Comparison between intra-articular bupivacaine with epinephrine and epinephrine alone on short-term and long-term pain after knee arthroscopic surgery under general anesthesia in day-surgery patients

Utilization of epinephrine-soaked gauzes to address bleeding from osteotomy sites in non-tourniquet total knee arthroplasty: a retrospective cohort study

Background

Reducing tourniquet inflation time is important because of the complications of tourniquet extensively used for the control of hemorrhage in total knee arthroplasty (TKA). Bleeding management is critical to acquire a relative bloodless arthrotomy interface for maximize cement fixation in non-tourniquet TKA. The purpose of this study was to investigate hemostatic and hemodynamic effects of epinephrine-soaked gauzes in cemented TKAs.

Methods

A retrospective cohort study of 101 patients in two groups was performed. The first group (n = 51) underwent unilateral TKA with our procedures of epinephrine use, the second group (n = 50) had the same protocol with tourniquet and no epinephrine utilization. Surgical field visualization was assessed by grading scale for difficulty of intraoperative visualization due to blood and number of surgical field clearances. Perioperative blood loss was recorded. Hemodynamic parameters were observed in the epinephrine group.

Results

There was statistically significant difference (p < 0.01) on surgeon-rated difficulty in visualization in the epinephrine group between before and after use of epinephrine, and no statistically significant difference (p = 0.96) between two groups before cementing. No statistically significant result on numbers of surgical field clearances between two groups (p = 0.25) was found. Epinephrine group showed significant difference in hidden blood loss compared with no epinephrine group (576.6 ± 229.3 vs 693.2 ± 302.9, respectively, p = 0.04). The hemodynamic effects of epinephrine may be under control.

Conclusion

The procedure of epinephrine soaked gauzes, as a prudent adjunct, may be effective to reduce blood loss and obtain bloodless bone sections in non-tourniquet TKAs, regardless of hemodynamics.

The Hemodynamic Effect of Epinephrine-Containing Local Infiltration Analgesia After Tourniquet Deflation During Total Knee Arthroplasty: A Retrospective Observational Study

BACKGROUND

Local infiltration analgesia (LIA) is widely used in patients undergoing total knee arthroplasty and often contains epinephrine for a prolonged analgesic effect and to reduce systemic absorption of the local anesthetic. This retrospective observational study investigated the hemodynamic effect of locally infiltrated epinephrine after deflation of the tourniquet during total knee arthroplasty.

METHODS

We reviewed the electronic medical records of patients who underwent total knee arthroplasty between January 2017 and February 2018 at a tertiary care university hospital. Total knee arthroplasty was performed using a conventional technique with a pneumatic tourniquet. LIA consisted of ropivacaine, morphine sulfate, ketorolac, and methylprednisolone. The patients were grouped according to whether or not epinephrine was included in the LIA. The incidence of a hypertensive response (systolic blood pressure >160 mmHg or mean blood pressure >110 mmHg) after deflation of the tourniquet was compared between the 2 groups.

RESULTS

A total of 452 patients had received LIA with (n = 188) or without (n = 264) epinephrine. A hypertensive response after deflation of the tourniquet was more common in patients who received LIA containing epinephrine (42/188 [22.3%]) than in those who received LIA without epinephrine (14/264 [5.3%], P < .001). However, the incidence of hypotension after deflation of the tourniquet was not significantly different between the 2 groups (P = .976).

CONCLUSION

Because epinephrine-containing LIA can result in a hypertensive response after deflation of the tourniquet during total knee arthroplasty, it should be cautiously administered, especially in patients with cardiovascular comorbidities.

Single administration of intra-articular bupivacaine in arthroscopic knee surgery: a systematic review and meta-analysis

Background

Single administration of intra-articular (IA) bupivacaine for pain relief after arthroscopic knee surgery is effective, but its active duration and dose–response relationship is unclear. We conducted this meta-analysis to summarize all published randomized controlled trials (RCTs), thus providing the most recent information on the safety and efficacy of single-administration IA bupivacaine for pain relief after arthroscopic knee surgery, and to determine whether a dose–response relationship exists.

Methods

A systematic electronic literature search (through April 2014) was conducted to identify those RCTs that addressed the safety and efficacy of a single administration of IA bupivacaine for pain management after arthroscopic knee surgery. Subgroup analysis was conducted to determine changes in visual analog scale (VAS) scores at seven postoperative time points. Meta-regression and subgroup analyses were carried out to assess the effects of various treatment factors on efficacy and to evaluate the dose–response relationship of bupivacaine. Weighted mean differences or relative risks were calculated and pooled using a random-effects model.

Results

Twenty-eight trials involving 1,560 patients who underwent arthroscopic knee surgery met the inclusion criteria. The trials were subject to medium risk of bias. VAS scores at 2, 4, 6, 12, and 24 h postoperatively were significantly lower, the number of patients requiring supplementary analgesia was smaller, and the time to first request for analgesia was longer in the IA bupivacaine group than in the placebo group. The analgesic effect of single-administration IA bupivacaine may be associated with the effect of concomitant administration of epinephrine and concentration of bupivacaine, and no dose–response relationship was identified. No significant difference in side effects was detected between groups.

