Addition of low-dose morphine to spinal anaesthesia improves analgesia with cFNB in TKA .
This report has been verified
by one or more authors of the
original publication.
OrthoEvidence Journal (OE Journal) - ACE Report
OE Journal. 2016;4(20):3 BMC Anesthesiol. 2016 Jul 16;16(1):3870 patients scheduled for total knee arthroplasty under spinal anesthesia and a continuous femoral nerve block were randomized to spinal anesthesia with or without the addition of mini-dose morphine (0.035mg). The purpose of this study was to evaluate if there was any significant difference between groups in pain scores and opioid consumption. Patients were monitored up to 48 hours postoperatively. Results demonstrated significantly lower pain scores and tramadol consumption in the group which received mini-dose spinal morphine. The incidence of postoperative nausea and vomiting was significantly greater within the first 6 hours in the group administered the mini-dose spinal morphine.
Was the allocation sequence adequately generated?
Was allocation adequately concealed?
Blinding Treatment Providers: Was knowledge of the allocated interventions adequately prevented?
Blinding Outcome Assessors: Was knowledge of the allocated interventions adequately prevented?
Blinding Patients: Was knowledge of the allocated interventions adequately prevented?
Was loss to follow-up (missing outcome data) infrequent?
Are reports of the study free of suggestion of selective outcome reporting?
Were outcomes objective, patient-important and assessed in a manner to limit bias (ie. duplicate assessors, Independent assessors)?
Was the sample size sufficiently large to assure a balance of prognosis and sufficiently large number of outcome events?
Was investigator expertise/experience with both treatment and control techniques likely the same (ie.were criteria for surgeon participation/expertise provided)?
Oui = 1
Incertain = 0,5
Non pertinent = 0
Non = 0
L'évaluation des critères de rapport permet d'évaluer la transparence avec laquelle les auteurs rapportent les caractéristiques méthodologiques et les caractéristiques de l'essai dans la publication. L'évaluation est divisée en cinq catégories qui sont présentées ci-dessous.
2/4
Randomization
3/4
Outcome Measurements
1/4
Inclusion / Exclusion
4/4
Therapy Description
4/4
Statistics
Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65
L'indice de fragilité est un outil qui aide à l'interprétation des résultats significatifs, en fournissant une mesure de la force d'un résultat. L'indice de fragilité représente le nombre d'événements consécutifs qui doivent être ajoutés à un résultat dichotomique pour que le résultat ne soit plus significatif. Un petit nombre représente un résultat plus faible et un grand nombre un résultat plus fort.
Pourquoi cette étude était-elle nécessaire maintenant ?
Severe knee pain following total knee arthroplasty is not uncommon and can delay physical therapy and recovery. Femoral nerve blocks are often used for postoperative analgesia after TKA, though mixed results regarding its efficacy have been reported. To improve the efficacy of a postoperative analgesia protocol involving FNB, use of mini-dose spinal morphine has been suggested as a possible supplementary method.
Quelle était la principale question de recherche ?
In total knee arthroplasty with a continuous femoral nerve block, is there any significant difference in postoperative analgesia efficacy between spinal anesthesia with and without the addition of mini-dose morphine, assessed over 48 hours postoperatively?
- Significant differences in median VAS pain scores were observed between groups, being significantly lower in the mini-dose morphine group compared to the control group at 12 hours (3 [0-7] vs. 6 [0-10]; p<0.01), 24 hours (3 [0-7] vs. 5 [0-10]; p<0.01), and 48 hours postoperatively (3 [0-7] vs. 4 [0-10]; p=0.03).
- Groups also demonstrated a significant difference in the incidence of severe postoperative pain, being significantly lower in the mini-dose morphine group compared to the control group at 12 hours (15/35 vs. 23/33; p=0.03), 24 hours (16/35 vs. 22/33; p=0.03), and 48 hours (9/35 vs. 17/33; p=0.03).
- Cumulative tramadol consumption over the first 48 hours postoperative was significantly lower in the mini-dose morphine group (125mg [50-400]) compared to the control group (200mg [50-500mg]) (p=0.01).
- The incidence of postoperative nausea and vomiting (PONV) was significantly greater in the mini-dose morphine group (40%) compared to the control group (15%) at 6 hours postoperatively (p=0.05); differences between groups at 1, 12, 24, 36, and 48 hours postoperatively were not significant.
De quoi dois-je me souvenir en priorité ?
In total knee arthroplasty, the addition of morphine 0.035mg to spinal anaesthesia with levobupivacaine, in combination with standardized continuous femoral nerve block, demonstrated significantly lower pain scores and incidences of severe pain within the first 48 hours postoperatively when compared to spinal anaesthesia without morphine, but also increased the incidence of PONV at 6 hours postoperatively.
Comment cela affectera-t-il les soins prodigués à mes patients ?
The results of this study suggest that the addition of low-dose morphine to spinal anesthesia may offer improved short-term analgesic efficacy of a multimodal regimen with continuous femoral nerve block in patients undergoing total knee arthroplasty. Nonetheless, even the low dose used in the current study was observed to increase the rate of postoperative nausea and vomiting to a significant degree. As such, there is a need for further study methods of potentially limiting the impact of the morphine-related side effects on patient outcome, or whether an even lower dose of morphine can demonstrate the same analgesic efficacy observed in this trial while avoiding an increase in the incidence of PONV.
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