|Year : 2017 | Volume
| Issue : 1 | Page : 253-257
The effects of adding dexamethasone to intra-articular morphine injection on postoperative pain after knee arthroscopy
Abd-Elazeem A El Bakry, Wesam-Eldin A Sultan
Lecturer of Anesthesia, Anesthesia Department, Faculty of Medicine, El Menoufia University, Egypt
|Date of Web Publication||3-Aug-2018|
Abd-Elazeem A El Bakry
Lecturer of Anesthesia, Anesthesia Department, Faculty of Medicine, Yassine Abd El Ghafar Street, El Menoufia Governorate-Shibin El Kom
Source of Support: None, Conflict of Interest: None
Background Postoperative analgesia after knee arthroscopy is mandatory for recovery and early rehabilitation. Medications were used intra-articularly to prolong postoperative analgesia and improve the quality of pain. The present study was scheduled to study the effects of dexamethasone addition to intra-articular morphine on postoperative pain after knee arthroscopy.
Patients and methods This randomized double-blinded controlled study was carried out on 90 patients undergoing knee arthroscopy. The patients were randomly allocated into three equal groups. All medications were injected intra-articularly at the end of surgery. In the control group, the patients were administered 0.5% bupivacaine in normal saline. In M group, the patients were administered 5 mg morphine added to bupivacaine 0.5%. In MD group, the patients were administered 5 mg morphine and 8 mg dexamethasone added to bupivacaine 0.5%. Vital signs, visual analog score for pain at rest and movement, duration of analgesia, total analgesic consumption and adverse effects were recorded.
Results MD Group showed lower visual analog score at rest and movement, prolonged postoperative analgesia, and decreased total analgesic consumption compared with the other groups (P<0.05).
Conclusion The addition of dexamethasone to intra-articular morphine after knee arthroscopy prolongs the duration of analgesia, lowers pain scores, and decreases total analgesic consumption with minimal adverse effects.
Keywords: dexamethasone, knee arthroscopy, local anesthetics, morphine, postoperative analgesia
|How to cite this article:|
El Bakry AEA, Sultan WEA. The effects of adding dexamethasone to intra-articular morphine injection on postoperative pain after knee arthroscopy. Ain-Shams J Anaesthesiol 2017;10:253-7
|How to cite this URL:|
El Bakry AEA, Sultan WEA. The effects of adding dexamethasone to intra-articular morphine injection on postoperative pain after knee arthroscopy. Ain-Shams J Anaesthesiol [serial online] 2017 [cited 2021 Sep 23];10:253-7. Available from: http://www.asja.eg.net/text.asp?2017/10/1/253/238479
| Introduction|| |
Postoperative pain after knee arthroscopy is commonly moderate to severe and can affect the patient’s activity level and satisfaction .
In an effort to provide safe, effective, and long-lasting postarthroscopy pain relief, many drug regimens were injected intra-articularly including local anesthetics alone or with additive drugs to prolong and improve the quality of postoperative analgesia ,,.
Intra-articular corticosteroids have been widely used for short-term pain relief for knee osteoarthritis and reported to give short-term pain relief for ∼2–3 weeks ,,.
The aim of the present study was to evaluate the effects of dexamethasone addition to intra-articular morphine on postoperative pain after knee arthroscopy.
