Does ramosetron reduce postoperative emesis and pain after TKA?

Efficacy of preoperative prophylactic application of betamethasone on postoperative nausea and vomiting in patients undergoing total knee arthroplasty: a prospective randomized controlled trial

Background

The demand for total knee arthroplasty (TKA) is increasing, yet postoperative nausea and vomiting (PONV) significantly hinder patient recovery. Preoperative prophylactic administration of glucocorticoids can alleviate PONV, with betamethasone showing promising results in breast and cardiac surgeries. However, its efficacy in TKA patients remains unclear. This study evaluates the efficacy and safety of preoperative betamethasone for PONV in TKA patients through a prospective randomized controlled trial (RCT).

Materials and methods

In this trial, 124 patients were randomly assigned to receive either 2 mL of normal saline (control group) or 2 mL of betamethasone sodium phosphate (10.52 mg total dose; experimental group) 10 min before anesthesia induction. Primary outcomes included nausea severity, vomiting frequency, and antiemetic use, while secondary outcomes were pain scores, knee range of motion, blood glucose, IL-6, CRP, ESR, and adverse reactions.

Results

Results showed the experimental group had significantly lower nausea severity at 2, 4, 6, 12, and 24 h post-surgery compared to controls. The average frequency of vomiting in the experimental group (0.060 ± 0.307) was lower than that in the control group (0.390 ± 0.662), with a statistical difference (P < 0.001). The postoperative use of metoclopramide in the experimental group (0.480 ± 2.163) was lower than that in the control group (4.520 ± 6.447), and there was a statistical difference between the two groups (P < 0.001). CRP in the experimental group on the second day after surgery (45.741 ± 47.044) was lower than that in the control group (65.235 ± 50.970), with a statistical difference (P = 0.014). IL-6 in the experimental group was lower on the first (51.853 ± 67.202) and second postoperative days (25.143 ± 31.912) than that in the control group on the first (79.477 ± 97.441) and second postoperative days (38.618 ± 36.282), with statistical differences (P = 0.039, P = 0.006). There was no significant difference in postoperative knee pain, knee range of motion, blood glucose, ESR, and adverse reactions between the two groups.

Conclusion

Our prospective RCT demonstrates that preoperative betamethasone is effective and safe for reducing PONV in TKA patients, suggesting a new clinical approach for prophylactic treatment of PONV post-TKA.

Perioperative duloxetine improves postoperative outcomes after anterior talofibular ligament repair for chronic lateral ankle instability for patients with depression: A prospective randomized clinical trial

BACKGROUND

Recent studies have indicated that depression is associated with persistent postoperative pain and decreased satisfaction following foot and ankle surgery. This study aimed to evaluate the effect of perioperative duloxetine on postoperative outcomes of anterior talofibular ligament (ATFL) surgical repair for chronic ankle instability (CAI) in patients with depression. We further sought to evaluate patients' satisfaction and side effects related to duloxetine.

MATERIAL AND METHODS

Patients undergoing ATFL repair were screened for depression preoperatively with the Patient Health Questionnaire (PHQ-9). Among 249 patients who underwent arthroscopic or open surgical Brostrom repair of the ATFL, 120 patients were identified as being "possibly depressed" and were included in the study. Sixty patients were randomly assigned to the duloxetine group (one day preoperatively and for 6 weeks postoperatively), and the other sixty were randomized to the placebo group. Painkillers and opioid consumption, pain scores, and patient satisfaction were recorded at 12, 24, 48, and 72hours postoperatively and at follow-up visits 1, 3, and 6 months after surgery. Patient-reported outcome measures (PROMs) were assessed preoperatively and at 3, 6, 12 and 24 months postoperatively. Duloxetine-related side effects such as nausea/vomiting and fatigue were also recorded.

RESULTS

The patients in the duloxetine group reported a significantly longer time to rescue analgesic and reduced opioid requirements (including celecoxib, pregabalin, acetaminophen, and tramadol). The patients experienced decreased pain intensity and greater satisfaction with their pain management at 24, 48, 72h and 1 and 3 months after surgery (p<0.05). The duloxetine group also had significantly better clinical and functional outcomes at 3 and 6 months of follow-up compared to the placebo group (p<0.05). The occurrence and rate of symptoms of duloxetine side effects were not significant.

DISCUSSION

Depression is an important factor to consider and address because its presence before surgery can predict poor postoperative outcomes, including more severe postoperative pain, persistent postoperative pain, and increased consumption of painkillers and opioids.

