This study compared the analgesic effects of intra-articular tramadol versus intra-articular morphine in 60 patients undergoing arthroscopic knee surgery. Patients were randomly assigned to receive either 50mg of tramadol or 5mg of morphine via intra-articular injection at the conclusion of surgery. Pain was assessed using a visual analogue scale at various time points post-operatively. The study found no significant differences in pain scores between the two groups at any time point. However, the tramadol group required less supplemental oral analgesics than the morphine group at the 6 hour post-operative time point. No other clinically significant differences, such as side effects, were observed between the groups. The study concluded that 50mg
A prospective, randomized, double blind study to evaluate Morphine sparing ef...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Background: This study compared the properties of propofol bolus for induction of general anaesthesia between proprietary and 3 generic formulations, to assess if solvent differences had clinically relevant consequences on effi cacy or side effects. Many studies have investigated different formulations of
propofol for side effects, in this study we also focused on effi cacy of different formulations for induction of general anesthesia.
Comparison between Tramadol and Nalbuphine As an Adjunct to Midazolam for Con...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Comparison of Ondansetron and Granisetron for Prevention of Nausea and Vomiti...Apollo Hospitals
The most common and distressing symptoms, which follow anaesthesia and surgery, are pain and emesis. The consequences of PONV are physical, surgical and anesthetic complications for patients as well as financial implications for the hospitals or institutions. Sometimes nausea and vomiting may be more distressing especially after minor and ambulatory surgery, delaying the hospital discharge. Laparoscopic surgery is one condition, where risk of PONV is particularly pronounced due to pneumo-peritoneum causing stimulation of mechanoreceptors in the gut. In spite of plenty of anti-emetic drugs available no single drug is 100% effective in prevention of PNV and combination therapy has got a lot of side effects.
A prospective, randomized, double blind study to evaluate Morphine sparing ef...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Background: This study compared the properties of propofol bolus for induction of general anaesthesia between proprietary and 3 generic formulations, to assess if solvent differences had clinically relevant consequences on effi cacy or side effects. Many studies have investigated different formulations of
propofol for side effects, in this study we also focused on effi cacy of different formulations for induction of general anesthesia.
Comparison between Tramadol and Nalbuphine As an Adjunct to Midazolam for Con...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Comparison of Ondansetron and Granisetron for Prevention of Nausea and Vomiti...Apollo Hospitals
The most common and distressing symptoms, which follow anaesthesia and surgery, are pain and emesis. The consequences of PONV are physical, surgical and anesthetic complications for patients as well as financial implications for the hospitals or institutions. Sometimes nausea and vomiting may be more distressing especially after minor and ambulatory surgery, delaying the hospital discharge. Laparoscopic surgery is one condition, where risk of PONV is particularly pronounced due to pneumo-peritoneum causing stimulation of mechanoreceptors in the gut. In spite of plenty of anti-emetic drugs available no single drug is 100% effective in prevention of PNV and combination therapy has got a lot of side effects.
Effectiveness of intra-articular dexmedetomidine as postoperative analgesia i...iosrphr_editor
Background And Objectives: To study the effect of inj.Ropivacaine (0.25%) 2mg/kg with and without Inj.Dexmedetomidine (1-2μg/kg) intraarticularly for postoperative analgesia in arthroscopic knee surgery.1:To Evaluate Onset, Duration and analgesic efficacy of Intraarticular Dexmedetomidine2: To monitor the safety of Dexmedetomidine and Ropivacaine.
Methods: A prospective randomized double blind study, was conducted in 50 patients undergoing elective arthroscopy of knee joint under spinal anaesthesia. At the completion of the surgery, all patients were divied into two groups;GroupP(n=25):received Inj. Ropivacaine 0.25% and GroupD(n=25):received Inj.Ropivacaine(0.25%)+Inj. Dexmedetomidine(1μg/kg) total volume 20 ml was deposited intra-articularly.Patients were monitored in the postoperative ward for the hemodynamic parameters and their Sedation score was assessed.. The efficacy of the drug was determined by improvement in VAS score, duration of analgesia and total number of rescue analgesics during 24 hr in post operative period.
