Brazilian Journal of Anesthesiology
https://app.periodikos.com.br/journal/rba/article/doi/10.1590/S0034-70942010000100001
Brazilian Journal of Anesthesiology
Scientific Article

Eficácia analgésica do uso de dose alta de morfina intra-articular em pacientes submetidos à artroplastia total de joelho

Analgesic efficacy of the intra-articular administration of high Doses of morphine in patients undergoing total knee arthroplasty

João Batista Santos Garcia Garcia; José Osvaldo Barbosa Neto; José Wanderley Vasconcelos; Letácio Santos Garcia Ferro; Rafaelle Carvalho e Silva

Downloads: 0
Views: 1081

Resumo

JUSTIFICATIVA E OBJETIVOS: Apesar da eficácia da morfina intraarticular (IA) permanecer controversa, tem-se mostrado que doses maiores promovem melhores resultados e, consequentemente, menor consumo pós-operatório de analgésico, caracterizando, assim, efeito dose-dependente na ação periférica. Foi conduzido estudo controlado, aleatório e duplamente encoberto para avaliar a eficácia de 10 mg de morfina por via intra-articular em pacientes submetidos à artroplastia total de joelho. MÉTODO: Foram avaliados 50 pacientes submetidos à artroplastia total de joelho, distribuídos aleatoriamente em dois grupos: o grupotratamento recebeu 10 mg (1 mL) de morfina por via intra-articular diluído em 19 mL de solução fisiológica a 0,9% (SF), enquanto o grupo-controle recebeu injeção intra-articular contendo 20 mL de SF, ambos após o fechamento da cápsula articular, ao final da operação. Morfina subcutânea sob demanda esteve disponível para dor residual. As seguintes variáveis foram avaliadas: intensidade da dor graduada na Escala Numérica (EN) às 2 h (M1), 6 h (M2), 12 h (M3) e 24 h (M4) após injeção IA; tempo para primeira solicitação de analgésico; consumo de analgésicos e efeitos adversos. CONCLUSÕES: O grupo-tratamento apresentou menores valores na EN que o grupo-controle em M1 e M2, enquanto que nos outros momentos não houve diferença significativa. O intervalo para primeira solicitação de analgésicos foi significativamente maior no grupo tratamento e o consumo de analgésicos nas primeiras 24 horas foi menor neste grupo. Não houve diferença entre incidência de efeitos adversos entre os grupos. Concluiu-se que 10 mg de morfina reduziram dor pós-operatória 2 e 6 horas após injeção IA, promoveram maior período sem analgésico de resgate e reduziram seu consumo nas primeiras 24 horas.

Palavras-chave

ANALGESIA, Pós-operatória, ANALGÉSICOS, Opioide, CIRURGIA, Ortopédica

Abstract

BACKGROUND AND OBJECTIVES: Although the efficacy of intraarticular (IA) morphine is still controversial, it has been shown that higher doses promote better results and consequently decrease postoperative analgesic consumption, characterizing a dose-dependent peripheral action. A controlled, randomized, double-blind study was undertaken to evaluate the efficacy of the intra-articular administration of 10 mg of morphine in patients undergoing total knee arthroplasty. METHODS: Fifty patients undergoing total knee arthroplasty were randomly divided into two groups: the treatment group received 10 mg (1 mL) of intra-articular morphine diluted in 19 mL of NS, while the control group received the intra-articular administration of 20 mL of NS, both after closure of the capsule at the end of the surgery. On demand subcutaneous morphine was available for residual pain. The following parameters were evaluated: pain severity according to the numeric scale (NS), 2 h (M1), 6 h (M2), 12 h (M3), and 24 h (M4) after the IA injection; time until the first request of analgesic; analgesic consumption, and side effects. CONCLUSIONS: The treatment group had lower NS than the control group in M1 and M2, while significant differences were not observed in the other moments. The time until the first request of analgesics was significantly higher in the treatment group, and analgesic consumption in the first 24 hours was also lower in this group. The incidence of side effects did not differ between both groups. We concluded that the postoperative IA administration of 10 mg of morphine promoted a longer period without rescue analgesics and reduced their consumption in the first 24 hours.

