Optimizing the dose of intrathecal morphine when combined with continuous 3-in-1 nerve block after total knee replacement

다국어 초록 (Multilingual Abstract)

Background: Continuous femoral 3-in-1 block alone is insufficient for the treatment of severe pain after total knee replacement (TKR). Intrathecal (IT) morphine provides effective postoperative analgesia but may result in many side effects. The optimal dose of spinal morphine when combined with continuous 3-in-1 block after TKR is not known.
Methods: Patients were randomized to receive IT morphine in five groups (n = 20 per group): 1) 0.0 mg, 2) 0.05 mg, 3) 0.1 mg, 4) 0.15 mg, and 5) 0.2 mg. All patients received continuous 3-in-1 block performed with 20 ml of 0.25% bupivacaine, followed by a continuous infusion of 0.125% bupivacaine at the rate of 2 ml/h plus PCA boluses of 1 ml with a lockout of 10 minutes. The intensity of pain at rest and on movement of the knee was assessed by using a visual analog scale for the first two postoperative days.
Results: All treatment groups produced effective pain relief and decreased cumulative femoral PCA bolus use of 0.125% bupivacaine compared with control, respectively (P＜ 0.05); however, there were no significant differences among the treatment groups. The incidence of vomiting was significantly more frequent with 0.1−0.2 mg IT morphine groups compared with control, respectively (P ＜ 0.05). The rate of administration of antipruritic medication was increased as IT morphine dose increased (P ＜ 0.05).
Conclusions: Use of 0.05 mg IT morphine would appear to provide the optimal balance between pain relief and adverse effects following TKR.

다국어 초록 (Multilingual Abstract)

Background: Continuous femoral 3-in-1 block alone is insufficient for the treatment of severe pain after total knee replacement (TKR). Intrathecal (IT) morphine provides effective postoperative analgesia but may result in many side effects. The optimal dose of spinal morphine when combined with continuous 3-in-1 block after TKR is not known.
Methods: Patients were randomized to receive IT morphine in five groups (n = 20 per group): 1) 0.0 mg, 2) 0.05 mg, 3) 0.1 mg, 4) 0.15 mg, and 5) 0.2 mg. All patients received continuous 3-in-1 block performed with 20 ml of 0.25% bupivacaine, followed by a continuous infusion of 0.125% bupivacaine at the rate of 2 ml/h plus PCA boluses of 1 ml with a lockout of 10 minutes. The intensity of pain at rest and on movement of the knee was assessed by using a visual analog scale for the first two postoperative days.
Results: All treatment groups produced effective pain relief and decreased cumulative femoral PCA bolus use of 0.125% bupivacaine compared with control, respectively (P＜ 0.05); however, there were no significant differences among the treatment groups. The incidence of vomiting was significantly more frequent with 0.1−0.2 mg IT morphine groups compared with control, respectively (P ＜ 0.05). The rate of administration of antipruritic medication was increased as IT morphine dose increased (P ＜ 0.05).
Conclusions: Use of 0.05 mg IT morphine would appear to provide the optimal balance between pain relief and adverse effects following TKR.

참고문헌 (Reference)

1 박창길, "전슬관절치환술 후 지속적인 3-in-1 신경차단과 정맥내 통증자가조절의 술 후 진통에 관한 비교" 대한마취과학회 51 (51): 76-81, 2006

2 Rathmell JP, "The role of intrathecal drugs in the treatment of acute pain" 101 (101): S30-S43, 2005

3 De Kock MF, "The clinical role of NMDA receptor antagonists for the treatment of postoperative pain" 21 : 85-98, 2007

4 박창길, "The Effect of Intrathecal Morphine added to Continuous Femoral 3-in-1 Nerve Block for Analgesia After Total Knee Replacement" 대한마취과학회 54 (54): 544-551, 2008

5 Cardoso MM, "Small doses of intrathecal morphine combined with systemic diclofenac for postoperative pain control after cesarean delivery" 86 : 538-541, 1998

6 Glass PS, "Respiratory depression following only 0.4 mg of intrathecal morphine" 60 : 256-257, 1984

7 Ashburn MA, "Postoperative pain. in: Bonica’s management of pain. 3rd ed" Lippincott Williams & Wilkins 769-, 2001

8 Gjessing J, "Postoperative pain control with intrathecal morphine" 36 : 268-276, 1981

9 Wilder-Smith OH, "Postoperative hyperalgesia: its clinical importance and relevance" 104 : 601-607, 2006

10 Ready LB, "Postoperative epidural morphine is safe on surgical wards" 75 : 452-456, 1991

11 Macalou D, "Postoperative analgesia after total knee replacement: the effect of an obturator nerve block added to the femoral 3-in-1 nerve block" 99 : 251-254, 2004

12 Murphy PM, "Optimizing the dose of intrathecal morphine in older patients undergoing hip arthroplasty" 97 : 1709-1715, 2003

13 Slappendel R, "Optimization of the dose of intrathecal morphine in total hip surgery: a dose-finding study" 88 : 822-866, 1999

14 Horlocker TT, "Neuraxial block and low-molecular-weight heparin: balancing perioperative analgesia and thromboprophylaxis" 23 : 164-177, 1998

15 Uchiyama A, "Low dose intrathecal morphine and pain relief following caesarean section" 3 : 87-91, 1994

16 Pang WW, "Is total knee replacement more painful than total hip replacement?" 38 : 143-148, 2000

17 Kuipers PW, "Intrathecal opioids and lower urinary tract function: a urodynamic evaluation" 100 : 1497-1503, 2004

18 Schaer H, "Intrathecal morphine for postoperative pain" 41 : 689-693, 1992

19 Rathmell JP, "Intrathecal morphine for postoperative analgesia: a randomized, controlled, dose-ranging study after hip and knee arthroplasty" 97 : 1452-1457, 2003

20 Chadwick HS, "Intrathecal and epidural morphine sulfate for post-cesarean analgesia--a clinical comparison" 68 : 925-929, 1988

21 Cole PJ, "Efficacy and respiratory effects of low-dose spinal morphine for postoperative analgesia following knee arthroplasty" 85 : 233-237, 2000

22 Singelyn FJ, "Effects of intravenous patient-controlled analgesia with morphine, continuous epidural analgesia, and continuous three-in-one block on postoperative pain and knee rehabilitation after unilateral total knee arthroplasty" 87 : 88-92, 1998

23 Kalso E, "Effects of intrathecal morphine, injected with bupivacaine, on pain after orthopaedic surgery" 55 : 415-422, 1983

24 Bailey PL, "Dose-response pharmacology of intrathecal morphine in human volunteers" 79 : 49-59, 1993

25 Edwards ND, "Continuous low-dose 3-in-1 nerve blockade for postoperative pain relief after total knee replacement" 75 : 265-267, 1992

26 Tarkkila P, "Comparison of intrathecal morphine and continuous femoral 3-in-1 block for pain after major knee surgery under spinal anaesthesia" 15 : 6-9, 1998

27 Hwang HS, "Comparison of analgesic requirements for postoperative pain control in patients undergoing major orthopedic surgery" 17 : 228-233, 2004

28 Yaksh TL, "Analgesia produced by a spinal action of morphine and effects upon parturition in the rat" 51 : 386-392, 1979

29 Ben-David B, "Analgesia after total knee arthroplasty: is continuous sciatic blockade needed in addition to continuous femoral blockade?" 98 : 747-749, 2004

30 Jacobson L, "A dose-response study of intrathecal morphine: efficacy, duration, optimal dose, and side effects" 67 : 1082-1088, 1988