Elsevier

Journal of Clinical Anesthesia

Volume 37, February 2017, Pages 7-13
Journal of Clinical Anesthesia

Original Contribution
Comparison of ropivacaine with and without fentanyl vs bupivacaine with fentanyl for postoperative epidural analgesia in bilateral total knee replacement surgery,☆☆

https://doi.org/10.1016/j.jclinane.2016.08.020Get rights and content

Highlights

  • Postsurgery epidural LA is effective in knee arthroplasty.

  • Addition of fentanyl to epidural ropivacaine provided selective analgesia without motor block.

Abstract

Study Objectives

Pain after total knee replacement (TKR) interferes with early rehabilitation. Although the use of epidural bupivacaine in post-TKR patients is associated with effective analgesia, the associated motor blockade effect delays functional recovery. We compared analgesic efficacy and side effects of postoperative patient-controlled epidural analgesia (PCEA) with plain ropivacaine 0.1% with/without fentanyl 2.5 μg/mL vs plain bupivacaine 0.0625% with fentanyl 2.5 μg/mL in patients undergoing bilateral TKR.

Design

Prospective, double-blind, randomized study.

Settings

Operation room, postoperative recovery room, and intensive joint replacement unit.

Patients

Ninety American Society of Anesthesiologists I to II post-TKR patients who were randomly allocated to receive postoperative PCEA with plain ropivacaine 0.1% (group 1), ropivacaine 0.1% with fentanyl 2.5 μg/mL (group 2), and plain bupivacaine 0.0625% with fentanyl 2.5 μg/mL (group 3).

Intervention

Postoperatively, the PCEA settings were standardized for a basal flow of 4 mL/h, demand dose of 6 mL, and lock-out interval of 20 minutes. “Rescue” analgesia included epidural boluses (6 mL) of respective study drug over and above PCEA administration.

Measurements

Postoperative pain profile, total PCEA drug used, heart rate, and noninvasive blood pressure, side effects, and patient satisfaction were recorded.

Main results

Demographic parameters, duration of surgery, and hemodynamic variables (heart rate and noninvasive blood pressure) were comparable for the 3 study groups. Pain scores and rescue drug requirements were greater in “ropivacaine-only” group. Motor blockade was greatest in “bupivacaine-fentanyl” group. Postoperatively, despite the presence of minor side effects (nausea, itching) in the “ropivacaine-fentanyl” and bupivacaine-fentanyl groups, the patients belonging to these groups were more satisfied.

Conclusion

After bilateral TKR, ropivacaine-fentanyl combination administered through a PCEA system resulted in “superior” analgesic efficacy, that is, pain relief without motor blockade, than “ropivacaine alone” (lesser pain relief) and bupivacaine-fentanyl (pain relief but with attendant motor blockade). Overall, the addition of fentanyl to epidural local anesthetic returned favorable postoperative analgesia profile and patient satisfaction with minor incidence of opioid-related side effects.

Introduction

Osteoarthritis or the “degenerative joint disease” is an abnormality involving degradation of large joints. Joint replacement surgery is indicated when pain due to osteoarthritis is persistent and is associated with debilitation and/or significant joint movement limitation.

Pain after total knee replacement (TKR) interferes with early rehabilitation. Unrelieved postarthroplasty pain may result in “clinical” (deep vein thrombosis, pulmonary embolism, coronary ischemia, myocardial infarction, pneumonia, poor wound healing, and insomnia) [1], [2] and “psychological” changes that increase patient morbidity as well as the associated costs [1]. Negative clinical outcome resulting from ineffective post-TKR pain management and the add-on medical and economic implications (extended length of stay, readmission, and patient dissatisfaction) worsen the problem [3]. Therefore, not only adequacy of post-TKR analgesia is vital to early postoperative mobilization and successful rehabilitation but also is a key to successful functional outcome [4].

Bupivacaine, the most widely used local anesthetic (LA) for epidural analgesia, is a chiral compound [5] and racemic mixture of S (−) and R (+) enantiomers. Typically, selective epidural administration of S-enantiomers, for example, ropivacaine, produces rarer motor blockade than racemic mixture of bupivacaine [6]. Although ropivacaine and bupivacaine are quite similar in structure, the former is relatively less toxic in terms of cardiovascular and central nervous systems effects [7]. There is evidence that suggests that epidural ropivacaine results in greater sensory blockade and motor block sparing and has lower cardiac toxicity [7] potential than bupivacaine [8].

Interestingly, Polley et al [9] who calculated the relative potencies of LA agents (bupivacaine and ropivacaine) by using an up-down sequential allocation study design reported ropivacaine to be significantly less potent than bupivacaine (potency ratio, 0.6) [9]. However, they contended that, for practical clinical situations, different LA solutions provide the same analgesic effectiveness.

Addition of fentanyl to epidural LA agent is not uncommon. There is evidence that epidurally administered LA when combined with opioids decreases LA requirements and potentiates pain relief [10]. However, addition of fentanyl to epidural LA adds to complications, such as nausea-vomiting, itching, sedation, and delayed respiratory depression [11].

With the contention that epidural ropivacaine, when administered alone, produces sensory blockade equivalent to racemic bupivacaine and because it has selective action on the pain transmitting Aδ and C fibers, it can decrease the need of adding fentanyl to epidural LA solution. We took plain ropivacaine as an isolated group to avoid the complication of opioids. Hence, our study compared the analgesic efficacy and side effects of equipotent ropivacaine (plain, 0.1%) with or without fentanyl (2.5 μg/mL) vs bupivacaine (plain, 0.0625%) with fentanyl (2.5 μg/mL) combination.

Section snippets

Materials and methods

After institutional ethics committee approval (EC/01/11/212 dated January 18, 2011) and written informed consent from the patient-participants, this prospective, randomized, and double-blind study was performed on 90 American Society of Anesthesiologists I to II adults (age range, 40-60 years; sex, male or female) who underwent bilateral TKR under combined spinal-epidural (CSE) anesthesia administered via a needle-through-needle technique. Exclusion criteria included patient refusal, revision

Demographic and surgery profile

All the recruited 90 participants (n = 90) completed the study. Demographic parameters (age, sex, body weight, height, and BMI), vitals (heart rate, noninvasive blood pressure [mean], and respiratory rate), and duration of surgery were comparable for the 3 study groups (Table 1).

Pain scores

For the first 4 hours postoperatively, pain scores at rest and at motion were comparable across the 3 groups. Thereafter, the median pain scores were significantly lower in “ropivacaine-fentanyl” and

Discussion

Commonly, surgery is followed by acute pain. Notably, correct identification of the type of postoperative pain enables selection of appropriate treatment to bring down patient morbidity. TKR is generally associated with moderate to severe postoperative pain [14]. This prospective double-blind study compared analgesic efficacy, side effects, and patient satisfaction with the use of postoperative PCEA with “ropivacaine 0.1% with/without fentanyl (2.5 μg/mL)” vs “bupivacaine (0.0625%)–fentanyl

Conclusions

  • 1.

    PCEA administration of ropivacaine-fentanyl combination leads to adequate postoperative analgesia, quantitative reduction of LA drug usage, and heightened satisfaction;

  • 2.

    The addition of fentanyl to LA solutions (ropivacaine and bupivacaine), except for minor burden (PONV and itching), ensures better postoperative analgesia and patient satisfaction;

  • 3.

    In comparison to ropivacaine-alone and ropivacaine-fentanyl combinations, bupivacaine plus fentanyl was associated with greater intensity of motor

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Funding: Purely departmental/institutional.

☆☆

Conflict of interest: None declared.

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