Results: There was no statistically significant differences observed in heart rate except changes at 6 and 8 hr. At 6 and 8 hr in group P pulse (82.48 ± 7.49, 81.44 ± 8.78) as compared to group D (75.38 ± 6.52, 74.96 ± 5.70),because of duration of action of ropivacaine with or without dexmedetomidine.There was no statistically significant difference in blood pressure was found, except at 12 hour and 24 hour (p=0.018), because of longer duration of action of intrarticular dexmedetomidine with ropivacaine in group D.At 6 hrs patients in Group P had a mean VAS score of 3.2 as compared to VAS score values of 1.8 in Group D which is statistically significant..At 2 , 4, 6 and 8 hour VAS score in P group was 1.64, 2.44, 3.24, 2.84 respectively. As compared to group P, in group D VAS score at 2, 4, 6 and 8 hour was 0.92, 1.04, 1.79 and 2.08 respectively. So VAS score lower in group D as compared to group P at 2, 4, 6 and 8 hrs.
A Prospective Study of Evaluation of Operative Duration as a Predictor of Mortality in Pediatric Emergency Surgery: Concept of 100 Minutes Laparotomy in Resource-limited Setting
Ketamine Injection USP 10mg/ml, 50mg/ml, 100mg/ml Taj Pharma: Uses, Side Effects, Interactions, Pictures, Warnings, Ketamine Dosage & Rx Info | Ketamine Uses, Side Effects Ketamine: Indications, Side Effects, Warnings, Ketamine -Drug Information –Taj Pharma, Ketamine dose Taj pharmaceuticals Ketamine interactions, Taj Pharmaceutical Ketamine contraindications, Ketamine price, Ketamine Taj Pharma Ketamine SmPC-Taj Pharma Stay connected to all updated on Ketamine Taj Pharmaceuticals Mumbai. Patient Information Leaflets, SmPC.
Effectiveness of intra-articular dexmedetomidine as postoperative analgesia i...iosrphr_editor
Background And Objectives: To study the effect of inj.Ropivacaine (0.25%) 2mg/kg with and without Inj.Dexmedetomidine (1-2μg/kg) intraarticularly for postoperative analgesia in arthroscopic knee surgery.1:To Evaluate Onset, Duration and analgesic efficacy of Intraarticular Dexmedetomidine2: To monitor the safety of Dexmedetomidine and Ropivacaine.
Methods: A prospective randomized double blind study, was conducted in 50 patients undergoing elective arthroscopy of knee joint under spinal anaesthesia. At the completion of the surgery, all patients were divied into two groups;GroupP(n=25):received Inj. Ropivacaine 0.25% and GroupD(n=25):received Inj.Ropivacaine(0.25%)+Inj. Dexmedetomidine(1μg/kg) total volume 20 ml was deposited intra-articularly.Patients were monitored in the postoperative ward for the hemodynamic parameters and their Sedation score was assessed.. The efficacy of the drug was determined by improvement in VAS score, duration of analgesia and total number of rescue analgesics during 24 hr in post operative period.
Results: There was no statistically significant differences observed in heart rate except changes at 6 and 8 hr. At 6 and 8 hr in group P pulse (82.48 ± 7.49, 81.44 ± 8.78) as compared to group D (75.38 ± 6.52, 74.96 ± 5.70),because of duration of action of ropivacaine with or without dexmedetomidine.There was no statistically significant difference in blood pressure was found, except at 12 hour and 24 hour (p=0.018), because of longer duration of action of intrarticular dexmedetomidine with ropivacaine in group D.At 6 hrs patients in Group P had a mean VAS score of 3.2 as compared to VAS score values of 1.8 in Group D which is statistically significant..At 2 , 4, 6 and 8 hour VAS score in P group was 1.64, 2.44, 3.24, 2.84 respectively. As compared to group P, in group D VAS score at 2, 4, 6 and 8 hour was 0.92, 1.04, 1.79 and 2.08 respectively. So VAS score lower in group D as compared to group P at 2, 4, 6 and 8 hrs.