| Patients and methods|| |
This randomized double-blinded controlled study was conducted on 90 patients of both sexes, after approval of the ethical committee of El Menoufia University hospitals and obtaining informed written consent. The study was conducted in El Menoufia University hospitals from May 2015 to March 2016. Inclusion criteria were as follows: age between 20 and 60 years, American Society of Anesthesiologists (ASA) I and II physical status, and scheduled for minor arthroscopic knee surgeries (partial meniscectomy, chondroplasty, removal of loose bodies, and diagnostic arthroscopy). Patients with evidence of any major systemic illness, major knee surgery, history of allergy to any of the drugs in the study, morphine addiction, or history of convulsive disorders were excluded from the study. General anesthesia was given to all patients. On arrival to the operating room, routine monitors were applied (Nihon Kohden, Tokyo, Japan). Anesthesia was induced by intravenous fentanyl 1 µg/kg and propofol 2 mg/kg. Cuffed endotracheal tube of appropriate size was inserted after complete muscle relaxation by atracurium hydrochloride 0.8 mg/kg. Anesthesia was maintained by isoflurane 1.2 minimum alveolar concentration (MAC) in oxygen 100%. The patients were randomly allocated into three equal groups, 30 patients in each group, using research randomizer, a computer-generated program. In the control group, 10 ml of 0.5% bupivacaine (Markyrene 0.5%; Sigmatec Pharmaceuticals Industries Co. packed by Al-Debeiky Pharma, Obour city, Egypt) and 5 ml isotonic saline (total volume 15 ml) was injected intra-articularly. In the morphine (M) group, 5 mg morphine (morphine sulfate 20 mg/ml; Misr Company for Pharmaceuticals, Abo Zaabal, Qalubia, Egypt) diluted in 5 ml normal saline+10 ml of 0.5% bupivacaine was injected intra-articularly (total volume 15 ml). In the morphine-dexamethasone (MD) group, 5 mg morphine+8 mg dexamethasone (dexamethasone 4 mg/ml; Egyptian International Pharmaceutical Industries Co., 10th of Ramadan City, Egypt) completed to 5 ml with normal saline+10 ml of 0.5% bupivacaine (total volume 15 ml) was injected intra-articularly. All solutions were injected at the end of the operation and before tourniquet release. The tourniquet was released 10 min after the injection was administered. The drains were closed from the time of injection until the release of the tourniquet. Preoperatively, the patients were instructed to report their pain using visual analog score (VAS) with ‘0’ representing ‘no pain’, whereas ‘10 cm’ representing the ‘worst imaginable pain’. Postoperative pain at rest and movement was assessed by VAS at the following postoperative periods: time of full recovery, 1, 2, 3, 4, 6, 12, 18, and 24 h. The patients were monitored postoperatively for a period of 24 h for the following parameters: heart rate (HR), mean arterial blood pressure (MABP), respiratory rate, SpO2, time of first analgesic request (usually associated with VAS >3), and need for supplemental analgesic. Supplemental analgesia was provided with intravenous diclofenac sodium 75 mg if VAS greater than 3 and total consumption was recorded over 24 h. Adverse effects like nausea, vomiting, pruritus, respiratory depression, and urine retention were recorded. The study drugs were prepared by one anesthesiologist and injected by another anesthesiologist who was blinded to the study drugs. The nurse who was observing the patient and recoding the postoperative study parameters was blinded to the study drugs.
A pilot study was conducted on 10 patients divided into two equal groups. In one group (group B), the patients were administered intra-articular 10 ml of 0.5% bupivacaine and 5 ml isotonic saline, and in the other group MD, the patients were administered intra-articular 5 mg morphine+8 mg dexamethasone completed to 5 ml with normal saline+10 ml of 0.5% bupivacaine. The mean duration of analgesia in the B group was 6.22±3.33 h and in the MD group was 9.62±3.56 h by using Graphpad instat program version 3 (GraphPad Software Inc., La Jolla, San Diego, USA). At 0.05 level of significance and power of 95%, the estimated number was 25 patients. For possible drop outs, the number of patients chosen for the study was increased to 30 patients in each group.
Statistical analysis was done using SPSS 15 (SPSS Inc., IBM Company, Chicago, Illinois, USA). The patients’ sex, ASA, type of surgery, and incidence of adverse effects were analyzed using χ2-test. Age, weight, duration of surgery, HR, MABP, SpO2, and respiratory rate were analyzed using one-way analysis of variance test with Tukey’s test as post-hoc test. P value less than 0.05 was considered statistically significant.
| Results|| |
As shown in [Table 1], patient characteristics, ASA, type of surgery, and duration of surgery were comparable among groups (P>0.05). The HR, MABP, SpO2, and respiratory rate showed no statistically significant difference among all groups in the intraoperative and postoperative periods (P>0.05). As shown in [Figure 1] and [Figure 2], VAS scores for pain at rest and movement were significantly lower in M group in comparison with the control group for the first 6 postoperative hours (P<0.0001). VAS scores at rest and movement were significantly lower in the MD group compared with the control and M groups for the first 12 postoperative hours (P<0.0001) and was comparable among groups at other periods of measurement. The time for first analgesic request was significantly prolonged in the M group (7.83±2.46 h) and MD group (10.88±2.55 h) groups compared with the control group (5.77±2.88 h) (P<0.0001) and significantly prolonged in the MD group compared with the M group (P<0.01). The total consumption of diclofenac was significantly lower in the M group (90.56±38.56 mg) and MD group (46.41±26.41 mg) groups compared with the control group (160.21±40.14 mg) (P<0.0001) and significantly lower in the MD group compared with the M group (P<0.0001). The number of patients with pruritus was three patients in the M group and two patients in the MD group, with no statistically significant difference (P>0.05). No cases of pruritus were reported in the control group. There were no reported cases of respiratory depression, nausea, or vomiting in the three groups.
|Figure 1 Visual analog score (VAS) for pain at rest. Data represented as mean±SD. Significance compared with the control group.|
Click here to view
|Figure 2 Visual analog score (VAS) for pain at movement. Data represented as mean±SD. Significance compared with the control group.|
Click here to view
| Discussion|| |
The present study was an attempt to improve the recovery after knee arthroscopy by providing effective and prolonged postoperative analgesia. The present study resulted in prolonged analgesia, low VAS for pain (at rest and movement), and decreased analgesic consumption when dexamethasone was added to intra-articular morphine after knee arthroscopy operations.