Keywords

ANALGESIA, Postoperative, ANALGESICS, Opioids, SURGERY, Orthopedic

References

Tanaka N, Sakahashi H, Sato E. The efficacy of intra-articular analgesia after total knee arthroplasty in patients with rheumatoid arthritis and in patients with osteoarthritis. J Arthroplasty. 2001;16:306-311.

Pitimana-Aree S, Visalyaputra S, Komoltri C. An economic evaluation of bupivacaine plus fentanyl versus ropivacaine alone for patient-controlled epidural analgesia after total-knee replacement procedure: a double-blinded randomized study. Reg Anesth Pain Med. 2005;30:446-451.

Klasen JA, Opitz SA, Melzer C. Intraarticular, epidural, and intravenous analgesia after total knee arthroplasty. Acta Anaesthesiol Scand. 1999;43:1021-1026.

Sitsen E, van Poorten F, van Alphen W. Postoperative epidural analgesia after total knee arthroplasty with sufentanil 1 microg/ml combined with ropivacaine 0.2%, ropivacaine 0.125%, or levobupivacaine 0.125%: a randomized, double-blind comparison. Reg Anesth Pain Med. 2007;32:475-480.

Sites BD, Beach M, Biggs R. Intrathecal clonidine added to a bupivacaine-morphine spinal anesthetic improves postoperative analgesia for total knee arthroplasty. Anesth Analg. 2003;96:1083-1088.

Good RP, Snedden MH, Schieber FC. Effects of a preoperative femoral nerve block on pain management and rehabilitation after total knee arthroplasty. Am J Orthop. 2007;36:554-557.

Stein C, Comisel K, Haimerl E. Analgesic effect of intraarticular morphine after arthroscopic knee surgery. N Engl J Med. 1991;325:1123-1126.

Stein C. The control of pain in peripheral tissue by opioids. N Engl J Med. 1995;332:1685-1690.

Dalsgaard J, Felsby S, Juelsgaard P. Analgesi af lavdosis intraartikulaer morfin efter ambulant knaeartroskopi. Ugeskr Laeger. 1993;155:4166-4169.

Björnsson A, Gupta A, Vegfors M. Intraarticular morphine for postoperative analgesia following knee arthroscopy. Reg Anesth. 1994;19:104-108.

Chan ST. Intra-articular morphine and bupivacaine for pain relief after therapeutic arthroscopic knee surgery. Singapore Med J. 1995;36:35-37.

De Andres J, Valia JC, Barrera L. Intra-articular analgesia after arthroscopic knee surgery: comparison of three different regimens. Eur J Anaesthesiol. 1998;15:10-15.

Likar R, Kapral S, Steinkellner H. Dose-dependency of intra-articular morphine analgesia. Br J Anaesth. 1999;83:241-244.

Mauerhan DR, Campbell M, Miller JS. Intra-articular morphine and/or bupivacaine in the management of pain after total knee arthroplasty. J Arthroplasty. 1997;12:546-552.

Ritter MA, Koehler M, Keating EM. Intra-articular morphine and/or bupivacaine after total knee replacement. J Bone Joint Surg Br. 1999;81:301-303.

Solheim N, Rosseland LA, Stubhaug A. Intra-articular morphine 5 mg after knee arthroscopy does not produce significant pain relief when administered to patients with moderate to severe pain via an intraarticular catheter. Reg Anesth Pain Med. 2006;31:506-513.

Jensen MP, Karoly P, Braver S. The measurement of clinical pain intensity: a comparison of six methods. Pain. 1986;27:117-126.

Ayres M, Ayres Jr M, Ayres DL. Bioestat versão 4.0: Aplicações Estatísticas nas Áreas das Ciências Biológicas e Médicas. 2005.

Rosseland LA. No evidence for analgesic effect of intra-articular morphine after knee arthroscopy: a qualitative systematic review. Reg Anesth Pain Med. 2005;30:83-98.

Katz JA, Kaeding CS, Hill JR. The pharmacokinetics of bupivacaine when injected intra-articularly after knee arthroscopy. Anesth Analg. 1988;67:872-875.