A Prospective Study of Evaluation of Operative Duration as a Predictor of Mortality in Pediatric Emergency Surgery: Concept of 100 Minutes Laparotomy in Resource-limited Setting
Ketamine Injection USP 10mg/ml, 50mg/ml, 100mg/ml Taj Pharma: Uses, Side Effects, Interactions, Pictures, Warnings, Ketamine Dosage & Rx Info | Ketamine Uses, Side Effects Ketamine: Indications, Side Effects, Warnings, Ketamine -Drug Information –Taj Pharma, Ketamine dose Taj pharmaceuticals Ketamine interactions, Taj Pharmaceutical Ketamine contraindications, Ketamine price, Ketamine Taj Pharma Ketamine SmPC-Taj Pharma Stay connected to all updated on Ketamine Taj Pharmaceuticals Mumbai. Patient Information Leaflets, SmPC.
TIPS IBU BAPA CEMERLANG SELEPAS ANAK MEMBESAR-SMART PARENTING-KELUARGA BAHAGIA-ANAK SOLLEH-RUMAHKU SYURGAKU-KELUARGA SUNNAH-PANDUAN AKHKLAK ANAK CEMERLANG-KAEDAH ANAK BELAJAR-BERFIKIR HEBAT-KEM MOTIVASI REMAJA- KEM CUTI SEKOLAH- KEM PELAJAR CEMERLANG-
ORIGINAL ARTICLE HIP - ANESTHESIAA randomized controlled.docxgerardkortney
ORIGINAL ARTICLE � HIP - ANESTHESIA
A randomized controlled trial of postoperative analgesia following
total knee replacement: transdermal Fentanyl patches
versus patient controlled analgesia (PCA)
M. J. Hall1 • S. M. Dixon2 • M. Bracey3 • P. MacIntyre4 • R. J. Powell3 •
A. D. Toms3
Received: 13 November 2014 / Accepted: 12 February 2015 / Published online: 11 March 2015
� Springer-Verlag France 2015
Abstract
Background This randomized controlled trial compared a
standard patient controlled analgesic (PCA) regime with a
transdermal and oral Fentanyl regime for post-operative
pain management in patients undergoing total knee
replacement.
Methods One hundred and ninety-six patients undergoing
total knee replacement were recruited. Pre- and post-op-
eratively Visual Analogue Score (VAS), Oxford Knee
Score, Health Anxiety and Depression Score and Brief Pain
Inventory Score were completed. According to the day 1,
VAS score patients were randomly allocated to either a
PCA regime or a Fentanyl transdermal/oral regime. Patient
reported outcomes were measured until the patients were
discharged.
Results The results demonstrate that in terms of analgesic
effect, day of discharge and side effect profile the two
regimes are comparable.
Conclusions We conclude that a Fentanyl transdermal
regime provides adequate analgesic effect comparable to a
standard PCA regime in conjunction with a low side effect
profile. Using a transdermal analgesic system provides ef-
ficient continuous delivery enabling a smooth transition
from hospital to home within the first week. Transdermal
Fentanyl provides an alternative analgesic regime that can
provide an equivalent analgesic effect so as to enable a
satisfactory outcome for the patient in terms of function
and pain.
Level of evidence II.
Keywords Total knee replacement � Post-operative
analgesia � Patient controlled analgesia � Fentanyl patches
Introduction
Knee replacement surgery has proved a successful and
cost-effective method for relieving pain and restoring
function in patients with osteoarthritis [1]. However, pain
management after knee replacement surgery remains a
significant problem, with patients reporting this as a major
concern prior to surgery [2]. Implementing relevant pre-
operative screening methods may facilitate the identifica-
tion of individuals at high risk of experiencing high post-
operative pain [3]. Despite recent advances in the aetiology
of pain, improved pain treatments and the development of
clinical guidelines for pain assessment, the under-treatment
of post-operative pain remains a challenge to both surgeon
and anaesthetist. Recent studies have clearly demonstrated
that patient satisfaction following total knee replacement is
multifactorial with the most significant predictor of dis-
satisfaction being a painful total knee replacement [1].
