Spinal Anestezi İle Artroskopik Diz Cerrahisi Geçiren Olgularda Intraartiküler Morfin Ve Ketaminin Postoperatif Aneljeziye Etkisi

Abstract

The Effect of Intraarticular Morphine and Ketamine on Postoperative Analgesia in Patients Undergoing Arthroscopic Knee Surgery Under Spinal Anesthesia Arthroscopic surgery of the knee is a common out patient procedure. Anesthesia for this kind of surgery should provide sufficient surgical conditions, good postoperative analgesia and early discharge from hospital and minimum side effects. The aim of this study was to eva luate the effects of intraarticular morphine and ketamine on postoperative analgesia and find out the side effects of them in the patients undergoing arthroscopy under spinal a n e sthesia. ASA I-II, 90 patients scheduled for arthroscopic surgery were included in this study. All patients operated under spinal anaesthesia. Spinal anesthesia was performed at L4-5 inte rsp ac e with 10 mg 0.5% hyperbaric bupivacain. Patients were randomly allocated to receive intraarticular 0.1 mg kg-1 morphine diluted with saline into 30 ml (group M, n=30) or intraarticular 0.5mg kg-1 ketamine diluted with saline into 30 ml (group K, n=30) or intraarticular 30 ml saline (group SF, n=30) at the and of the surgery. Visual analogue score at 4, 8, 12, 24 hr after surgery, ,duration of motor block, duration of first mobilization, the first pain feeling time, the VAS score during first mobilization, the number of patient r e q u e ring rescue analgesic and adverse effects were recorded. VAS scores at 4, 8, 12, 24 hours and during first mobilization were lower in group M and K than in group SF. First analgesic rescue times were longer in group M (139.5±25.0) and group K'nin (145.5± 40.0) than group SF (124.2±16.2). The number of patients requiring analgesic in 24 hours was higher in group SF than group M and K. No side effect was seen in group M and SF but hallucination was observed in one patient in group K. Conclusion: Intraarticular morphine and ketamine provided better postoperative analgesia than saline group in outpatients requiring arthroscopic knee surgery under spinal anesthesia, However unwanted side effects might seen in ketamine group. That's why we belive that intraarticular morphine administration for postoperative analgesia is suitable in patient undergoing arthroscopic knee surgery. Artroskopik diz cerrahisi genellikle günübirlik girişim olarak planlanır. Bu girişimlerde uygulanacak anestezi, yeterli cerrahi koşullar ile birlikte postoperatif analjeziyi ve erken mobi-lizasyonu da sağlamalıdır. Bu çalışmanın amacı, spinal anestezi ile artroskopik cerrahi uygulanan olgularda, girişim sonunda intraartiküler verilen morfin, ketamin ve serum fizyolojiğin postoperatif analjezi ve yan etkiler yönünden karşılaştırılmasıdır. Çalışmaya, yaşları 18-44 arasında, ASA I-II, artroskopik cerrahi planlanan 90 hasta dahil edildi. Tüm olgulara L3-4 seviyesinden 10 mg 0.5% hiperbarik bupivakain ile spinal anestezi yapıldı. Olgular randomize olarak her grupta 30 olgu olacak şekilde 3 gruba ayrıldı. Operasyonun sonunda, birinci gruba (Grup M) intraartiküler 0,1 mg/kg morfin (toplam 30 ml serum fizyolojik içinde), ikinci gruba (Grup K) intraartiküler 0,5 mg/kg ketamin (toplam 30 ml serum fizyolojik içinde) ve serum fizyolojik grubuna (Grup SF) intraartiküler 30 ml serum fizyolojik verildi.Tüm hastalarda postoperatif 4, 8, 12 ve 24.saatlerdeki VAS değerleri, motor blok süreleri, ilk mobilizasyon zamanları, ilk analjezik gereksinim zamanları (İAGZ), ilk mo-bilizasyon sırasındaki VAS değerleri, postoperatif analjezik ihtiyacı olan hasta sayıları ve yan etkiler kaydedildi. Grup M ve K nın 4, 8, 12 ve 24. saatlerdeki ve ilk mobilizasyon sırasındaki VAS değerleri Grup SF' ye göre anlamlı derecede düşüktü. Grup M (139.5±25.0) ve K'nın (145.5± 40.0) ilk analjezik gereksinim zamanları Grup SF'ye (124.2±16.2) göre anlamlı derecede uzundu. Grup SF'de ilk 24 saatte ek analjezik ihtiyacı olan hasta sayısı Grup M ve K'ya göre anlamlı derecede fazla bulundu (p<0.001). Grup M ve SF'de herhangi bir yan etki gözlenmezken, Grup K'da 1 hastada intra artiküler enjeksiyona bağlı halüsinasyon gözlendi (p>0.05). Spinal anestezi ile artroskopik diz operasyonu yapılan günübirlik olgularda, intraartiküler verilen morfin ve ketaminin kontrol grubu ile karşılaştırıldığında etkin postoperatif analjezi sağladığı, ancak ketamin grubunda istenmeyen sistemik yan etkiler gözlenebileceği için, ar-troskopik girişim yapılacak olgularda postoperatif analjezi amacı ile intraartiküler morfin verilmesinin uygun olduğu kanısına varıldı.

