Immediate and prolonged effects of pre– versus postoperative epidural analgesia with bupivacaine and morphine on pain at rest and during mobilisation after total knee arthroplasty

Abstract

Thirty-two patients scheduled for total knee arthroplasty were randomized to receive an identical epidural blockade initiated 30 min before surgical incision (N = 16), or at closure of the surgical wound (N = 16). Before induction of general anaesthesia the epidural catheter was tested with bupivacaine 7.5 mg.ml-1, 2 ml. General anaesthesia was induced with thiopentone, pancuronium or atracurium, and fentanyl 0.1-0.3 mg, and maintained with N2O/O2 and enflurane. The epidural regimen consisted of a bolus of 16 ml of bupivacaine 7.5 mg.ml-1 plus morphine 2 mg, and continuous infusion of bupivacaine 1.25 mg.ml-1 plus morphine 0.05 mg.ml-1, 4 ml.h-1 for the first 24 h, and bupivacaine 0.625 mg.ml-1 plus morphine 0.05 mg.ml-1, 4 ml.h-1, for the next 24 h after operation. Additional morphine 2.5-5 mg was administered i.v. or i.m. for the first 24 h postoperatively, and ketobemidone or morphine 5-10 mg orally or rectally from 24 h to 7 d postoperatively, on request. Paracetamol 1000 mg every 8 h was administered from 48 h to 7 days postoperatively. No significant differences were observed in request for additional opioids, or in pain scores at rest or during mobilisation of the operated limb, during or after cessation of the epidural regimen. These results do not suggest timing of analgesia with a conventional, continuous epidural regimen to be of major clinical importance in patients undergoing total knee arthroplasty.

Analgesia preemptiva

“…There were no significant differences in total analgesic consumption or pain scores by VAS and verbal scale during postoperative evaluation without evidences of preemptive effects. These same authors used a similar scheme of local anesthetics associated to opioids in patients submitted to total knee replacement and obtained the same results 65 . Katz et al 66 studied 30 patients submitted to thoracotomies with lumbar epidural fentanyl (4 µg.kg -1 ) before or after incision and observed a significant decrease in postoperative pain and drug consumption, thus evidencing preemptive analgesia.…”

Effects of anesthesia on pain after lower-limb amputation

“…Gottschalk and Frank [9] found that intraoperative attenuation of noxious stimuli with epidural block reduced pain and wound hyperalgesia for three weeks after surgery in one patient. Flisberg et al [10] and Dahl et al [11] reported that epidural analgesia started in the postoperative period was as effective as epidural analgesia started preoperatively and continued into the postoperative period.…”

A procedure‐specific systematic review and consensus recommendations for postoperative analgesia following total knee arthroplasty

“…Clonidine [114] NS at rest or on movement compared with no clonidine Adrenaline [115] NS compared with no adrenaline Ropivacaine [30,92], bupivacaine [30,92] NS Timing of administration Oral and IV conventional NSAID [10] NS pre-+ postoperative vs postoperative administration Lumbar epidural bupivacaine plus opioid [116] NS pre-+ postoperative vs postoperative administration Lumbar epidural lidocaine plus ketamine plus morphine [111] Inconclusive results pre-vs post-incision Intra-articular bupivacaine [94] NS pre-vs postoperative techniques. The systemic analgesia trials compare active intervention groups of analgesics [paracetamol, conventional non-steroidal anti-inflammatory drugs (NSAID), COX-2-selective inhibitors, weak opioids, and strong opioids] with either a control or placebo group.…”