Chapter 32 Intra-Articular and Intraperitoneal Opioids for Postoperative Pain Flashcards
KEY POINTS 1. IA morphine, in some studies, has been shown to provide improved analgesia after knee arthroscopy when compared to local anesthetic alone or to saline placebo. 2. IA morphine may be more beneficial for use in “high inflammatory” arthroscopic knee surgery (e.g., anterior cruciate ligament reconstruction, lateral release, patellar shaving, and plicae removal) than for use in “low-inflammatory” surgery (knee arthroscopy for meniscectomy). 3. IA morphine has not shown promising res
intra-articular NSAIDs
NSAIDs have consistently demonstrated a benefit in modulating postoperative
pain when injected IA, yet there is a concern that
they may inhibit or retard bone healing
intra-articular Clonidine
use of the alpha-2 agonist clonidine IA has demonstrated a modest and limited reduction in postoperative pain, although the same controversy exists as to whether these benefits are
mediated systemically or are local phenomena
The effects of IA opioids may be mediated through
the G-protein–coupled receptors affecting the cAMP pathway. Stimulation of chondrocytes with beta-endorphin resulted in decreased phosphorylation of
the transcription factor cAMP responsive element binding
protein (CREB), an effect reversible by naloxone
Benefit of IA morphine added as a component of multimodal analgesia following arthroscopic ankle surgery
there was a significant reduction in pain, joint swelling, time of immobilization, duration of sick leave, and return to physical activity.
Meperidine
synthetic opioid agonist at m- and k-opioid receptors derived from phenylepiperidine
Structurally, meperidine
is similar to
atropine, and it possesses a mild atropine-like
antispasmodic effect.
Meperidine vs. Morphine
It is about one-tenth as potent as morphine and its duration of pharmacologic action is
about 2 to 4 hr.
IA Meperidine
Meperidine has been injected IA in doses of 10 to 200 mg, alone or in combination with local anesthetics and tenoxicam.
Fentanyl vs. Morphine
fentanyl is about 75 to 100 times more potent than morphine. A single dose of fentanyl administered intravenously has a more rapid onset than morphine and a
shorter duration of clinical effect, although the elimination
half-life is longer than that of morphine.
IA Fentanyl
IA bupivacaine was noted to provide superior analgesia
compared to IA fentanyl in the immediate postoperative
period, for up to 2 hr, following knee arthroscopy
Sufentanil vs Fentanyl
sufentanil has a greater affinity for opioid receptors than fentanyl,and is about 12 times as potent. Sufentanil is extensively protein bound (92.5% vs. fentanyl at 79% to 87%) and is highly lipid soluble. Its elimination half-life is intermediate between that of fentanyl and alfentanil
IA Sufentanil and Fentanyl
conclusion, IA fentanyl analgesia in doses up to 100 mg
or sufentanil up to 10 mg both appear to be modestly
successful in modulating nociception after knee arthroscopy.
Tramadol
Tramadol is a synthetic narcotic with a weak mu-receptor
agonist activity. It also enhances the function of the spinal
descending inhibitory pathway by inhibition of reuptake
of both 5-hydroxytryptamine (5-HT) and norepinephrine
and stimulate the presynaptic release of 5-HT
IA tramadol
IA tramadol 100 mg appears to
have analgesic effects after knee arthroscopies and medial
meniscectomies.
order of IP (intraperitoneally) potencies
remifentanil > alfentanil > morphine, while
the duration of analgesia was morphine > > alfentanil >
remifentanil
