Acta Anaesthesiol &and 1992: 36: 643-646
Intra-articular bupivacaine plus adrenaline for arthroscopic surgery of the knee J. P. GYRN,K.
s. OLSEN, E. APPELQUIST', B. CHRAEMMER-JQRGENSEN, B. DUUs' and L. BERNERHANSEN'
Departments of Anaesthesiology and 'Orthopaedic Surgery, Glostrup Hospital, University of Copenhagen, Glostrup, Denmark
The purpose of the study was to evaluate three different doses of intra-articular bupivacaine plus adrenaline in relation to per- and postoperative pain relief following arthroscopy. Sixty patients were allocated to three groups of 20 patients each scheduled for arthroscopy. They were randomized prospectively to receive bupivacaine plus adrenaline 25 mg+ 50, pg, 50 mg+ 100 pg, 75 mg+ 150 pg, respectively, diluted to a volume of 30 ml. Four patients were excluded because the operation could not be carried out under intraarticular analgesia, I8 patients had a diagnostic arthroscopy and 38 patients had different arthroscopic operations performed. The number of patients scoring pain in the knee as moderate or severe was less in Group 3 than in the other two groups, i.e. the highest dose had a better pain relief. No adverse effects were registered. With respect to per- or postoperative administration of analgesics, postoperative pain occurrence, and the surgeon's acceptance of the method, there were no statistically significant differences. Ninety-two percent of the patients would prefer intraarticular analgesia if they should need to have another arthroscopy performed. Received 5 October 1991, acceptedfor publication 7 February 1992
Key words: Anesthesia, local: bupivacaine, intra-articular injection; anesthetics, local: bupivacaine; anesthetic techniques, local: knee arthroscopy.
Arthroscopy is often performed under spinal, epidural or general anaesthesia (1). In recent years, however, intra-articular analgesia (IAA) with different volumes and concentrations of local anaesthetics has been introduced for arthroscopy (2-6). Although IAA has become an increasingly popular technique, only a few studies have dealt with intra-articular (IA) bupivacaine as the local anaesthetic (7-9). Only one of these studies was controlled and double-blind. It dealt with the absorption of 0.25%, 0.5%, and 0.75% solutions of bupivacaine during arthroscopy (9). It has been shown that adrenaline added to IA bupivacaine reduces the plasma concentration of bupivacaine (7). In an attempt to establish the lowest dose giving effective analgesia and a minimum of side-effects, the present study was designed to examine, in a controlled doubleblind way, the per- and postoperative analgesic effect of three different, quite small doses of IA bupivacaine with adrenaline for diagnostic arthroscopy and arthroscopic surgery of the knee joint. PATIENTS AND METHODS Sixty patients (ASA physical status I or 11) scheduled for arthroscopic examination and possible arthroscopic surgery of one knee were included in the study. All patients gave informed consent according
to the Helsinki 2 declaration. The study was approved by the regional ethics committee and the Danish health authorities. The study was carried out as a prospective randomized doubleblind study. Arthroscopy was performed by three experienced orthopaedic surgeons. The patients were randomized, by drawing an envelope containing the number 1, 2 or 3, to one of three groups, receiving IA bupivacaine (B) with adrenaline (A) B 25 mg and A 50 pg (Group I ) , B 50 mg and A 100 pg (Group 2), or B 75 mg and A 150 pg (Group 3), diluted in isotonic saline to a total volume of 30 ml. One hour before surgery all patients were premedicated with oral diazepam (Tabl. Stesolid") 2 mg/lO kg. Blood pressure and EGG were monitored in the operating room and all patients had a cannula placed in a peripheral vein. The skin at the puncture sites (1.5 cm proximal to the tibia1 condyles on the medial and the lateral side of the patella tendon, as well as close to the upper-lateral corner of the patella) was injected with 1% lidocaine 4 ml at each side. Then IA injection, according to the allocation, was made over 30 s through one of the anaesthetized skin portals. The knee was flexed 5 times to achieve an even distribution. No tourniquet was used. Fifteen minutes after the IA injection the arthroscope was introduced into the knee joint, which was continuously flushed with isotonic saline. The total amount of flushing fluid was recorded. If the patient had pain during the procedure, an analgesic was offered. If the patient accepted the offer, alfentanil (Rapifen"), 0.5 mg i.v. was administered. Five minutes later the patient was asked whether another dose of the analgesic was necessary. In this case additional alfentanil 0.5 mg i.v. was administered. No further analgesics were administered. If the patient continued to have unacceptable pain, general anaesthesia was given.
644
J. P. GYRN E T AL.
Postoperatively the patient scored for worst intraoperative pain in the knee and leg (by manipulation of the leg), respectively. The pain was assessed on a four-point scale: none, slight, moderate, or severe pain. The surgeon was asked about the acceptability of the method (bad, moderate, good, excellent). Postoperatively the patient was transported directly to the ward. If the patient had pain, paracetamol 1 g orally was offered. If this proved insufficient, sublingual buprenorphine (Temgesic@)0.2 mg was offered. The time from the end of operation to pain occurrence and the total amount of analgesics administered during the first 24 postoperative hours were registered. After 24 h the patients were asked if they would have the same type of regional analgesia, should they need another arthroscopy.
