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      Bupivacaina ou bupivacaina e morfina intra-articular pós reconstrução do LCA Translated title: Intra-articular bupivacaine or bupivacaine and morphine after ACL reconstruction

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          Abstract

          OBJETIVO: A cirurgia de reconstrução do LCA é hoje uma das mais realizadas e o controle da dor pós-operatória faz parte das prioridades do cirurgião. Dentro do arsenal de analgesia temos a aplicação intra-articular de drogas, sendo a mais estudada a bupivacaina associada ou não a morfina. Neste estudo comparamos a aplicação de bupivacaina associada ou não a morfina com grupo controle, após reconstrução do LCA com enxerto de tendões flexores. MÉTODOS: Quarenta e cinco pacientes foram randomizados em três grupos, sendo que no grupo I foi aplicado ao fim da cirurgia 20ml de soro fisiológico intra-articular, no grupo II 20ml de bupivacaina 0,25% e no grupo III bupivacaina 0,25% associado a 1mg de morfina. Os grupos foram avaliados quanto ao grau de dor pela escala analógica visual com 6, 24 e 48 horas de pós-operatório. RESULTADOS: O grupo III teve menos dor em todos os momentos, porém a dor não foi tão intensa em todos os grupos a ponto de necessitar medicações extras além do protocolo estabelecido. CONCLUSÃO: A aplicação intra-articular destas medicações pós-reconstrução do LCA com enxerto dos tendões flexores quando realizada sob anestesia raquideana não traz vantagens suficientes para fazer seu uso regularmente. Nível de Evidência II, Ensaio Clínico Randomizado de Menor Qualidade.

          Translated abstract

          OBJECTIVE: Reconstructive surgery of the ACL is one of the most commonly performed surgeries today and the control of postoperative pain is part of the priorities of the surgeon. Within the arsenal of analgesia we have the intra-articular application of drugs, and the most studied one is bupivacaine with or without morphine. This study compared the application of bupivacaine with or without morphine with a control group after ACL reconstruction with flexor tendon graft. METHODS: Forty-five patients were randomized into three groups: in group I, 20 ml of saline were applied intra-articularly at the end of the surgery; in group II, 20 ml of bupivacaine 0.25%; and in group III, bupivacaine 0.25% associated with 1 mg of morphine. The groups were assessed for degree of pain by the Visual Analog Scale at 6, 24 and 48 hours postoperatively. RESULTS: Group III had less pain at all times, but the pain was not as intense in all groups to the point of needing extra medications beyond the established protocol. CONCLUSION: The intra-articular application of these medications after ACL reconstruction with flexor tendon graft when performed under spinal anesthesia is not useful enough to use regularly. Level of Evidence II, Lesser quality RCT.

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          Most cited references21

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          Intraarticular morphine, bupivacaine, and morphine/bupivacaine for pain control after knee videoarthroscopy.

          Evidence has accumulated that opioids can produce potent antinociceptive effects by interacting with opioid receptors in peripheral tissues. This study sought to compare the effects of morphine with those of bupivacaine administered intraarticularly upon pain following arthroscopic knee surgery. In a double-blind, randomized manner, 33 patients received either morphine (1 mg in 20 ml NaCl; n = 11), bupivacaine (20 ml, 0.25%; n = 11), or a combination of the two (n = 11) intraarticularly at the completion of surgery. After 1, 2, 3, and 4 h and at the end of the 1st and 2nd postoperative days, pain was assessed by a visual analogue scale, and supplemental analgesic requirements were recorded. Pain scores were significantly greater in the morphine group than in the other two groups at 1 h. There were no significant differences at 2 and 3 h. From 4 h until the end of the study period, pain scores were significantly greater in the bupivacaine group than in the other two groups. Analgesic requirements were significantly greater in the morphine group than in the other groups at 1 h but were significantly greater in the bupivacaine group than in the other groups throughout the remainder of the study period. We conclude that intraarticular morphine produces an analgesic effect of delayed onset but of remarkably long duration. The combination of these two drugs results in satisfactory analgesia throughout the entire observation period.
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            The effect of bupivacaine and morphine in a coculture model of diarthrodial joints.

