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Comparison of the analgesic efficacy and plasma concentrations of high-dose intra-articular and intramuscular morphine for knee arthroscopy

Published online by Cambridge University Press:  28 January 2005

N. Raj ,
A. Sehgal ,
J. E. Hall ,
A. Sharma ,
K. R. Murrin  and
N. D. Groves
N. Raj
Affiliation:
University Hospital of Wales, Department of Anaesthetics and Intensive Care Medicine, Cardiff, UK
A. Sehgal
Affiliation:
University Hospital of Wales, Department of Anaesthetics and Intensive Care Medicine, Cardiff, UK
J. E. Hall
Affiliation:
University Hospital of Wales, Department of Anaesthetics and Intensive Care Medicine, Cardiff, UK
A. Sharma
Affiliation:
University Hospital of Wales, Department of Anaesthetics and Intensive Care Medicine, Cardiff, UK
K. R. Murrin
Affiliation:
University Hospital of Wales, Department of Anaesthetics and Intensive Care Medicine, Cardiff, UK
N. D. Groves
Affiliation:
University Hospital of Wales, Department of Anaesthetics and Intensive Care Medicine, Cardiff, UK
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Extract

Summary

Background and objective: It is important to provide good postoperative analgesia after discharge from day case surgery. The usefulness of intra-articular morphine for analgesia after day case knee arthroscopy remains controversial. A large dose of morphine intra-articularly may provide a good long-lasting analgesia, but its efficacy and pharmacokinetics are not known and may be no better than intramuscular morphine. We compared the effect of 10 mg intra-articular and intramuscular morphine for 24 h post-injection in a randomized double-blind study.

Methods: Forty adults undergoing knee arthroscopy were recruited and received either 10 mg morphine intra-articularly or intramuscularly. Our primary outcome was overall visual analogue assessment of pain (0–100 mm scale where 0 is no pain and 100 is worst possible pain) between 4 h (on discharge) and 24 h (postoperatively). Plasma morphine concentrations were measured at 15 min, and 1, 2, 4 and 24 h. The use of additional analgesia was noted.

Results: The assessment of pain experienced between discharge (4 h) and 24 h was significantly better in the intra-articular (n = 20; mean ± SD: 18 ± 19) than the intramuscular (n = 19; mean ± SD: 34 ± 20) group (P = 0.027). The number of patients consuming any additional analgesia between discharge and 24 h was significantly lower in the intra-articular morphine group (P = 0.038), with 4 (20%) patients in the intra-articular group and 11 (60%) patients in the intramuscular group consuming supplementary analgesia. There were no differences in plasma morphine concentrations between the groups.

Conclusions: A large dose of intra-articular morphine provided better analgesia than the same dose of intramuscular morphine, low plasma morphine levels suggesting a peripheral mechanism.

Keywords

ANALGESIA, POSTOPERATIVE, morphine, intra-articular, intramuscularPAIN, postoperative, management
Type
Original Article
Information
European Journal of Anaesthesiology , Volume 21 , Issue 12 , December 2004 , pp. 932 - 937
Copyright
© 2004 European Society of Anaesthesiology

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Footnotes

The results of the study were presented at the 2002 Annual Scientific Meeting of the Association of Anaesthetists of Great Britain and Ireland, in Bournemouth, UK.