Statistics The X’-test or Kruskal-Wallis one-way analysis of variance by ranks was used to compare sex, type of surgery, and other patient data as appropriate. The statistical significance of differences in pain score, duration of surgery and surgeon’s evaluation between groups was analysed by the Kruskal-Wallis test. A P-value of less than 0.05 was considered statistically significant.
RESULTS Four patients were excluded from the study. Three of these required general anaesthesia (one had spasms of the quadriceps musculature (Group l ) , one had a “tight knee” (no room for the arthroscope) making arthroscopy impossible (Group l ) , and one had a large loose body IA, removal of which required arthrotomy (Group 3 ) ) . One (Group 3) had an arthrotomy after supplement of local analgesia (large loose body IA). There was no statistically significant difference regarding the time from IA injection to final flushing of the knee, duration of arthroscopy, or the percentage of arthroscopic surgery in relation to the total number Table 1 Patient and operative data. Values are median (range), except for sex and surgical procedure which are patient counts. There was a difference in age between groups (P=0.03). Differences between other parameters were not statistically significant. Few patients had more than one operative procedure performed.
Age (years) Weight (kg) Sex (M/F) Surgery duration (min) Operative/diagnostic Operations performed: Plica resection Loose body removed Debridement (patellae) Flap tear in meniscus Bucket handle lesion Lateral release Meniscus trimmed Partial meniscectomy Total miniscectomy Suture of meniscus Excision of cartilage
Group 1
Group 2
Group 3
37 ( 1 7-50) 67 (53-84) 9/9 36 ( 13-90) 13/5
27 (18-47) 70 (48-94) 11/9 3.5 (14-63) 13/7
28 (18-48) 68 (47-101) 6/12 27 ( 15-48) 9i9
4 I
3
5 1
I
1
3
5
2
I I
2 2
4 1
1 1
1
I
1 2
of arthroscopies in each group (72%, 65%, and 50%, respectively) (Table 1). Peroperative pain scores in both knee and leg were similar in the three groups (P>O.O5) (Table 2). However, as regards patients with severe and moderate pain in the knee, there were nine and eight respectively i n Group 1 and 2, but only one in Group 3 (P
Intra-articular bupivacaine plus adrenaline for arthroscopic surgery of the knee J. P. GYRN,K.
s. OLSEN, E. APPELQUIST', B. CHRAEMMER-JQRGENSEN, B. DUUs' and L. BERNERHANSEN'
Departments of Anaesthesiology and 'Orthopaedic Surgery, Glostrup Hospital, University of Copenhagen, Glostrup, Denmark
The purpose of the study was to evaluate three different doses of intra-articular bupivacaine plus adrenaline in relation to per- and postoperative pain relief following arthroscopy. Sixty patients were allocated to three groups of 20 patients each scheduled for arthroscopy. They were randomized prospectively to receive bupivacaine plus adrenaline 25 mg+ 50, pg, 50 mg+ 100 pg, 75 mg+ 150 pg, respectively, diluted to a volume of 30 ml. Four patients were excluded because the operation could not be carried out under intraarticular analgesia, I8 patients had a diagnostic arthroscopy and 38 patients had different arthroscopic operations performed. The number of patients scoring pain in the knee as moderate or severe was less in Group 3 than in the other two groups, i.e. the highest dose had a better pain relief. No adverse effects were registered. With respect to per- or postoperative administration of analgesics, postoperative pain occurrence, and the surgeon's acceptance of the method, there were no statistically significant differences. Ninety-two percent of the patients would prefer intraarticular analgesia if they should need to have another arthroscopy performed. Received 5 October 1991, acceptedfor publication 7 February 1992
Key words: Anesthesia, local: bupivacaine, intra-articular injection; anesthetics, local: bupivacaine; anesthetic techniques, local: knee arthroscopy.
