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Comparison of the relative analgesic efficacies of epidural or intramuscular diamorphine following total knee arthroplasty

Published online by Cambridge University Press:  01 November 2007

R. J. Green ,
J. Chambers ,
P. W. Thomas ,
L. Monnery ,
G. Titley  and
T. Doyle
R. J. Green*
Affiliation:
Royal Perth Hospital, Perth, UK
J. Chambers
Affiliation:
Salisbury District Hospital, Salisbury NHS Foundation Trust, Salisbury, Wiltshire, UK
P. W. Thomas
Affiliation:
Dorset Research and Development Support Unit, Poole Hospital NHS Trust, Poole, Dorset, UK
L. Monnery
Affiliation:
Southampton University Hospital NHS Trust, Shackleton Department of Anaesthesia, Southampton, UK
G. Titley
Affiliation:
Poole Hospital NHS Trust, Ronald Fisher Anaesthetic Department, Poole, Dorset, UK
T. Doyle
Affiliation:
WestDorset General Hospital, Anaesthetic Department, Dorchester, UK
*
Correspondence to: Richard James Green, Royal Perth Hospital, Wellington Street, Perth WA 6000, UK. E-mail: rjgreen@doctors.org.uk; Tel: +44 61 8 9224 2244; Fax: +44 61 8 9224 1111
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Summary

Background and objectives

Debate has proliferated as to the true site of action of opioids when placed in the epidural space. The aim of this study was to compare the analgesic effects of a bolus of diamorphine given by the epidural or intramuscular route.

Methods

Sixty patients having elective primary total knee replacements were recruited and randomized to receive epidural or intramuscular diamorphine. A lumbar epidural catheter was sited and 10 mL of bupivacaine 0.5% wt vol−1 was injected. Patients subsequently received diamorphine 5 mg into the epidural space or as an intramuscular injection. Patient-controlled analgesia with intravenous morphine was used for postoperative analgesia. The primary outcome measures included time to first patient-controlled analgesia use and total morphine consumption in 24 h. Secondary end-points considered possible treatment complications.

Results

All primary end-points showed significant differences in favour of epidural diamorphine. Medians for times to first patient-controlled analgesia use and total 24 h morphine requirements were significantly different (P < 0.001) at 418 vs. 198 min and 11 vs. 39 mg, respectively. There were no significant differences in secondary end-points.

Conclusions

This study has shown the superior analgesic efficacy of epidural diamorphine when compared to intramuscular injection.

Keywords

POSTOPERATIVE NAUSEA AND VOMITINGANAESTHETIC RECOVERY PERIODANALGESIA, postoperativeOPIOIDS, diamorphineANALGESIA EPIDURAL
Type
Original Article
Information
European Journal of Anaesthesiology , Volume 24 , Issue 11 , November 2007 , pp. 951 - 957
Copyright
Copyright © European Society of Anaesthesiology 2007

