Comparison of intrathecal morphine versus local infiltration analgesia for pain control in total knee and hip arthroplasty

B, Qi; Yu, Jing; Qiao, Wei-Song

doi:10.1097/md.0000000000021971

Cited by 12 publications

(12 citation statements)

References 28 publications

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“…The incidence of nausea and pruritis was significantly higher in the ITM group, even though the overall opioid consumption was similar in both groups. Our trial results remain in line with a metanalysis which showed an associated increased pruritis and a decreased patient satisfaction [ 26 , 27 ], although no difference in side effect profile was observed in one study [ 28 ].…”

Section: Discussionsupporting

confidence: 89%

Efficacy and Side Effect Profile of Intrathecal Morphine versus Distal Femoral Triangle Nerve Block for Analgesia following Total Knee Arthroplasty: A Randomized Trial

Janiak

Kowalczyk

Górniewski

et al. 2022

JCM

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(1) Background: The management of postoperative pain after knee replacement is an important clinical problem. The best results in the treatment of postoperative pain are obtained using multimodal therapy principles. Intrathecal morphine (ITM) and single-shot femoral nerve block (SSFNB) are practiced in the treatment of postoperative pain after knee replacement, with the most optimal methods still under debate. The aim of this study was to compare the analgesic efficacy with special consideration of selected side effects of both methods. (2) Materials and methods: Fifty-two consecutive patients undergoing knee arthroplasty surgery at the Department of Orthopedics and Traumatology of the Medical University of Warsaw were included in the study. Patients were randomly allocated to one of two groups. In the ITM group, 100 micrograms of intrathecal morphine were used, and in the SSFNB group, a femoral nerve block in the distal femoral triangle was used as postoperative analgesia. The other elements of anesthesia and surgery did not differ between the groups. (3) Results: The total dose of morphine administered in the postoperative period and the effectiveness of pain management did not differ significantly between the groups (cumulative median morphine dose in 24 h in the ITM group 31 mg vs. SSFNB group 29 mg). The incidence of nausea and pruritus in the postoperative period differed significantly in favor of patients treated with a femoral nerve block. (4) Conclusions: Although intrathecal administration of morphine is similarly effective in the treatment of pain after knee replacement surgery as a single femoral triangle nerve block, it is associated with a higher incidence of cumbersome side effects, primarily nausea and pruritus.

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Section: Discussionsupporting

confidence: 89%

Efficacy and Side Effect Profile of Intrathecal Morphine versus Distal Femoral Triangle Nerve Block for Analgesia following Total Knee Arthroplasty: A Randomized Trial

Janiak

Kowalczyk

Górniewski

et al. 2022

JCM

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“…In all studies, intrathecal morphine was associated with increased pruritus and decreased patient satisfaction. In a more recent meta-analysis, 87 intrathecal morphine was compared with LIA in both TKA and THA. The four RCTs in TKA patients showed no differences in postoperative analgesia and opioid-sparing with intrathecal morphine (100 to 300 μg) 91–94 .…”

Section: Resultsmentioning

confidence: 99%

“…[73][74][75][76][77][78][79][80][81][82][83][84] Three meta-analyses including four RCTs compared intrathecal morphine with FNB 85,86 and with LIA. 87 The dose of intrathecal morphine varied between 100 and 300 mcg (Table S1, http://links.lww.com/EJA/ A701). Compared with single shot FNB, there was no clinically significant difference in postoperative pain at rest or during mobilisation and no postoperative opioidsparing effect.…”