Conclusions

Current evidence shows that the use of single-administration IA bupivacaine is effective for postoperative pain management in patients undergoing arthroscopic knee surgery, with satisfactory short-term safety. Low-dose administration of IA bupivacaine 0.5% combined with epinephrine adjuvant in clinical practice should be performed. Additional high-quality RCTs with longer follow-up periods are required to examine the safety of single-administration IA bupivacaine.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-015-0477-6) contains supplementary material, which is available to authorized users.

Single-dose intra-articular bupivacaine after knee arthroscopic surgery: a meta-analysis of randomized placebo-controlled studies

PURPOSE

The purpose of this meta-analysis was to examine the efficacy and safety of single-dose intra-articular bupivacaine in the management of pain after knee arthroscopic surgery.

METHOD

The comprehensive literature search, using MEDLINE, the Cochrane Central Register of Controlled Trials, and Embase databases, was conducted to identify randomized controlled trials that used single-dose intra-articular bupivacaine for postoperative pain. The relative risk (RR), weighted mean difference (WMD), and their corresponding 95 % confidence intervals (CIs) were calculated using RevMan(®) statistical software.

RESULT

Twenty-three studies (n = 1287) were included (647 subjects in bupivacaine group and 640 subjects in the control group). Statistically significant differences were observed in the VAS values (WMD -1.1; 95 % CI -1.7 to -0.5), number of patients requiring supplementary analgesia (RR 0.83; 95 % CI 0.74-0.94), and time to first analgesic request (WMD 129.3; 95 % CI 15.4-243.1) among the bupivacaine group when compared to the control group. However, short-term side effects had no significant difference between these two groups (RR 0.73; 95 % CI 0.44-1.24).

CONCLUSIONS

On the basis of the currently available literature, single-dose intra-articular bupivacaine was shown to be significantly better than placebo at relieving pain after knee arthroscopic surgery. More high-quality randomized controlled trials with long follow-up are highly required for examining the safety of single-dose intra-articular bupivacaine. Besides, routine use of single-dose intra-articular bupivacaine is still an effective way for pain management after knee arthroscopic surgery.

Analgesic effect of intra-articular magnesium sulphate compared with bupivacaine after knee arthroscopic menisectomy

This work aimed to evaluate the analgesic efficacy of intra-articular injection of magnesium sulphate (4%) compared with equivalent volume of bupivacaine (0.5%) after outpatient knee arthroscopic meniscectomy. Forty patients were randomly assigned to two groups. Group M (n = 20) received intra-articular magnesium sulphate 4%, group B (n = 20) received bupivacaine (0.5%). Analgesic effect was evaluated by analgesic duration, and by measuring pain intensity at 1, 2, 4, 6, 12, 24 h both at rest and on knee movement to 90°. The primary outcome variable was pain intensity on the VAS at 1, 2, 4, 6, 12, 24 h post arthroscopy at rest and on movement (flexion of knee to 90°), although the magnesium group had lower time weighted averages (TWAs) at rest and on movement, these TWAs were not statistically significant. The median duration of postoperative analgesia was significantly longer in the patients treated with magnesium sulphate (528 min) than in the bupivacaine group (317 min) (p < 0.0001), with less number of patients needing supplementary analgesia in magnesium group (8/20) than those of the bupivacaine group (16/20) (p < 0.022). Also analgesic consumption was significantly lower in the magnesium sulphate group (p < 0.002). We concluded that the use of magnesium sulphate is rational and effective in reducing pain, and is more physiological and shortens convalescence after outpatient arthroscopic meniscectomy, however our hypotheses that analgesic efficacy of intra-articular isotonic magnesium sulphate would be superior to intra-articular local anaesthetic cannot be supported with this study.

Efficacy and safety of oxymorphone immediate release for the treatment of mild to moderate pain after ambulatory orthopedic surgery: results of a randomized, double-blind, placebo-controlled trial

OBJECTIVE

To assess the analgesic efficacy and safety of 5 mg of oxymorphone immediate release (IR) for mild to moderate pain.

DESIGN

Multicenter, double-blind, randomized, placebo-controlled study.

SETTING

Ambulatory surgical centers.

PARTICIPANTS

Outpatients (age, > or = 18 y) undergoing knee arthroscopy.

INTERVENTION

Randomization to 5 mg of oxymorphone IR or placebo hourly as needed for up to 8 hours.

MAIN OUTCOME MEASURE

Sum of pain intensity difference (SPID) from baseline to 8 hours.

RESULTS

Among 122 patients randomized, 70.5% and 28.7% had moderate or mild postsurgical pain at baseline, respectively. The mean SPID score was significantly greater in the oxymorphone IR group, showing greater pain relief, compared with the placebo group (least squares mean difference +/- standard error, 76.9+/-28.09; 95% confidence interval, 21.26-132.59; P=.007). More placebo patients (48.4%) required rescue medication than oxymorphone IR patients (16.7%), with median times to use of rescue medication of 6 hours 54 minutes and more than 8 hours, respectively (P<.001). More patients (47.4%) rated oxymorphone IR "very good" or "excellent" for pain relief versus placebo (25.0%). No oxymorphone IR-treated patients discontinued because of adverse events (AEs) or experienced serious AEs.

CONCLUSIONS

Five milligrams of oxymorphone IR was well tolerated and effective at relieving mild or moderate postsurgical pain after outpatient knee surgery.