Providing effective pain relief in the post-operative pe-
riod is essential to enable early mobili.
Preemptive Analgesia for Attenuation of Postoperative Pain in Patients Underg...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Antiemetic Prophylaxis in Major Gynaecological Surgery With Intravenous Grani...inventionjournals
In a prospective double blind randomized study we evaluated the prophylactic anti emetic efficacy of granisetron, a 5HT3 receptor antagonist and metoclopramide, a benzamide anti emetic on postoperative nausea and vomiting after major gynaecological surgery under general anaesthesia. The patients received a single dose of granisetron, 40mcg/kg (Group A, n = 25) or metoclopramide, 0.15mg/kg (Group B, n = 25) before induction of anaesthesia in a coded syringe. The response was assessed during 0-4 hrs, 4-8 hrs, 8-16hrs and 16-24 hrs time intervals after recovery from anaesthesia by means of presence or absence of nausea, retching or vomiting. The overall control of PONV during early postoperative period (0-4 hrs) did not show statistically significant differences after administration of either drug. The incidence of PONV during the next 20 hours was 12% and 48% with Group A (Granisetron) and Group B (Metoclopramide) respectively. Nausea scores are significantly lower in-group A (Granisetron) than in Group B (Metoclopramide) in all the four assessment periods. Although there were no emetic episodes in the granisetron group, 32% of patients in metoclopramide group were observed to have such episodes during the assessment periods. (P value< 0.05). No clinically important adverse events due to drugs were observed in any of the groups. In conclusion, the prophylactic use of granisetron is more effective and superior to metoclopramide in preventing postoperative nausea and vomiting in patients under going major gynaecological surgery under general anaesthesia.
Antiemetic Prophylaxis in Major Gynaecological Surgery With Intravenous Grani...inventionjournals
In a prospective double blind randomized study we evaluated the prophylactic anti emetic efficacy of granisetron, a 5HT3 receptor antagonist and metoclopramide, a benzamide anti emetic on postoperative nausea and vomiting after major gynaecological surgery under general anaesthesia. The patients received a single dose of granisetron, 40mcg/kg (Group A, n = 25) or metoclopramide, 0.15mg/kg (Group B, n = 25) before induction of anaesthesia in a coded syringe. The response was assessed during 0-4 hrs, 4-8 hrs, 8-16hrs and 16-24 hrs time intervals after recovery from anaesthesia by means of presence or absence of nausea, retching or vomiting. The overall control of PONV during early postoperative period (0-4 hrs) did not show statistically significant differences after administration of either drug. The incidence of PONV during the next 20 hours was 12% and 48% with Group A (Granisetron) and Group B (Metoclopramide) respectively. Nausea scores are significantly lower in-group A (Granisetron) than in Group B (Metoclopramide) in all the four assessment periods. Although there were no emetic episodes in the granisetron group, 32% of patients in metoclopramide group were observed to have such episodes during the assessment periods. (P value< 0.05). No clinically important adverse events due to drugs were observed in any of the groups. In conclusion, the prophylactic use of granisetron is more effective and superior to metoclopramide in preventing postoperative nausea and vomiting in patients under going major gynaecological surgery under general anaesthesia.
To Evaluate the Role of Inj. Ketamine (0.3mg/Kg) Intravenously, Before Skin I...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Pregabalin is an effective and safe adjuvant for reducing chronic
post-thoracotomy pain, without significant side effects, in all age
groups and either gender. The pain relief becomes statistically
significant after three weeks of treatment and it continues till six
months. However, larger randomized and placebo-controlled trials
of longer durations are required to further validate these findings.
To improving postoperative pain management, we need to;
- Always applies multi-modal analgesia. (get the advantages of multimodal analgesia)
- Implementation of the existing EB regarding the use of non-opioid + opioid on as needed basis.
- Use available specific evidence for optimizing multimodal pain management procedure (PROSPECT Web site).