Previous animal studies reported the presence of peripheral opioid receptors ,. These peripheral opioid receptors are inactive under basal conditions and become stimulated during tissue injury and inflammation which leads to increased number and efficacy of opioid receptors .
Stein et al.  studied the effects of low doses of intra-articular and intravenous morphine and concluded that low doses of 0.5 and 1 mg of intra-articular morphine can significantly reduce pain after knee surgery through an action specific to local opioid receptors that reaches its maximal effect 3–6 h after injection. The effects of morphine were reversible by intra-articular naloxone used which confirms the presence of peripheral opioid receptors .
Higher doses of 5 mg intra-articular morphine were used by Jazayeri et al.  and a dose of 10 mg intra-articular morphine was used by Hosseini et al. , and they reported effectiveness for postoperative analgesia with minimal adverse effects. In the present study, the dose of morphine chosen was 5 mg like in the study by Jazayeri and colleagues and resulted in effective analgesia in quality and duration with minimal adverse effects. Moreover, the duration of analgesia was comparable to the results of the previous studies ,,.
In the present study, the absence of adverse effects, except for statistically nonsignificant pruritus of morphine, may be because binding to local receptors decreases the rate of systemic absorption and results in low plasma concentration, which was insufficient to provide severe adverse effects or systemic analgesic effect, which in turn supports that the action is mediated through local opioid receptors . Moreover, previous studies reported that the addition of dexamethasone to opioids had no effect on the adverse effects of opioids ,.
Dexamethasone is a potent anti-inflammatory glucocorticoid with minimal mineralocorticoid effects, which is commonly used for intra-articular injection for osteoarthritis . Steroids were reported to block impulse transmission through nociceptive C fibers ,. Moreover, previous studies reported prolongation of peripheral nerve block when dexamethasone was added to local anesthetics ,. Previous studies also reported that dexamethasone prolonged the nerve block when added to local anesthetics through a local action on the steroid receptors .
These observations may explain the postoperative analgesic effects of intra-articular dexamethasone used in the present study which were additive to the effects of morphine when used together.
Previous studies revealed that chondrotoxicity to the intra-articular bupivacaine injection was higher with the 0.5% bupivacaine than 0.25%, and the incidence increased with the use of epinephrine and continuous infusion rather than single-shot injection ,. In the present study, bupivacaine 0.5% without epinephrine was administered as single shot to minimize as much as possible the chondrotoxicity.
A limitation to the present study was that the anti-inflammatory effect of dexamethasone was not studied on long-term recovery and rehabilitation. Further research is recommended for studying this anti-inflammatory effect.
In conclusion, the addition of dexamethasone to intra-articular morphine after knee arthroscopy prolongs the duration of analgesia, lowers the pain scores, and decreases the total analgesic consumption, with minimal adverse effects.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
McGrath B, Elgendy H, Chung F, Kamming D, Curti B, King S. Thirty percent of patients have moderate to severe pain 24 h after ambulatory surgery: a survey of 5,703 patients. Can J Anaesth 2004; 51:886–891.
Ates Y, Kinik H, Binnet MS, Ates Y, Canakci N, Kecik Y. Comparison of prilocaine and bupivacaine for post-arthroscopy analgesia: a placebo-controlled double-blind trial. Arthroscopy 1994; 10: 108–109.
Kaeding CC, Hill JA, Katz J, Benson L. Bupivacaine use after knee arthroscopy: pharmacokinetics and pain control study. Arthroscopy 1990; 6:33–39.
Moiniche S, Mikkelsen S, Wetterslev J, Dahl JB. A systematic review of intra-articular local anesthesia for postoperative pain relief after arthroscopic knee surgery. Reg Anesth Pain Med 1999; 24:430–437.
Bellamy N, Campbell J, Welch V, Gee TL, Bourne R, Wells GA. Intraarticular corticosteroid for treatment of osteoarthritis of the knee. Cochrane Database Syst Rev 2006; 2:CD005328.