Keywords

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References

1. Chapman CR, Casey KL, Dubner R, Foley KM, Gracely RH, Reading AE. Pain measurement: an overview. Pain 1985; 22: 1–31.
2. Goranson BD, Lang S, Cassidy JD, Dust WN, Kerrel JM. A comparison of three regional anaesthesia techniques for outpatient knee arthroscopy. Can J Anaesth 1997; 44: 371–376.
3. Parnass SM. Ambulatory surgical patient priorities. Review Nurs Clin North Am 1993; 28: 531–45.
4. Kaeding CC, Hill JA, Katz J, Benson L. Bupivacaine use after knee arthroscopy: pharmacokinetics and pain control study. Arthroscopy 1990; 6: 33–9.
5. Chirwa SS, MacLeod BA, Day B. Intraarticular b u p i v a c a i n e after arthroscopic meniscectomy: A r a n d o m i z e d
6. Arthroscopy 1989; 5: 33–35. controlled
7. study. 6. Gentili M, Haussel P, Osman M, Henel D, Jubel A, Bonet F. Intraarticular morphine and clonidine p r o d u c e comparable analgesia but the combination is not more effective. Br J Anaesth 1997; 79: 660–661. 7. Yang LC, Chen LM, Wang CJ, Buerkle H. Postoperative analgesia by intraarticular neostigmine in
8. Anesthesiology 1998; 88: 334–339. knee