Total knee replacement post op pain control protocol for surgeons Al Razi Ort...Farah Jafri
This is the information sheet for surgeons at Al Razi Orthopedic Hospital interested in knowing about the acute pain protocol for Total Knee Replacement.
Acute pain management requires a multimodal and multidisciplinary approach with a clear organization framework. Regional anesthesia techniques for surgical anesthesia are a highly effective component of acute pain management.
With the advancement of ultrasonographic technology with higher resolution and penetration imaging, there is increasing use of ultrasonography (US) in acute and chronic pain blocks.
Similar to 8. Intra articular Tramadol and morphine article (20)
Prof. Darto - regional analgesia as modality in aps
8. Intra articular Tramadol and morphine article
1. N e p a l O r t h o p e d i c A s s o c i a t i o n J o u r n a l14
NOAJ Jan-July 2013|Vol 3| Issue 1Original Article
INTRODUCTION
Arthroscopic knee surgery is one of the most common
surgical procedures done in an outpatient basis.
Postoperativelyimprovedpaincontrolofpatientshasmade
this surgery as a day care procedure, reducing patient’s
expenses and hospital staffs work load1
. Various analgesic
drugs have been administered into the joint following
this type of surgery. Intra-articular injection of morphine
following knee arthroscopy has been practiced in many
centres all over the world. Morphine is an opioid agonist
drug and it has long been known to relieve severe pain
with remarkable efficacy2
. Tramadol is a synthetic codeine
analog that is a weak opioid receptor agonist. Generally
opioids also can produce analgesia when administered
peripherally,sincethesereceptorsarepresentonperipheral
nerves and will respond to peripherally applied opioids
and locally released endogenous opioid compounds
when up-regulated during inflammatory pain states3
. Part
of tramadols analgesic effect is produced by inhibition
of uptake of norepinephrine and serotonin, which are
neurotransmitters in neuronal circuit responsible for pain
and many other actions.4
And hence beign having local
anaesthetic effect that is not opioid receptor related.5-6
Tramadol’s analgesic effect has been equated with that
of morphine, with a more favorable side-effect profile for
tramadol including less respiratory depression, nausea
and vomitting7
. Whether opioid and nonopioid actions
of tramadol would provide superior peripheral analgesia
compared with opioid morphine needs to be explored.
The aim of the study was to compare the analgesic effect
of intra-articular (IA) tramadol with IA morphine.
AnalgesicEffectofIntraarticularTramadolwithMorphine
after Arthroscopic Knee Surgery
Hussain Faisal1
, Arjun Lamichhane1
, Deepak Mahara1
.
1
Department of Orthpaedics and Trauma Surgery. Institute of Medicine Tribhuvan University,
Kathmandu, Nepal
ABSTRACT
Introduction: Post-operative improved pain control of patients has made arthroscopy as a day care procedure,
reducing patient’s expenses and hospital staffs work load. Various analgesic drugs have been administered into the
joint following Arthroscopy. Intra-articular injection of morphine has been practiced in many centres all over the
world. We aimed to compare the efficacy of intra-articular tramadol and morphine. Tramadol is an opioid drug with
similar analgesic properties like morphine. Tramadol unlike morphine is readily available over the counter not being
abused and has more favourable side effects.
Methods: It was a prospectively randomized double-blind study in which sixty patients having elective arthroscopic
surgery of the knee were randomized into two groups. Group A (Tramadol Group) received intra-articular tramadol
50mg and Group B (Morphine Group) received morphine 5mg in equivalent volumes. Post-operative pain using
Visual Analogue Score (VAS) between 0 and 10, (0 no pain to 10 worst pain) requirement of first analgesic, and
incidence of side effects were recorded postoperatively at intervals of 3,4,5,6 and 24 hours.
Results: The assessment of VAS score among the two groups in 3,4,5,6 and 24 hours of IA injection showed a p
value of 0.349, 0.807, 0.676, 0.271 and 0.163 respectively, suggesting non significant difference in two groups. There
was statistically significant result (p=0.005) for request of first analgesia (Ibuprofen 400mg+ Paracetalmol 500mg)
at 6 hours of IA injection with tramadol group, requiring less analgesics. There are no other clinically important
differences between the groups, including preoperative duration of symptoms, postoperative pain scores and side
effects irrespective of the diagnosis and the procedure performed.