Arthroscopy is often performed under spinal, epidural or general anaesthesia (1). In recent years, however, intra-articular analgesia (IAA) with different volumes and concentrations of local anaesthetics has been introduced for arthroscopy (2-6). Although IAA has become an increasingly popular technique, only a few studies have dealt with intra-articular (IA) bupivacaine as the local anaesthetic (7-9). Only one of these studies was controlled and double-blind. It dealt with the absorption of 0.25%, 0.5%, and 0.75% solutions of bupivacaine during arthroscopy (9). It has been shown that adrenaline added to IA bupivacaine reduces the plasma concentration of bupivacaine (7). In an attempt to establish the lowest dose giving effective analgesia and a minimum of side-effects, the present study was designed to examine, in a controlled doubleblind way, the per- and postoperative analgesic effect of three different, quite small doses of IA bupivacaine with adrenaline for diagnostic arthroscopy and arthroscopic surgery of the knee joint. PATIENTS AND METHODS Sixty patients (ASA physical status I or 11) scheduled for arthroscopic examination and possible arthroscopic surgery of one knee were included in the study. All patients gave informed consent according
to the Helsinki 2 declaration. The study was approved by the regional ethics committee and the Danish health authorities. The study was carried out as a prospective randomized doubleblind study. Arthroscopy was performed by three experienced orthopaedic surgeons. The patients were randomized, by drawing an envelope containing the number 1, 2 or 3, to one of three groups, receiving IA bupivacaine (B) with adrenaline (A) B 25 mg and A 50 pg (Group I ) , B 50 mg and A 100 pg (Group 2), or B 75 mg and A 150 pg (Group 3), diluted in isotonic saline to a total volume of 30 ml. One hour before surgery all patients were premedicated with oral diazepam (Tabl. Stesolid") 2 mg/lO kg. Blood pressure and EGG were monitored in the operating room and all patients had a cannula placed in a peripheral vein. The skin at the puncture sites (1.5 cm proximal to the tibia1 condyles on the medial and the lateral side of the patella tendon, as well as close to the upper-lateral corner of the patella) was injected with 1% lidocaine 4 ml at each side. Then IA injection, according to the allocation, was made over 30 s through one of the anaesthetized skin portals. The knee was flexed 5 times to achieve an even distribution. No tourniquet was used. Fifteen minutes after the IA injection the arthroscope was introduced into the knee joint, which was continuously flushed with isotonic saline. The total amount of flushing fluid was recorded. If the patient had pain during the procedure, an analgesic was offered. If the patient accepted the offer, alfentanil (Rapifen"), 0.5 mg i.v. was administered. Five minutes later the patient was asked whether another dose of the analgesic was necessary. In this case additional alfentanil 0.5 mg i.v. was administered. No further analgesics were administered. If the patient continued to have unacceptable pain, general anaesthesia was given.
644
J. P. GYRN E T AL.
Postoperatively the patient scored for worst intraoperative pain in the knee and leg (by manipulation of the leg), respectively. The pain was assessed on a four-point scale: none, slight, moderate, or severe pain. The surgeon was asked about the acceptability of the method (bad, moderate, good, excellent). Postoperatively the patient was transported directly to the ward. If the patient had pain, paracetamol 1 g orally was offered. If this proved insufficient, sublingual buprenorphine (Temgesic@)0.2 mg was offered. The time from the end of operation to pain occurrence and the total amount of analgesics administered during the first 24 postoperative hours were registered. After 24 h the patients were asked if they would have the same type of regional analgesia, should they need another arthroscopy.
Statistics The X’-test or Kruskal-Wallis one-way analysis of variance by ranks was used to compare sex, type of surgery, and other patient data as appropriate. The statistical significance of differences in pain score, duration of surgery and surgeon’s evaluation between groups was analysed by the Kruskal-Wallis test. A P-value of less than 0.05 was considered statistically significant.
RESULTS Four patients were excluded from the study. Three of these required general anaesthesia (one had spasms of the quadriceps musculature (Group l ) , one had a “tight knee” (no room for the arthroscope) making arthroscopy impossible (Group l ) , and one had a large loose body IA, removal of which required arthrotomy (Group 3 ) ) . One (Group 3) had an arthrotomy after supplement of local analgesia (large loose body IA). There was no statistically significant difference regarding the time from IA injection to final flushing of the knee, duration of arthroscopy, or the percentage of arthroscopic surgery in relation to the total number Table 1 Patient and operative data. Values are median (range), except for sex and surgical procedure which are patient counts. There was a difference in age between groups (P=0.03). Differences between other parameters were not statistically significant. Few patients had more than one operative procedure performed.
Age (years) Weight (kg) Sex (M/F) Surgery duration (min) Operative/diagnostic Operations performed: Plica resection Loose body removed Debridement (patellae) Flap tear in meniscus Bucket handle lesion Lateral release Meniscus trimmed Partial meniscectomy Total miniscectomy Suture of meniscus Excision of cartilage
Group 1
Group 2
Group 3
37 ( 1 7-50) 67 (53-84) 9/9 36 ( 13-90) 13/5
27 (18-47) 70 (48-94) 11/9 3.5 (14-63) 13/7
28 (18-48) 68 (47-101) 6/12 27 ( 15-48) 9i9
4 I
3
5 1
I
1
3
5
2
I I
2 2
4 1
1 1
1
I
1 2
of arthroscopies in each group (72%, 65%, and 50%, respectively) (Table 1). Peroperative pain scores in both knee and leg were similar in the three groups (P>O.O5) (Table 2). However, as regards patients with severe and moderate pain in the knee, there were nine and eight respectively i n Group 1 and 2, but only one in Group 3 (P
