Low dose spinal morphine and intravenous diclofenac for postoperative analgesia after total hip and knee arthroplasty (original) (raw)
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Cureus, 2020
Introduction As total hip arthroplasty (THA) and total knee arthroplasty (TKA) transition to outpatient settings, appropriate pain management remains a challenge. Nonsteroidal anti-inflammatory drugs (NSAIDs) may subvert the need for postoperative opioids. This study evaluated: 1) total opioid consumption; 2) postoperative pain intensity; 3) discharge destination; 4) length of stay (LOS); and 5) THA and TKA patients' satisfaction in receiving adjunctive intravenous (IV) diclofenac or ketorolac. Methods In this retrospective cohort study, patients scheduled to undergo primary THA or TKA by a single surgeon between March 2017 and April 2018 were identified. Patients were stratified based on the receipt of IV diclofenac (THA: n = 25; TKA: n = 51) or IV ketorolac (THA: n = 28; TKA: n = 32) in addition to the standard pain management regimen. Student's t-testing and Chi-square were used to analyze continuous and categorical variables, respectively. Results TKA diclofenac patients had lower opioid consumption 12 hours postoperatively (p: 0.037). TKA patients in the diclofenac cohort were discharged to home less often (p: 0.025). Both diclofenac cohorts had greater patient satisfaction than the ketorolac cohorts (p: <0.05). There was no significant difference between groups in postoperative pain intensity at 24 or 48 hours or in the length of stay (p: >0.05 for all). Conclusion This study demonstrated that both TKA and THA patients treated with IV diclofenac had no difference in postoperative pain intensity while THA patients had no difference in opioid consumption relative to those treated with IV ketorolac. Further comparison of IV NSAIDs with other IV pain medications may provide broader insight into the ideal management for postoperative pain for this widening patient population.
Research Square (Research Square), 2022
Background Orthopaedic surgeries are among the most painful procedures. Pоstоperаtive pаin аdversely аffeсts the reсоvery оf pаtients. By adding low-dose morphine to intrathecal bupivacaine for spinal anasthesia, the analgesic effect can be prolonged and improved. The objeсtive of the study was tо compare the e cacy and safety of lоw-dоse (0.1 mg аnd 0.2 mg) intrаtheсаl mоrphine (ITM). Methods А prоspeсtive rаndоmised study was соnduсted аt the Hоspitаl оf Trаumаtоlоgy аnd Оrthоpaediсs, Riga, Latvia, frоm February 2020 tо May 2021. The study enrolled 90 subjects whо met the inclusion criteria and were scheduled for total hip аrthrоplаsty. All subjects were randomised intо three study grоups, using the online tool оn www.randomiser.org. All groups received spinal anaesthesia with bupivacaine 15 to 18 mg. Grоup I was the control group. Grоup II and Group III received, respectively, 0.1 mg and 0.2 mg of
Anesthesiology Research and Practice, 2014
Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are major orthopedic surgery models, addressing mainly ageing populations with multiple comorbidities and treatments, ASA II–IV, which may complicate the perioperative period. Therefore effective management of postoperative pain should allow rapid mobilization of the patient with shortening of hospitalization and social reintegration. In our review we propose an evaluation of the main analgesics models used today in the postoperative period. Their comparative analysis shows the benefits and side effects of each of these methods and guides us to how to use evidence-based medicine in our daily practice.
European Journal of Anaesthesiology, 1998
Major knee surgery is associated with moderate or severe post-operative pain. Intrathecal morphine and continuous femoral 3-in-1 block were compared prospectively in 40 patients for pain after major knee surgery under spinal anaesthesia, with 4 mL isobaric 0.5% bupivacaine. In a random order, 20 patients received preservative free morphine 0.3 mg mixed with spinal bupivacaine. In 20 patients, following spinal anaesthesia with only bupivacaine, femoral 3-in-1 block was performed post-operatively with 0.5% bupivacaine 2 mg kg-1. The block was continued via a catheter with 0.25% bupivacaine 0.1 mL h-1 kg-1 until the next morning (24 h after induction of spinal anaesthesia). Intramuscular oxycodone was given as a rescue analgesic in all patients. Two patients from the femoral group were excluded due to technical failure. Three patients in the morphine group and one patient in the femoral group did not need any additional oxycodone. In the morphine group on average 2.8 (range 0-7) and in the femoral group 3.2 (0-5) additional doses of oxycodone were needed during the 24 h observation period. The mean pain scores were significantly lower in the morphine group at 9 and 12 h into the 24-h trial. Itching was seen only in the morphine group (40% of the patients). Other side effects were similar in the two groups. All patients were satisfied with their pain therapy. Both intrathecal morphine and femoral 3-in-1 block alone were insufficient for the treatment of severe pain after major knee surgery.
Canadian Journal of Anesthesia/Journal canadien d'anesthésie, 2000
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 iv 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 # 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. Objectif : Intérêt d'un titrage de la morphine peropératoire pour l'analgésie postopératoire. Méthode : Quarante patients opérés pour une prothèse totale de hanche sous anesthésie générale ont été inclus. Dans le groupe Perop (n = 20) la morphine a été titrée, en intraveineux, à la fin de l'intervention (3 mg toutes les 5 ou 10 min) chez des patients intubés, respirant spontanément jusqu'à diminution de la fréquence respiratoire (FR). Aucune administration de morphine peropératoire n'a été faite chez les patients du groupe Postop (n = 20). À la salle de réveil, les patients des deux groupes recevaient de la morphine titrée jusqu'à analgésie efficace définie par un score EVA = 30 mm. Les patients utilisaient ensuite une analgésie autocontrôlée pendant 24 h. Les délais d'analgésie, les doses de morphine nécessaires et les effets secondaires étaient évalués en salle de réveil. Résultats : Les caractéristiques des patients et de l'intervention chirurgicale sont similaires dans les deux groupes. Dans le groupe Perop les patients reçoivent 10,3 ± 1,3 mg (2-20 mg) de morphine peropératoire. Les patients du groupe Perop ont une analgésie efficace plus rapidement (42 ± 7 min (0-95 min) vs 76 ± 7 min (35-150 min) que ceux du groupe Postop; P = 0,0026). L'analgésie efficace est obtenue avec plus de morphine dans la salle de réveil pour le groupe Postop (15,4 ± 1,5 mg; 9-29 mg) que pour le groupe Perop (7,3 ± 1,3 mg (3-28 mg); P = 0,0004). L'importance du ralentissement de la FR durant le titrage de morphine peropératoire est en corrélation avec la diminution des besoins en morphine à la salle de réveil (P = 0.035). La dépression respiratoire en salle de réveil est plus fréquente dans le groupe Postop (5 patients vs 0 patient dans le group Perop; P = 0,017). Conclusion : La morphine peropératoire titrée facilite l'analgésie postopératoire immédiate.
Anesthesia & Analgesia, 1998
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.