9. arthroscopy. 8. Stein C, Comisel K, Haimerl E, et al. Analgesic effect of intraarticular morphine after arthroscopic knee surgery. N Engl J Med 1991; 325: 1123–1126.
10. Standl T, Burmeister MA. Fast-track regional a n e s t h e s i a . Curr Opin Anaesthesiol 2000; 13: 643–649.
11. Dahl V, Raeder J. Regional anaesthesia in ambulatory surgery. Curr Opin Anaesthesiol 2003; 16: 471–476. 11. Russon K, Sardesai AM, Ridgway S, et al. Postoperative shoulder surgery initiative (POSSI): an interim report of major shoulder surgery as a day case procedure. Br J Anaesth 2006; 97: 869–873.
12. Aasbo V, Raeder JC, Grogaard R, Roise O. No additional analgesic effect of intraarticular morphine or bupivacaine compared with placebo after elective knee arthroscopy. Acta Anaesthesiol Scand 1996; 40: 585–588.
13. Allen GC, St Amand MA, Lui AC, Johnson DH, Lindsay MP. Postarthroscopy analgesia with intraarticular bupivacaine/morphine. A randomized clinical trial. Anesthesiology 1993; 79: 475–80.
14. Badner NH, Bourne RB, Rorabeck CH, Doyle JA. Addition of morphine to intraarticular bupivacaine does not improve analgesia following knee joint replacement. Regional Anaesthesia 1997; 22: 347–350.
15. Haynes TK, Appadurai IR, Power I, Rosen M. Intra- a r t i c u l a r morphine and bupivacaine analgesia after arthroskopic knee surgery. Anaesthesia 1994; 49: 54–56.
16. Heard SO, Edwards WT, Ferrari D, et al. Analgesic effect of intraarticular bupivacaine or morphine after arthroscopic knee surgery. Anesth Analg 1992; 74: 822–826.
17. Jaureguito JW, Wilcox JF, Cohn SJ, Thisted RA, Reider B. A comparison of intraarticular morphine and bupivacaine for pain control after outpatient knee arthroscopy. A prospective, randomized, double-blinded study. Am J Sports Med 1995; 23: 350–353.
18. Joshi GP, McCarroll SM, Cooney CM, et al. Intra- articular morphine for pain relief after knee arthroscopy. J Bone Joint Surg Br 1992; 74: 749–751. 19. Joshi GP, McCarroll SM, Brady OH, Hurson BJ, Walsh G: Intra-articular morphine for pain relief after anterior cruciate ligament repair. Br J Anaesth 1993; 70: 87–88.
19. Khoury GF, Chen AC, Garland DE, Stein C: Intraarticular morphine bupivacaine and morphine/bupivacaine for pain
20. Anesthesiology 1992; 77: 263–266. knee
21. videoartroscopy. 21. Batra YK, Mahajan R, Kumar S, Nagi ON, Dhillon MS. Bupivacaine/ketamine is superior to intra-articular ketamine analgesia following arthroscopic knee surgery. Can J Anesth 2005; 52: 832–836.
22. Zhang GH, Min SS, Lee KS, et al. Intraarticular p r e t r e a t m e n t with ketamine and memantine could prevent arthritic pain: Relevance to the decrease of spinal fos expression in rats. Anesth Analg 2004; 99: 152–158.
23. Gupta A, Axelsson K, Allvin R, et al. Postoperative pain following knee arthroscopy: The effects of intra- articular ketorolac and/or Morfhine. Reg Anesth Pain Med 1999; 24: 225–230.
24. Dal D, Tetik O, Altunkaya H, Tetik O, Doral MN. The efficacy of intra-articular ketamine for postoperative analgesia in outpatient arthroscopic surgery. Arthroscopy 2004; 20: 300–305.
25. Jeavery KB, Ussery TW, Steber HG, Colclough GW. Comparison of morphine and morphine with ketamine for postoperative analgesia. Can J Anaesth 1996; 43:22–215.
26. Rosseland LA, Stubhaug A, Sandberg L, Breivik H. Intra-articular (IA) catheter administration of p o s t o p e r a t i v e analgesics. A new trial design allows evaluation of baseline pain, demontrates large v a r i a t i o n in need of analgesics, and finds no anagesic effect of IA ketamine compared with IA saline. Pain 2003; 104: 25–34
27. Joris JL, Dubner R, Hargreaves KM: Opioid analgesia at peripheral sites: A targetfor opioids released during stress and ınflammation? Anest Analg 1987; 66: 1277–1281.
28. Stein C, Yassouridis LA. Peripheral morphine a n a l g e s i a . Pain 1997; 71: 119–121.
29. Stein C, Pflüger M, Yassouridis A, Hoelzi J, et al. No tolerance to peripheral morphine analgesia in p r e s e n c e of opioid expression in inflamed synovia. J Clin Invest 1996; 98: 793–799.
30. Joshi GP, McSwney M, Hurson BJ, McCarrol SM, O’Rourke P, Effects of intraarticular morphine on analgesic requirements after anterior cruciate ligament repair. Reg Anesth 1993; 254–25.