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References

1.Behar, M, Magora, F, Olshwang, D, Davidson, JT. Epidural morphine in treatment of pain. Lancet 1979; 10 (1): 527–529.Google Scholar
2.Brill, S, Gurman, GM, Fischer, A. A history of neuroaxial administration of local analgesics and opioids. Eur J Anaesth 2004; 21 (4): 329–330.Google Scholar
3.McLeod, GA, Munishankar, B, Columb, MO. Is the clinical efficacy of epidural diamorphine concentration-dependent when used as analgesia for labour? Br J Anaesth 2005; 94 (2): 229–233.CrossRefGoogle ScholarPubMed
4.Ginosar, Y, Columb, MO, Cohen, SE et al. . The site of action of epidural fentanyl infusions in the presence of local anesthetics: a minimum local analgesic concentration infusion study in nulliparous labor. Anesth Analg 2003; 97: 1439–1445.Google Scholar
5.Ginosar, Y, Riley, E, Angst, M. The site of action of epidural fentanyl in humans: the difference between infusion and bolus administration. Anesth Analg 2003; 97: 1428–1438.Google Scholar
6.Liu, SS, Gerancher, JC, Bainton, BG, Kopacz, DJ, Carpenter, RL. The effects of electrical stimulation of different frequencies on perception and pain in human volunteers: epidural vs. intravenous administration of fentanyl. Anesth Analg 1996; 82: 98–102.Google Scholar
7.Geller, E, Chrubasik, J, Graf, R, Chrubasik, S, Schulte-Monting, J. A randomised double-blind comparison of epidural sufentanil vs. intravenous sufentanil or epidural fentanyl analgesia after major abdominal surgery. Anesth Analg 1993; 76: 1243–1250.CrossRefGoogle ScholarPubMed
8.Cohen, S, Pantuck, CB, Amar, D, Burley, E, Pantuck, EJ. The primary action of epidural fentanyl after Cesarean delivery is via spinal mechanism. Anesth Analg 2002; 94: 674–679.CrossRefGoogle ScholarPubMed
9.Bernards, C. Understanding the physiology and pharmacology of epidural and intrathecal opioids. Best Pract Res Clin Anaesth 2002; 16: 489–505.Google Scholar
10.Bernards, CM, Shen, DD, Sterling, ES et al. . Epidural, cerebrospinal fluid, and plasma pharmacokinetics of epidural opioids (Part 1): differences among opioids. Anesthesiology 2003; 99 (2): 455–465.Google Scholar
11.Herz, A, Albus, K, Metys, J, Schubert, P, Teschemacher, H. On the central sites for the antinociceptive action of morphine and fentanyl. Neuropharmacology 1970; 9: 539–551.CrossRefGoogle ScholarPubMed
12.Herz, A, Teschemacher, H. Activities and sites of antinociceptive action of morphine- like analgesics and kinetics of distribution following intravenous, intracerebral and intraventricular application. In: Simmonds, A, ed. Advances in Drug Research. London: Academic Press, 1997: 79–117.Google Scholar
13.Kilbride, M, Senagore, A, Mazier, W, Ferguson, C, Ufkes, T. Epidural analgesia. Surg Gynaecol Obstet 1992; 174: 137–140.Google Scholar
14.Loper, KA, Ready, LB, Downey, M et al. . Epidural and intravenous fentanyl infusions are clinically equivalent after knee surgery. Anesth Analg 1990; 70: 72–75.CrossRefGoogle ScholarPubMed
15.Bernards, C, Hill, H. Physical and chemical properties of drug molecules governing their diffusion through the spinal meninges. Anesthesiology 1992; 77: 750–756.Google Scholar
16.D’Angelo, R, Gerancher, JC, Eisenach, JC, Raphael, BL. Epidural fentanyl produces labour analgesia by spinal mechanism. Anaesthesiology 1998; 88: 1519–1523.Google Scholar
17.Lyons, G, Columb, M, Hawthorne, L, Dresner, M. Extradural pain relief in labour: bupivacaine sparing by extradural fentanyl is dose dependent. Br J Anaesth 1997; 78: 493–497.Google Scholar
18.Polley, LS, Columb, MO, Naughton, NN et al. . Effect of intravenous vs. epidural fentanyl on the minimum local analgesic concentration of epidural bupivacaine in labor. Anesthesiology 2000; 93 (1): 122–128.Google Scholar
19.Capogna, G, Camorcia, M, Columb, MO. Minimum analgesic doses of fentanyl and sufentanil for epidural analgesia in the first stage of labor. Anesth Analg 2003; 96: 1178–1182.Google Scholar
20.van den Nieuwenhuyzen, MC, Stienstra, R, Burm, AG, Vletter, AA, van Kleef, JW. Alfentanil as an alternative to epidural bupivacaine in the management of postoperative pain after laparotomies: lack of evidence of spinal action. Anaesth Analg 1998; 86: 574–578.Google Scholar
21.Miguel, R, Barlow, I, Morrell, M, Scharf, J, Sanusi, D, Fu, E. A prospective, randomised, double-blind comparison of epidural and intravenous sufentanil infusions. Anesthesiology 1994; 81: 346–352.Google Scholar
22.Menigaux, C, Guignard, B, Fletcher, D, Sessler, DI, Levron, JC, Chauvin, M. More epidural than intravenous sufentanil is required to provide comparable postoperative pain relief. Anesth Analg 2001; 93: 472–476.CrossRefGoogle ScholarPubMed
23.McLeod, GA, Munishankar, B, Columb, MO. An isobolographic analysis of diamorphine and levobupivacaine for epidural analgesia in early labour. Br J Anaesth 2007; 98 (4): 497–502.Google Scholar
24.Mather, LE, Cousins, MJ. The site of action of epidural fentanyl: what can be learned by studying the difference between infusion and bolus administration? The importance of history, one hopes. Anesth Analg 2003; 97 (5): 1211–1213.Google Scholar
25Keenan, GMA, Munishankarappa, S, Elphinstone, ME et al. . Extradural diamorphine with adrenaline in labour: comparison with diamorphine and bupivacaine. Br J Anaesth 1991; 66: 242–246.Google Scholar
26.Bloor, K, Thompson, M, Chung, N. A randomised, double-blind comparison of subarachnoid and epidural diamorphine for elective caesarean section using a combined spinal-epidural technique. Int J Obstet Anaesth 2000; 9 (4): 233–237.Google Scholar