            To perform a controlled laboratory study to evaluate the effect of bupivacaine and morphine on chondrocytes and synovium in a coculture model of diarthrodial joints. A proven coculture model that allows for the assessment of cartilage and synovium exists. The model allows for simulation of the diarthrodial joint in both health and disease by using culture media with or without the addition of interleukin-1. Effects of the presence of bupivacaine and morphine were evaluated by measuring media concentration of glycosamino glycans (GAG), nitric oxide (NO), and prostaglandin E(2) (PGE(2)), and tissue concentration of GAG, water, and collagen. Cell viability was determined through the use of confocal microscopy on days 1 and 2. Cell viability 2 days after exposure to 0.5% bupivacaine was significantly less in the presence of bupivacaine than in the other groups, nearing a 100% decrease in viability. There was little effect of bupivacaine on cartilage water content or the tissue concentration of GAG and collagen. Morphine and bupivacaine both inhibited the expected rise in NO and PGE(2) when interleukin-1 was added to the media. Continuous 0.5% bupivacaine exposure has a clear detrimental effect on chondrocytes in this in vitro study. Both bupivacaine and morphine appear to have anti-inflammatory effects. Continuous morphine exposure does not cause gross chondrotoxicity in vitro and presents itself as a potential alternative intra-articular analgesic. Intra-articular bupivacaine infusion is an effective analgesic strategy and is frequently used in both office and outpatient surgical settings. This study provides evidence that the continued usage of postoperative bupivacaine continuous infusion pumps may have a detrimental effect on chondrocytes. Morphine has been shown to be an effective intra-articular analgesic, and its anti-inflammatory role seen in this study makes it a potential alternative to bupivacaine.
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              Intraarticular tramadol-bupivacaine combination prolongs the duration of postoperative analgesia after outpatient arthroscopic knee surgery.

              Intraarticular (IA) local anesthetics are often used for the management and prevention of pain after arthroscopic knee surgery. Recently, IA tramadol was also used for the management of these patients. However, the IA combination of local anesthetic and tramadol has not been evaluated in arthroscopic outpatients. Our primary aim in this study was to evaluate the analgesic effect of an IA combination of bupivacaine and tramadol when compared with each drug alone using visual analog scale (VAS) pain scores in patients undergoing day-care arthroscopic knee surgery. Additionally, we assessed analgesic demand. Ninety ASA I/II patients undergoing arthroscopic partial meniscectomy, performed by a single surgeon under general anesthesia, were assigned in a randomized, double-blind manner into three groups: group B (n = 30) received 0.25% bupivacaine, group T (n = 30) received 100 mg tramadol, and group BT (n = 30) received 0.25% bupivacaine and 100 mg tramadol to a total volume of 20 mL by the IA route after surgery. Postoperative pain scores were measured on a VAS, at rest and on mobilization at 0.5, 1, 2, 4, 6, 8, 12, and 24 h. Duration of analgesia, the subsequent 24 h consumption of rescue analgesia, time to ambulation, and time to discharge were evaluated. In addition, the systemic side effects of the IA injected drugs were also assessed. The results showed significantly lower VAS pain scores in group BT (P < 0.1) when compared with groups T and B. Group BT had a later onset of postsurgical pain and longer time to first rescue analgesic than groups B and T. The 24 h consumption of analgesic was significantly less in group BT when compared with the other two groups (26.7% of the patients required rescue analgesia in group BT, whereas this number was 90% in group B and 86.7% in group T). In addition, time in hours to discharge and time to unassisted ambulation were significantly shorter in group BT when compared with groups T and B, and this was not associated with any detectable systemic effects. The IA admixture of tramadol 100 mg with bupivacaine 0.25% provides a pronounced prolongation of analgesia compared with either drug alone in patients undergoing day care arthroscopic knee surgery.
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                Author and article information

                Journal
                aob
                Acta Ortopédica Brasileira
                Acta ortop. bras.
                ATHA EDITORA (São Paulo, SP, Brazil )
                1413-7852
                1809-4406
                2012
                : 20
                : 5
                : 258-261
                Affiliations
                [01] Londrina Paraná orgnameHospital Evangélico de Londrina Brasil
                Article
                S1413-78522012000500002 S1413-7852(12)02000500002
                a6e25a72-eecc-4b5c-92c7-a4b5b8cf2e0f

                This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

                History
                : 04 December 2010
                : 05 March 2011
                Page count
                Figures: 0, Tables: 0, Equations: 0, References: 21, Pages: 4
                Categories
                Artigo Original

                morfina,Morphine,Pain measurement,Bupivacaine,Anesthesia & analgesia,Anterior cruciate ligament,medição da dor,bupivacaina,anestesia e analgesia,ligamento cruzado anterior

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