Conclusion: 50 mg IA tramadol provides analgesia equivalent to 5 mg IA morphine.
Key Words: Analgesic; Intra-articular; Morphine; Pain; Postoperative.
Correspondence
Dr. Hussain Faisal
Department of Orthopaedics and Trauma Surgery
Institute of Medicine, Tribhuvan Unversity Teaching
Hospital.Kathmandu, Nepal
Email: hussain_phaisal@hotmail.com
2. NOAJ Jan-July 2013|Vol 3| Issue 1
N e p a l O r t h o p e d i c A s s o c i a t i o n J o u r n a l 15
METHODS
After ethical committee approval, informed written
consent was obtained from 60 patients who fulfill the
inclusion criteria to undergo elective knee arthroscopic
surgery. Standard general anaesthesia was given to all
the cases. A short-acting opioids (fentanyl) was used
and general anesthesia was maintained with halothane
and oxygen at the beginning of the operation. No non-
steroidal anti-inflammatory drugs or additional pain
medications were administered. All the arthroscopies
were performed under tourniquet application on thigh
and by two orthopaedic surgeons trained in arthroscopic
surgery in department of orthopaedics and trauma, TUTH.
Two standard portals (anteromedial and anterolateral) or
more was_used.
Patients aged between 15 to 70 years, who under
went diagnostic arthroscopies, Arthroscopic meniscal
excision or repair, Arthroscopic removal of loose
bodies, Arthroscopic debridement or combination of
these procedure were included in the study. Those who
required Epidural or spinal anaesthesia, Allergies to
local anaesthetic or opioids, Ligament reconstruction
and articular cartilage procedures, Cases of extensive
arthroscopic synovectomy, Severe cardiovascular,
respiratory, metabolic or neurological diseases,
Postoperative splinting and pregnant were excluded from
this study.
At the conclusion of surgery, patients were randomized
to a particular group, Group A (Tramadol Group -30
patients) and Group B (Morphine Group - 30 patients)
and the appropriate study drug was injected into the
knee by the surgeon, who was blinded to its contents.
The study drug prepared by the scrub nurse, who keeps
the record of injection, was injected before the release
of tourniquet. All cases were observed by the author
who was also blinded and recorded pain, supplemental
analgesic requirements, and incidence of side effects at
3,4,5,6 and 24 hours post-operatively. Post-operative
pain was assessed using Visual Analogue Score (VAS)
between 0 and 10, (0 no pain to 10 worst pain). Pain score
was assessed in the recovery room for 6 hours. In case of
need of supplementary analgesics, Ibuprofen 400 mg plus
500mg paracetamol was administered orally. In the event
that there was no pain relief, 75 mg diclofenac was injected
intramuscular. The time to the first request for analgesia
and the total analgesic consumption was recorded for
24 hours duration at intervals of 3,4,5,6, and 24 hours.
At the time of discharge the patients were instructed to
take oral analgesic combination of Ibuprofen 400mg +
paracetamol 500mg, as required for a maximum of 8
hourly intervals. The patients were discharged from the
recovery room after 6 hours with a copy of VAS to record
pain at home at 24 hours of intra-articular injection. The
final VAS recording was taken when the patient returns to
OPD on the 4th
or 5th
day of surgery.
Demographic data, distribution of sex, preoperative
symptoms and post-operative analgesic consumption in
two groups were analyzed by analysis of variance and
comparedbyapplyingchi-squaretest.Comparisonofmean
VAS in two groups was done by applying independent t-
test. The Fisher's Exact test was used to compare analgesic
requirements and side effects. A probability of P <.05 was
considered statistically significant.
RESULT
There were no significant differences among the two
groups with respect to age, sex, duration of pre-operative,
VAS score for pain at the specified intervals, Table1.
