surgery.
Local anesthetics are thought to produce their effects through inhibition of the generation and / or propagation of action potentials at the neuronal membrane and a resultant blockade of afferent nociceptive barrage [3]. Various studies have suggested that the tourniquet needed to remain inflated for at least 10 minutes, so that the delayed return of blood flow will allow the morphine time to bind with the opiate receptors within the joint. Studies have shown that intra-articular administration of morphine results in very low plasma concentration of morphine and its major metabolites. Systemic side effects were not observed with morphine 5mg and can be used safely in day care patients [4,5].
REFERENCES 1. Chapman CR, Casey KL, Dubner R, Foley KM, Gracely RH, Reading AE. Pain Measurement: An overview. Pain 1985; 22: 1-31. 2. Scott J, Huskisson EC. Graphic representation of pain. Pain 1976; 2: 175-184.
Epinephrine has also been added to the intra-articular injection. Its use has been recommended to prevent local anaesthetic toxicity [6]. However, epinephrine may also contribute to analgesia effect but the mechanism of action is not clear.
3. J Opioid Stein C, Millan MJ, Shippenberg TS, Herz A. Peripheral effect of fentanyl upon nociception in inflamed tissue of the rat. Neurosci Lett 1988; 84: 225. 4. Bartho L, Szolcsanyi J. Opiate agonists inhibit neurogenic plasma extravasation in the rat. Eur J Pharmacol 1981; 73: 101-104.
The volume injected into joint space may be important to intra-articular opiate action. Volumes varying from 20 mL to 40 mL have been injected intraarticularly but the results have been variable for our we used a volume of 20 mL [7,8]. Besides morphine, bupivacaine and combination of morphine + bupivacaine other drugs can be injected intra-articularly like steroid for its anti-inflammatory action.
5. Joshi GP, McCarroll SM, Brady OH, Hurson BJ, Walsh G. Intraarticular morphine for pain relief after anterior cruciate ligament repair. Br J Anaesth 1993; 70: 87-88. 6. Joshi GP, McCarroll, SM Conney Blunnie WP, et.al. Intraarticular morphine after arthroscopic knee surgery. J Bone and Joint Surg 1992; 74: 749-751. 7. Stephen O. Heard, Thomas Edwards, et al. Analgesic effect of intraarticular bupivacaine or morphine after arthroscopic knee surgery: A randomized prospective, Double blind study. Anaesth Anal 1992; 74: 822-826.
SUMMARY AND CONCLUSION
8
Finally, we conclude from our experience that intraarticular bupivacaine injected at the end of procedure is a good analgesic for the first four hours post-operatively
Apollo Medicine, Vol. 5, No. 1, March 2008
44
Khoury GF, Chen ACN, Garland DE, Stein C. Intraarticular bupivacaine, morphine and morphine/ bupivacaine for pain control after knee video arthroscopy. Anaesthesiology 1992; 77: 263-266.
INTRA-ARTICULAR MORPHINE FOR POSTOPERATIVE ANALGESIA IN KNEE ARTHROSCOPY MEERA KHARBANDA* and VIKAS MAHESHWARI** *Senior Consultant Anaesthesiologist, **Senior Resident, Department of Anaesthesiology, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi 110 076, India. Correspondence to: Dr. Meera Kharbanda, Senior Consultant Anaesthesiologist, Department of Anaesthesiology, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi 110 076, India.
INTRODUCTION THERE exists evidence that in addition to their central effects opioids can produce potent antinociceptive effects by interacting with opioid receptors in peripheral tissue. The recent growth in outpatient surgery has presented new challenges in the field of postoperative pain management. The search continues for an ideal analgesic technique that is site specific, long-lasting easily administered and has a high therapeutic safety index. Arthroscopic surgery of the knee is a common outpatient procedure. Although intra-articular injection of bupivacaine following arthroscopy has been demonstrated to be safe and effective in providing postoperative analgesia, the mean duration of analgesia is only two hour. More recently longer lasting analgesia has been achieved using intra-articular morphine, although the onset of analgesia may be delayed. OUR STUDY Eighty patients were enrolled in the study conducted at our hospital we evaluated the response of 5 mg of morphine injected into the knee joint after arthroscopy alone and in combination with 0.25% bupivacaine. Patients were randomly divided into four groups for intra-articular injection at the end of surgery when knee was sealed. Patients in control Group C (n = 20) normal saline. Patients in Group M (n = 20) morphine 5mg in normal saline. Patients in Group B (n = 20) bupivacaine (0.25%). Twenty patients received a combination of 5 mg morphine and 20 mL 0.25% bupivacaine. The volume of solution was 20 mL and all solutions contained 1:2,00,000 adrenaline (Epinephrine). Rescue analgesia was provided by Injection Tramadol 50 mg given intravenously. The results showed that in patients undergoing arthroscopic knee surgery, intra-articular bupivacaine results in good analgesia in the immediate 43