Section: Intrathecal Morphinementioning

confidence: 99%

Pain management after total knee arthroplasty

Lavand’homme¹,

Kehlet²,

Rawal³

et al. 2022

European Journal of Anaesthesiology

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BACKGROUND The PROSPECT (PROcedure SPEcific Postoperative Pain ManagemenT) Working Group is a global collaboration of surgeons and anaesthesiologists formulating procedure-specific recommendations for pain management after common operations. Total knee arthroplasty (TKA) is associated with significant postoperative pain that is difficult to treat. Nevertheless, pain control is essential for rehabilitation and to enhance recovery. OBJECTIVE To evaluate the available literature and develop recommendations for optimal pain management after unilateral primary TKA.DESIGN A narrative review based on published systematic reviews and meta-analyses, using modified PROSPECT methodology.DATA SOURCES A literature search was performed in EMBASE, MEDLINE, PubMed and Cochrane Databases, between January 2014 and December 2020, for systematic reviews and meta-analyses evaluating analgesic interventions for pain management in patients undergoing TKA.ELIGIBILITY CRITERIA Each randomised controlled trial (RCT) included in the selected systematic reviews was critically evaluated and included only if met the PROSPECT requirements. Included studies were evaluated for clinically relevant differences in pain scores, use of nonopioid analgesics, such as paracetamol and nonsteroidal anti-inflammatory drugs and current clinical relevance.RESULTS A total of 151 systematic reviews were analysed, 106 RCTs met PROSPECT criteria. Paracetamol and nonsteroidal anti-inflammatory or cyclo-oxygenase-2-specific inhibitors are recommended. This should be combined with a single shot adductor canal block and peri-articular local infiltration analgesia together with a single intra-operative dose of intravenous dexamethasone. Intrathecal morphine (100 mg) may be considered in hospitalised patients only in situations when both adductor canal block and local infiltration analgesia are not possible. Opioids should be reserved as rescue analgesics in the postoperative period. Analgesic interventions that could not be recommended were also identified.CONCLUSION The present review identified an optimal analgesic regimen for unilateral primary TKA. Future studies to evaluate enhanced recovery programs and specific challenging patient groups are needed.

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“…The concept of administering local anaesthetics with opioid adjuncts via the intrathecal or epidural route is longstanding [33,34] and systematic reviews show this reduces the intrathecal local anaesthetic dose requirement [35] and prolongs analgesia in patients undergoing caesarean delivery [36][37][38] or lower limb arthroplasty [39,40]. Recent studies that compare intrathecal morphine with local infiltration analgesia for lower limb joint arthroplasty may change this practice, as local infiltration provides superior analgesia, reduces postoperative morphine consumption, shortens hospital stay and reduces morphine-related adverse effects [41,42].…”

Section: Anaesthetic Adjunctsmentioning

confidence: 99%

Pharmacological and clinical implications of local anaesthetic mixtures: a narrative review

Nestor

Sepúlveda

et al. 2021

Anaesthesia

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Summary Various techniques have been explored to prolong the duration and improve the efficacy of local anaesthetic nerve blocks. Some of these involve mixing local anaesthetics or adding adjuncts. We did a literature review of studies published between 01 May 2011 and 01 May 2021 that studied specific combinations of local anaesthetics and adjuncts. The rationale behind mixing long‐ and short‐acting local anaesthetics to hasten onset and extend duration is flawed on pharmacokinetic principles. Most local anaesthetic adjuncts are not licensed for use in this manner and the consequences of untested admixtures and adjuncts range from making the solution ineffective to potential harm. Pharmaceutical compatibility needs to be established before administration. The compatibility of drugs from the same class cannot be inferred and each admixture requires individual review. Precipitation on mixing (steroids, non‐steroidal anti‐inflammatory drugs) and subsequent embolisation can lead to serious adverse events, although these are rare. The additive itself or its preservative can have neurotoxic (adrenaline, midazolam) and/or chondrotoxic properties (non‐steroidal anti‐inflammatory drugs). The prolongation of block may occur at the expense of motor block quality (ketamine) or block onset (magnesium). Adverse effects for some adjuncts appear to be dose‐dependent and recommendations concerning optimal dosing are lacking. An important confounding factor is whether studies used systemic administration of the adjunct as a control to accurately identify an additional benefit of perineural administration. The challenge of how best to prolong block duration while minimising adverse events remains a topic of interest with further research required.

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Comparison of intrathecal morphine versus local infiltration analgesia for pain control in total knee and hip arthroplasty

Cited by 12 publications

References 28 publications

Efficacy and Side Effect Profile of Intrathecal Morphine versus Distal Femoral Triangle Nerve Block for Analgesia following Total Knee Arthroplasty: A Randomized Trial

Efficacy and Side Effect Profile of Intrathecal Morphine versus Distal Femoral Triangle Nerve Block for Analgesia following Total Knee Arthroplasty: A Randomized Trial

Pain management after total knee arthroplasty

Pharmacological and clinical implications of local anaesthetic mixtures: a narrative review

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