Table1. Demographic Variables
Characteristics Tramadol Morphine p
Age
30.30
± 12.69
30.63
± 9.23
0.908
Sex (M/F) 21/9 20/10 0.780
Side (Right/
Left)
17/13 15/15 0.605
Duration of
pre-operative
symptoms*
9.47
± 6.87
18.83
± 30.30
0.576
*Duration of pre-operative symptoms in months
Post-operative VAS for both groups at 3,4,5 and 6 hours
of intra-articular injection range from 3.00 to 4.13
(moderate pain) and their p values were statistically not
significant. The post-operative VAS for both groups at 24
hours range from 2.07 to 2.67 (mild pain). This is also not
significant statistically for both groups, Table 2
Two patients (6.7%) required first oral analgesic
(Ibuprofen400mg + paracetamol 500mg) in Group
A (Tramadol) at six hours of intra-articular injection
while eleven patients (36.7%) requested from Group B
(Morphine) during the same interval, Table 3. These
results are statistically significant. P=0.005. All other
intervals of analgesic consumption are not significant
including oral and injectible analgesic.
When postoperative VAS at interval of 3,4,5,6 and 24
hours of intra-articular injection was correlated with
duration of pre-operative symptoms within the two groups
all the results were not significant among the groups. This
shows that there is no significant difference of analgesia
with tramadol or morphine at these hours of intra-articular
injection irrespective of preoperative symptom.
3. N e p a l O r t h o p e d i c A s s o c i a t i o n J o u r n a l16
NOAJ Jan-July 2013|Vol 3| Issue 1
DISCUSSION
Post operative pain management with intra-articular
analgesic injection following knee arthroscopy has been
practiced many centeres.7-10
Analgesics with different
doses and different combinations have been applied to
provide optimum analgesia to patients undergoing knee
arthroscopy.7,11
Out of those combinations an ideal drug
with properties of good analgesic control, less systemic
side effect is to be identified. Further more, requirement
of additional analgesic is to be explored. Morphine has
good analgesic control when injected intra-articularly
following knee arthroscopy.8,11
However nausea vomiting
and respiratory depression are common side effects
of morphine. Tramadol is an opioid drug with similar
properties of morphine but causes less side effects
like nausea, vomiting and respiratory depression.12
Intra-articular local anaesthetics are often used for the
management and prevention of pain after arthroscopic
knee surgery, with bupivacaine most commonly used.13,14
However, because of their high systemic absorption, short
duration of effect, their uses are of limited bennefit.7,13,15
Stein et al.9
reported the intra-articular morphine-induced
analgesia in patients after arthroscopic knee surgery.
Since then many workers established that intra-articular
opioids produce a profound anti-nociceptive effect and
it has been widely used intra-articularly with or without
local anaesthetics for the management of pain after
arthroscopic knee surgery.6,8,15
Opioid receptors have
long been recognized in the brain and central nervous
system, but have only recently been demonstrated in the
periphery on nerve endings.16-20
Stein and his colleagues9
provided the first clinical evidence of the peripheral
action of opioids, showing that anti-nociceptive effect of
intra-articular morphine was blocked by intra-articular
naloxone. The peripheral opioid action involves a number
of mechanisms, including inhibition of action potentials
in pain fibres16,21
and inhibition of the release of excitatory
substance P.16,22
Action on Post-ganglionic nerve terminals
blocks the release of several sensitizing prostanoids,
which may be important in sympathetically maintained
pain syndrome.23
We did not use control case because tramdol is an opioid
drug with similar actions like morphine and several studies
has shown analgesic effect of morphine when injected
intra-articularly. Mahara DP et al10
concluded that low
dose (2mg) intra-articular morphine injection is a good
alternativetootherpainmanagementmodalitiesespecially
for day care patients following arthroscopic knee surgery.
In a similar study like our study by S. B. Akinci et al11
,
conclude that tramadol 50mg and morphine 5mg provide
similar analgesia when given intra-articularly.
We did not observe significant differences in results
between intra-articular tramadol 50mg and 5 mg morphine
with respect to pain using VAS system, and side effects.