post-operative period (i.e., 0 hr). In contrast, intraarticular Morphine failed to provide significant analgesia during the same period. Delayed analgesic effect was poor in the bupivacaine group as compared to group morphine and (bupivacaine + morphine). In (bupivacaine + morphine) group analgesia lasted up to 24 hours after the knee arthroscopy. The combination of (bupivacaine + morphine) had the best results with both early and delayed analgesia. DISCUSSION We found a decrease in the pain scores in all the active treatment group patients (morphine, bupivacaine and morphine + bupivacaine) when compared with placebo and no systemic side effects were detected. In patients undergoing arthroscopic knee surgery intra-articular bupivacaine results in good analgesia in the immediate post-operative period (i.e., 0-1 hr). In contrast intraarticular morphine failed to provide significant analgesia during the initial period as measured by VAS [1,2] scores and the demand of rescue analgesia. A combination of (bupivacain + morphine) behaves like bupivacaine in early post-operative period and like morphine in the late post-operative period. To discuss these time courses of action, one has to consider that local anaesthetics exert their effects through an action upon peripheral nerves. In studies done on humans, intra-articular morphine can significantly inhibit post-operative pain by activation of peripheral opioid receptors within the joint. Lawrence, et al. have identified opioid binding site in synovial tissue, indicating that analgesia is locally mediated. It has also been studied that morphine may diminish local post-traumatic inflammation through actions on leukocyte inhibition of bradykinin formation. Apollo Medicine, Vol. 5, No. 1, March 2008
Personal Practice
and beyond that its action is poor and intra-articular morphine injection at the end of procedure has minimal or no analgesic effect in the first 6 hours.It has a delayed onset of action (4-6 hr) and prolonged duration of action of 24 hr. Therfore, a combination of bupivacaine + morphine is suitable for use in day care knee arthroscopy surgery.
Local anesthetics are thought to produce their effects through inhibition of the generation and / or propagation of action potentials at the neuronal membrane and a resultant blockade of afferent nociceptive barrage [3]. Various studies have suggested that the tourniquet needed to remain inflated for at least 10 minutes, so that the delayed return of blood flow will allow the morphine time to bind with the opiate receptors within the joint. Studies have shown that intra-articular administration of morphine results in very low plasma concentration of morphine and its major metabolites. Systemic side effects were not observed with morphine 5mg and can be used safely in day care patients [4,5].
REFERENCES 1. Chapman CR, Casey KL, Dubner R, Foley KM, Gracely RH, Reading AE. Pain Measurement: An overview. Pain 1985; 22: 1-31. 2. Scott J, Huskisson EC. Graphic representation of pain. Pain 1976; 2: 175-184.
Epinephrine has also been added to the intra-articular injection. Its use has been recommended to prevent local anaesthetic toxicity [6]. However, epinephrine may also contribute to analgesia effect but the mechanism of action is not clear.
3. J Opioid Stein C, Millan MJ, Shippenberg TS, Herz A. Peripheral effect of fentanyl upon nociception in inflamed tissue of the rat. Neurosci Lett 1988; 84: 225. 4. Bartho L, Szolcsanyi J. Opiate agonists inhibit neurogenic plasma extravasation in the rat. Eur J Pharmacol 1981; 73: 101-104.
The volume injected into joint space may be important to intra-articular opiate action. Volumes varying from 20 mL to 40 mL have been injected intraarticularly but the results have been variable for our we used a volume of 20 mL [7,8]. Besides morphine, bupivacaine and combination of morphine + bupivacaine other drugs can be injected intra-articularly like steroid for its anti-inflammatory action.
5. Joshi GP, McCarroll SM, Brady OH, Hurson BJ, Walsh G. Intraarticular morphine for pain relief after anterior cruciate ligament repair. Br J Anaesth 1993; 70: 87-88. 6. Joshi GP, McCarroll, SM Conney Blunnie WP, et.al. Intraarticular morphine after arthroscopic knee surgery. J Bone and Joint Surg 1992; 74: 749-751. 7. Stephen O. Heard, Thomas Edwards, et al. Analgesic effect of intraarticular bupivacaine or morphine after arthroscopic knee surgery: A randomized prospective, Double blind study. Anaesth Anal 1992; 74: 822-826.
SUMMARY AND CONCLUSION
8
Finally, we conclude from our experience that intraarticular bupivacaine injected at the end of procedure is a good analgesic for the first four hours post-operatively
Apollo Medicine, Vol. 5, No. 1, March 2008
44
Khoury GF, Chen ACN, Garland DE, Stein C. Intraarticular bupivacaine, morphine and morphine/ bupivacaine for pain control after knee video arthroscopy. Anaesthesiology 1992; 77: 263-266.