Whitford A, Healy M, Joshi GP. The effect of tourniquet release time on the analgesic efficacy of intraarticular morphine after arthroscopic knee surgery. Anesth Analg. 1997;84:791-793.

Gupta A, Bodin L, Holmström B. A systematic review of the peripheral analgesic effects of intraarticular morphine. Anesth Analg. 2001;93:761-770.

Badner NH, Bourne RB, Rorabeck CH. Addition of morphine to intra-articular bupivacaine does not improve analgesia following knee joint replacement. Reg Anesth. 1997;22:347-350.

Jaureguito JW, Wilcox JF, Thisted RA. The effects of morphine on human articular cartilage of the knee: an in vitro study. Arthroscopy. 2002.

Elsner F, Radbruch L, Loick G. Intravenous versus subcutaneous morphine titration in patients with persisting exacerbation of cancer pain. J Palliat Med. 2005;8:743-750.

Koshy RC, Kuriakose R, Sebastian P. Continuous morphine infusions for cancer pain in resource-scarce environments: comparison of the subcutaneous and intravenous routes of administration. J Pain Pall Care Pharmacother. 2005;19:27-33.

Richardson MD, Bjorksten AR, Hart JA. The efficacy of intra-articular morphine for postoperative knee arthroscopy analgesia. Arthroscopy. 1997;13:584-589.

Dierking GW, Ostergaard HT, Dissing CK. Analgesic effect of intra-articular morphine after arthroscopic meniscectomy. Anaesthesia. 1994;49:627-629.

Joshi GP, McCarroll SM, Cooney CM. Intra-articular morphine for pain relief after knee arthroscopy. J Bone Joint Surg Br. 1992;74:749-751.

Raj N, Sehgal A, Hall JE. Comparison of the analgesic efficacy and plasma concentrations of high-dose intra-articular and intramuscular morphine for knee arthroscopy. Eur J Anaesthesiol. 2004;21:932-937.

Kalso E, Tramer MR, Carroll D. Pain relief from intra-articular morphine after knee surgery: a qualitative systemic review. Pain. 1997;71:127-134.

Kalso E, Smith L, McQuay HJ. No pain, no gain: clinical excellence and scientific rigour-lessons learned from IA morphine. Pain. 2002;98:269-275.

Karlsson J, Rydgren B, Eriksson B. Postoperative analgesic effects of intra-articular bupivacaine and morphine after arthroscopic cruciate ligament surgery. Knee Surg Sports Traumatol Arthroscopy. 1995;3:55-59.

Cepeda MS, Uribe C, Betancourt J. Pain relief after knee arthroscopy: intra-articular morphine, intra-articular bupivacaine, or subcutaneous morphine?. Reg Anesth. 1997;22:233-238.

Brandsson S, Karlsson J, Morberg P. Intraarticular morphine after arthroscopic ACL reconstruction: a double-blind placebo-controlled study of 40 patients. Acta Orthop Scand. 2000;71:280-285.

Akinci SB, Saricaoglu F, Atay OA. Analgesic effect of intra-articular tramadol compared with morphine after arthroscopic knee surgery. Arthroscopy. 2005;21:1060-1065.

Marchal JM, Delgado-Martinez AD, Poncela M. Does the type of arthroscopic surgery modify the analgesic effect of intraarticular morphine and bupivacaine?: A preliminary study. Clin J Pain. 2003;19:240-246.

Alvarez-Cabo JM, Lopez-Rouco M, Gonzalez-Paleo JR. Analgesic effect of intra-articular morphine after arthroscopic knee surgery. Ambul Surg. 1998;6:179-182.

Bourke M, Hayes A, Doyle M. A comparison of regularly administered sustained release oral morphine with intramuscular morphine for control of postoperative pain. Anesth Analg. 2000;90:427-430.

Rosseland LA, Stubhaug A. Gender is a confounding factor in pain trials: women report more pain than men after arthroscopic surgery. Pain. 2004;112:248-253.

5dd2ef780e88256d53c63493 rba Articles
Links & Downloads

Braz J Anesthesiol

Share this page
Page Sections