There was less analgesic requirement in tramadol group
with significant result for patients who required first
analgesic (Ibuprofen 400mg + Paracetamol 500mg) at 6
hours postoperatively, P = 0.005, Table 3. This may be due
to longer half life of the tramadol, more potent efficacy of
Table 2. Visual Analogue Score at different time period
VAS Tramadol Morphine P
VAS at 3 hours 4.13±1.78 3.67±2.04 0.349
VAS at 4 hours 3.63±1.56 3.73±1.60 0.807
VAS at 5 hours 3.27±1.46 3.43±1.61 0.676
VAS at 6 hours 3.00±1.51 3.47±1.74 0.271
VAS at 24 hours 2.07±1.36 2.67±1.88 0.163
VAS (Visual Analogue Score) at rest
Table 3. Comparative characteristics of Both the Groups.
Characteristics Tramadol Morphine P
Patients not requiring any extra analgesics 15(60%) 10(40%) 0.69
Patients required extra analgesics 15(43%) 20(57%) 0.190
Oral analgesics at 3 hours of post-op 3(10%) 3(10%) 1.00
Oral analgesics at 4 hours of post-op 3(10%) 3(10%) 1.00
Oral analgesics at 5 hours of post-op 2(6.7%) 0 0.47
Oral analgesics at 6 hours of post-op 2(6.7%) 11(36.7%) 0.005
Oral analgesics at 24 hours of post-op 13(43.3%) 16(53.3%) 0.43
I.M Diclofenac 75mg injection 3(10%) 3(10%) 1.00
Side effects (Nausea/Vomiting) 1(3.3%) 0 0.50
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N e p a l O r t h o p e d i c A s s o c i a t i o n J o u r n a l 17
metabolites and multiple mechanism of analgesic effect.24
The average duration of symptoms was 14.15 months.
Most symptomatic knees, 48 (80%) were within one year
of duration. Within this duration we expected patients to
have increased opioid receptors as well as inflammation
significantly. We observed that all patients in both groups
had VAS range 3 - 4.13 (moderate pain), till six hours of
post operatively and at 24 hours mean VAS range was
2.07 – 2.67 (mild pain). This persisting pain could be due
to chronic inflammatory mediators which have built up
within the knee joint.
Injury to the sensitive structures in the knee joint and
inflammation cause C and A-δ fibers to undergo changes
such as sensitization, increased activity in normally silent
nociceptors.2
Likar et al25
mentioned increasing duration
of symptoms increases the number of receptors in the
inflamed tissues. Several workers26.27
have demonstrated
that increased duration increase number of receptors in
the synovium. Most severe acute pain can usually be well
controlled with significant but tolerable adverse effects
with currently available opioid analgesics. However,
chronic pain is not very satisfactorily managed with
opioids.2
The moderate pain which persisted till 6 hours in
both groups and the mild pain which persisted at 24 hours
in both groups could be due to pain from the inflammatory
mediators.
Three patients in each group had severe pain at three
hours of intra-articular injection and received first
analgesic i.m diclofenac 75mg injection, P= 1, and it
was statistically not significant. Out of these six patients,
three patients did not take any other analgesic during the
24 hours. One patient consumed further three doses of
oral analgesic during the 24 hours duration. This could
be due to the inflammatory pain which either persisted
from the preoperative symptoms or after the arthroscopic
procedure, in which the opioid drugs has limited action.
Despite the combination of different analgesic mechanism
of tramadol, we could not find any superiority between
intra-articular tramadol and intra-articular morphine with
respect to VAS score, preoperative symptoms and side
effects. However tramadol, unlike morphine is readily
available over the counter, not being abused and have
more favourable side effects. In future further studies,
with larger number of patients are needed to compare
the side effects of intra-articular administered morphine
and tramadol. We believe that intra-articular tramadol
can be an alternative to intra-articular morphine for post-
operative analgesia after arthroscopic knee surgery.
CONCLUSION
We conclude that 50 mg intra-articular tramadol provides
analgesia equivalent to 5 mg intra-articular morphine.
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