References

Gupta A, Bodin L, Holmstrom B, Berggren L. A systematic review of the peripheral analgesic effects of intraarticular morphine. Anesth Analg 2001; 93: 761–770.Google Scholar
Kalso E, Tramer M, Carroll D, McQuay HJ, Moore RA. Pain relief from intra-articular morphine after knee surgery: a qualitative systematic review. Pain 1997; 71: 127–134.Google Scholar
Stein C, Comisel K, Haimerl E, et al. Analgesic effect of intraarticular morphine after arthroscopic knee surgery. N Engl J Med 1991; 325: 1123–1126.Google Scholar
Lawrence AJ, Joshi GP, Michalkiewicz A, Blunnie WP, Moriarty DC. Evidence for analgesia mediated by peripheral opioid receptors in inflamed synovial tissue. Eur J Clin Pharmacol 1992; 43: 351–355.Google Scholar
Joshi GP, McCarroll SM, Cooney CM, Blunnie WP, O'Brien TM, Lawrence AJ. Intra-articular morphine for pain relief after knee arthroscopy. J Bone Joint Surg Br 1992; 74: 749–751.Google Scholar
Stein C, Millan MJ, Yassouridis A, Herz A. Antinociceptive effects of mu- and kappa-agonists in inflammation are enhanced by a peripheral opioid receptor-specific mechanism. Eur J Pharmacol 1988; 155: 255–264.Google Scholar
Stein C, Millan MJ, Shippenberg TS, Peter K, Herz A. Peripheral opioid receptors mediating antinociception in inflammation. Evidence for involvement of mu, delta and kappa receptors. J Pharmacol Exp Ther 1989; 248: 1269–1275.Google Scholar
Keates HL, Cramond T, Smith M. Intraarticular and periarticular opioid binding in inflamed tissue in experimental canine arthritis. Anesth Analg 1999; 89: 409–415.Google Scholar
Heard SO, Edwards WT, Ferrari D, et al. Analgesic effect of intraarticular bupivacaine or morphine after arthroscopic knee surgery: a randomized, prospective, double-blind study. Anesth Analg 1992; 74: 822–826.Google Scholar
Raja SN, Dickstein RE, Johnson CA. Comparison of postoperative analgesic effects of intraarticular bupivacaine and morphine following arthroscopic knee surgery. Anesthesiology 1992; 77: 1143–1147.Google Scholar
Laurent SC, Nolan JP, Pozo JL, Jones CJ. Addition of morphine to intra-articular bupivacaine does not improve analgesia after day-case arthroscopy. Br J Anaesth 1994; 72: 170–173.Google Scholar
De Andres J, Valia JC, Barrera L, Colomina R. Intra-articular analgesia after arthroscopic knee surgery: comparison of three different regimens. Eur J Anaesthesiol 1998; 15: 10–15.Google Scholar
Aasbo V, Raeder JC, Grogaard B, Roise O. No additional analgesic effect of intra-articular morphine or bupivacaine compared with placebo after elective knee arthroscopy. Acta Anaesthesiol Scand 1996; 40: 585–588.Google Scholar
Møiniche S, Mikkelsen S, Wettesley J, Dahl JB. A systematic review of intra-articular local anesthesia for postoperative pain relief after arthroscopic knee surgery. Reg Anesth Pain Med 1999; 24: 430–437.Google Scholar
Joshi GP, McCarroll SM, O'Brien TM, Lenane P. Intraarticular analgesia following knee arthroscopy. Anesth Analg 1993; 76: 333–336.Google Scholar
Heine MF, Tillet ED, Tsueda K, et al. Intra-articular morphine after arthroscopic knee operation. Br J Anaesth 1994; 73: 413–415.Google Scholar
Cepeda MS, Uribe C, Betancourt J, Rugeles J, Carr DB. Pain relief after knee arthroscopy: intra-articular morphine, intra-articular bupivacaine, or subcutaneous morphine? Reg Anesth 1997; 22: 233–238.Google Scholar
Likar R, Kapral S, Steinkellner H, Stein C, Schafer M. Dose-dependency of intra-articular morphine analgesia. Br J Anaesth 1999; 83: 241–244.Google Scholar
Kanbak M, Akpolat N, Ocal T, Doral MN, Ercan M, Erdem K. Intraarticular morphine administration provides pain relief after knee arthroscopy. Eur J Anaesthesiol 1997; 14: 153–156.Google Scholar
Rosseland LA, Stubhaug A, Skoglund A, Breivik H. Intra-articular morphine for pain relief after knee arthroscopy. Acta Anaesthesiol Scand 1999; 43: 252–257.Google Scholar
Richardson MD, Bjorksten AR, Hart JA, McCullough K. The efficacy of intra-articular morphine for postoperative knee arthroscopy analgesia. Arthroscopy 1997; 13: 584–589.Google Scholar
Brandsson S, Karlsson J, Morberg P, Rydgren B, Eriksson BI, Hedner T. Intra-articular morphine after arthroscopic ACL reconstruction: a double blind placebo controlled study of 40 patients. Acta Orthop Scand 2000; 71: 280–285.Google Scholar
Dahlstrom B, Tamsen A, Paalzow L, Hartvig P. Patient-controlled analgesic therapy, Part IV: pharmacokinetics and analgesic plasma concentrations of morphine. Clin Pharmacokin 1982; 7: 266–279.Google Scholar
Graves DA, Arrigo JM, Foster TS, Baumann TJ, Batenhorst RL. Relationship between plasma morphine concentrations and pharmacologic effects in postoperative patients using patient-controlled analgesia. Clin Pharm 1985; 4: 41–47.Google Scholar
Stanski DR, Greenblatt DJ, Lowenstein E. Kinetics of intravenous and intramuscular morphine. Clin Pharmacol Ther 1978; 24: 52–59.Google Scholar