Bjordal JM, Klovning A, Ljunggren AE, Slordal L. Short-term efficacy of pharmacotherapeutic interventions in osteoarthritic knee pain: a meta-analysis of randomized placebo-controlled trials. Eur J Pain 2007; 11:125–138.
Jüni P, Hari R, Rutjes AW, Fischer R, Silletta MG, Reichenbach S, da Costa BR. Intra-articular corticosteroid for knee osteoarthritis. Cochrane Database Syst Rev 2015; 10:CD005328.
Stein C, Millan MJ, Shippenberg TS, Herz A. Peripheral effect of fentanyl upon nociception in inflamed tissue of the rat. Neurosci Lett 1988; 84:225–228.
Stein C, Millan MJ, Shippenberg TS, Peter K, Herz A. Peripheral opioid receptors mediating antinociception in inflammation: evidence for involvement of mu, delta and kappa receptors. J Pharmacol Exp Ther 1989; 248:1269–1275.
Berg KA, Patwardhan AM, Sanchez TA, Silva YM, Hargreaves KM, Clarke WP. Rapid modulation of (micro)-opioid receptor signaling in primary sensory neurons. J Pharamcol Exp Ther 2007; 321:839–847.
Stein C, Comisel K, Haimerl E, Yassouridis A, Lehrberger K, Herz A. Analgesic effect of intraarticular morphine after arthroscopic knee surgery. N Engl J Med 1991; 325:1123–1126.
Jazayeri SM, Mosaffa F, Abbasian M, Hosseinzadeh HR. Comparing the efficacy of intra-articular application of morphine and tramadol on postoperative pain after arthroscopic knee surgery. Anesth Pain Med 2012; 2:28–31.
Hosseini H, Abrisham SMJ, Jomeh H, Alghoraishi MR, Ghahramani R, Mozayan MR. The comparison of intraarticular morphine-bupivacaine and tramadol-bupivacaine in postoperative analgesia after arthroscopic anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2012; 20:1839–1844.
Joshi GP, Mc Carroll SM, Cooney CM, Blunnie WP, O’Brien TM, Lawerence AJ. Intra-articular morphine for pain relief after knee arthroscopy. J Bone Joint Sur Br 1992; 74:749–751.
Banihashem N, Hasannasab B, Alereza H. Does dexamethasone prevent subarachnoid meperidin-induced nausea, vomiting and pruritus after cesarean delivery? Saudi J Anaesth 2013; 7:138–141.
] [Full text]
Szarvas S, Chellapuri RS, Harmon DC, Owens J, Murphy D, Shorten GD. A comparison of dexamethasone, ondansetron, and dexamethasone plus ondansetron as prophylactic antiemetic and antipruritic therapy in patients receiving intrathecal morphine for major orthopedic surgery. Anesth Analg 2003; 97:259–263.
Maricar N, Callaghan MJ, Felson DT, O’Neill TW. Predictors of response to intra-articular steroid injections in knee osteoarthritis − a systematic review. Rheumatology 2013; 52:1022–1032.
Golwala MP, Swadia VN, Aditi AD, Sridhar NV. Pain relief by dexamethasone as an adjuvant to local anesthetics in supraclavicular brachial plexus block. J Anaesth Clin Pharmacol 2009; 25:285–288.
Shrestha BR, Maharjan SK, Tabedar S. Supraclavicular brachial plexus block with or without dexamethasone − a comparative study. Kathmandu Univ Med J 2003; 1:158–160.
Shrestha BR, Maharjan SK, Shrestha S, Gautam B, Thapa C, Thapa PB et al.
Comparative study between tramadol and dexamethasone as an admixture to bupivacaine in supraclavicular brachial plexus block. J Nepal Med Assoc 2007; 46:158–164.
Bhattacharjee DP, Biswas C, Haldar P, Ghosh S, Piplai G, Rudra JS. Efficacy of intraarticular dexamethasone for postoperative analgesia after arthroscopic knee surgery. J Anaesthesiol Clin Pharmacol 2014; 30:387–390.
Webb ST, Ghosh S. Intra-articular bupivacaine: potentially chondrotoxic? Br J Anaesth 2009; 102:439–441.
Chu CR, Coyle CH, Chu CT, Szczodry M, Seshadri V, Karpie JC et al.
In vivo effects of single intra-articular injection of 0.5% bupivacaine on articular cartilage. J Bone Joint Surg Am 2010; 92:599–608.
[Figure 1], [Figure 2]