Efficacy of epinephrine in local infiltration analgesia on pain relief and opioid consumption following total knee arthroplasty: a randomized controlled trial
DOI:
https://doi.org/10.2340/17453674.2023.8482Abstract
Background and purpose: Local infiltration analgesia (LIA) is one of the effective regimens to reduce pain after total knee arthroplasty (TKA). Epinephrine is a commonly used sympathetic adjunct in LIA. It is expected to enhance the intensity and extend the duration of LIA. The primary aim of the study was to evaluate the efficacy of epinephrine on postoperative pain control after primary TKA.
Patients and methods: A total of 80 patients who underwent primary TKA were randomized into an epinephrine (EN) and a control (C) group. Postoperative visual analogue pain score (VAPS) and morphine consumption were recorded every 6 hours until 48 hours after operation. The VAPS 6–48 hours were compared using repeated measure statistics. The range of motion (ROM) on discharge and complications were also compared between these 2 groups.
Results: The study showed that although VAPS differed statistically between the 2 groups at 12 hours (C higher) and 48 hours (C lower) postoperatively (p = 0.04 and 0.02, respectively), repeated measures analysis revealed that there were no significant differences in 6–48 hours VAPS (p = 0.6). Total morphine consumption in the EN and C groups was 3.4 (SD 3.7) and 4.2 (SD 4.4) mg, respectively (p = 0.4). ROM on discharge was also similar between the groups. No complications were detected in this study.
Conclusion: Our study showed that additional epinephrine in LIA had a statistically significant reduction in VAPS at 12 hours and morphine usage during 6–12 hours when compared with the control group. However, the magnitude of difference did not reach minimal clinically importance difference (MCID) value for TKA.
Downloads
References
Akyol O, Karayurt O, Salmond S. Experiences of pain and satisfaction with pain management in patients undergoing total knee replacement. Orthop Nurs 2009; 28(2): 79-85. DOI: https://doi.org/10.1097/NOR.0b013e3181945f62
Seangleulur A, Vanasbodeekul P, Prapaitrakool S, Worathongchai S, Anothaisintawee T, McEvoy M, et al. The efficacy of local infiltration analgesia in the early postoperative period after total knee arthroplasty: a systematic review and meta-analysis. Eur J Anaesthesiol 2016; 33(11): 816-31. DOI: https://doi.org/10.1097/EJA.0000000000000516
Ross J A, Greenwood A C, Sasser P, Jiranek W A. Periarticular injections in knee and hip arthroplasty: where and what to inject. J Arthroplasty 2017; 32(9S): S77-80. DOI: https://doi.org/10.1016/j.arth.2017.05.003
Förster J G, Rosenberg P H. Clinically useful adjuvants in regional anaesthesia. Curr Opin Anaesthesiol 2003; 16(5): 477-86. DOI: https://doi.org/10.1097/00001503-200310000-00007
Chareancholvanich K, Pornrattanamaneewong C. Does the length of incision in the quadriceps affect the recovery of strength after total knee replacement? A prospective randomised clinical trial. Bone Joint J 2014; 96-B(7): 902-6. DOI: https://doi.org/10.1302/0301-620X.96B7.33290
Pinsornsak P, Nangnual S, Boontanapibul K. Multimodal infiltration of local anaesthetic in total knee arthroplasty: is posterior capsular infiltration worth the risk? A prospective, double-blind, randomised controlled trial. Bone Joint J 2017; 99-B(4): 483-8. DOI: https://doi.org/10.1302/0301-620X.99B4.BJJ-2016-0877.R1
Danoff J R, Goel R, Sutton R, Maltenfort M G, Austin M S. How much pain is significant? Defining the minimal clinically important difference for the visual analog scale for pain after total joint arthroplasty. J Arthroplasty 2018; 33(7s): S71-S5.e2. DOI: https://doi.org/10.1016/j.arth.2018.02.029
Schotanus M G M, Bemelmans Y F L, van der Kuy P H M, Jansen J, Kort N P. No advantage of adrenaline in the local infiltration analgesia mixture during total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2017; 25(9): 2778-83. DOI: https://doi.org/10.1007/s00167-015-3723-4
Kong D Y, Oh J H, Choi W R, Ko Y-I, Choi C H. The impact of epinephrine in the periarticular injection cocktail using ropivacaine for total knee arthroplasty: a prospective, randomized, double-blind comparison study. J Arthroplasty 2020; 35(9): 2439-43. DOI: https://doi.org/10.1016/j.arth.2020.04.042
Kopacz D J, Carpenter R L, Mackey D C. Effect of ropivacaine on cutaneous capillary blood flow in pigs. Anesthesiology 1989; 71(1): 69-74. DOI: https://doi.org/10.1097/00000542-198907000-00013
Newton D J, Burke D, Khan F, McLeod G A, Belch J J, McKenzie M, et al. Skin blood flow changes in response to intradermal injection of bupivacaine and levobupivacaine, assessed by laser Doppler imaging. Reg Anesth Pain Med 2000; 25(6): 626-31. DOI: https://doi.org/10.1097/00115550-200011000-00014
Newton D J, McLeod G A, Khan F, Belch J J. Vasoactive characteristics of bupivacaine and levobupivacaine with and without adjuvant epinephrine in peripheral human skin. Br J Anaesth 2005; 94(5): 662-7. DOI: https://doi.org/10.1093/bja/aei095
Liu S, Carpenter R L, Chiu A A, McGill T J, Mantell S A. Epinephrine prolongs duration of subcutaneous infiltration of local anesthesia in a dose-related manner: correlation with magnitude of vasoconstriction. Reg Anesth 1995; 20(5): 378-84.
Tschopp C, Tramèr M R, Schneider A, Zaarour M, Elia N. Benefit and harm of adding epinephrine to a local anesthetic for neuraxial and locoregional anesthesia: a meta-analysis of randomized controlled trials with trial sequential analyses. Anesth Analg 2018; 127(1): 228-39. DOI: https://doi.org/10.1213/ANE.0000000000003417
Yoo S, Chung J-Y, Ro D H, Han H-S, Lee M C, Kim J-T. The hemodynamic effect of epinephrine-containing local infiltration analgesia after tourniquet deflation during total knee arthroplasty: a retrospective observational study. J Arthroplasty 2020; 35(1): 76-81. DOI: https://doi.org/10.1016/j.arth.2019.08.050
Kreuz P C, Steinwachs M, Angele P. Single-dose local anesthetics exhibit a type-, dose-, and time-dependent chondrotoxic effect on chondrocytes and cartilage: a systematic review of the current literature. Knee Surg Sports Traumatol Arthrosc 2018; 26(3): 819-30. DOI: https://doi.org/10.1007/s00167-017-4470-5
Additional Files
Published
How to Cite
License
Copyright (c) 2023 Keerati Chareancholvanich, Suphawat Tantithawornwat, Pakpoom Ruangsomboon, Rapeepat Narkbunnam, Swist Chatmaitri, Chaturong Pornrattanamaneewong
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