CONCLUSION

Perioperative administration of duloxetine following ATFL repair for CAI in patients with depression increased the time to first postoperative rescue analgesic request and reduced both opioid consumption and postoperative pain. This approach also led to a high level of patient satisfaction. In addition, duloxetine improved the quality of recovery without leading to significant side effects.

LEVEL OF EVIDENCE

I; prospective randomized controlled trial.

Reduction of postoperative nausea and vomiting risk in the second stage during bilateral total knee arthroplasty with a 1-week interval

PURPOSE

Total knee arthroplasty (TKA) is often performed sequentially on both sides during a single hospital stay. Patients who experience postoperative nausea and vomiting (PONV) after the first operation are concerned about PONV recurrence after the second operation. However, there are few studies regarding the incidence of PONV in staged bilateral TKA with a ≥ 1-week interval. This study aimed to identify the differences in (1) PONV incidence, (2) use of rescue antiemetics, and (3) the amount of opioid consumption between the first and second operations for staged bilateral TKA with a 1-week interval. Based on our anecdotal experience, the hypothesis of this study was that during staged bilateral TKA at a 1-week interval, the PONV incidence and rescue antiemetic requirement after the second operation will be lower than those after the first operation, regardless of opioid consumption.

METHODS

Fifty-eight consecutive patients who underwent staged bilateral TKA with a 1-week interval were retrospectively reviewed. All second-stage operations were performed with the same anaesthesia protocol and perioperative patient management protocol as the first-stage operation. PONV incidence was the primary outcome. The requirement for rescue antiemetic drugs and the amount of opioid consumption were secondary outcome variables. The outcome variables were recorded during three postoperative days (Days 0-2) for each stage and were compared between the first and second operations.

RESULTS

The incidence rates of nausea and vomiting on Day 0 (p = 0.001 and p = 0.004, respectively) and nausea on Day 1 (p = 0.008) were significantly lower after the second operation. Rescue antiemetic use on Day 0 was significantly lower after the second operation (p = 0.001). The total opioid consumption 72 h after surgery was significantly higher after the second operation (61.76 vs. 34.28 mg, p < 0.001).

CONCLUSION

During staged bilateral TKA with a 1-week interval, PONV incidence was lower after the second operation, even with increased opioid consumption.

LEVEL OF EVIDENCE

III.

Dose optimization of intravenous dexamethasone for total knee arthroplasty: when two is not better than one

BACKGROUND

The optimal dose regimen of dexamethasone in total knee arthroplasty (TKA) has not been determined. This study was performed to evaluate the impact of a single preoperative high-dose dexamethasone compared with two perioperative low-dose dexamethasone in TKA.

MATERIALS AND METHODS

We prospectively studied three regimens on dexamethasone: no dexamethasone (A), a single preoperative dose of 20-mg dexamethasone (B), and two perioperative doses of 10-mg dexamethasone (C). The primary outcome was postoperative pain level. The incidence of postoperative nausea and vomiting (PONV), use of analgesic and antiemetic rescue, interleukin-6 (IL-6) and C-reactive protein (CRP) levels, range of motion (ROM), and complications were also compared.

RESULTS

The dynamic pain scores and CRP and IL-6 levels were significantly lower for Group B compared to Groups A and C on postoperative days 1 and 2 (POD 1 and 2). Such differences were also detected between Groups C and A. Besides, the pain scores at rest were significantly lower in Groups B and C than in Group A on POD 1 and 2. Patients in Groups B and C had a lower incidence of PONV, reduced use of analgesic and antiemetic rescue, and improved ROM than in Group A. No complications occurred in any group.

CONCLUSION

Dexamethasone in TKA provides short-term advantages in analgesic, antiemetic and anti-inflammatory effects. Besides, regarding the effects of pain and inflammatory control on POD 1 and 2, a single preoperative high dose of 20-mg dexamethasone was more effective than two perioperative low doses of 10-mg dexamethasone.

LEVEL OF EVIDENCE

I.

Effects of Ramosetron on Nausea and Vomiting Following Spinal Surgery: A Meta-Analysis

BACKGROUND

Spinal surgery is associated with severe pain within the first few days after surgery. Opioids are commonly used to control postoperative pain, but these can lead to postoperative nausea and vomiting (PONV). Therefore, use of more effective and better-tolerated agents would be beneficial for these patients. Serotonin receptor antagonists, such as ramosetron, have been used to reduce PONV in patients receiving anesthesia.

OBJECTIVE

We conducted a meta-analysis of published randomized controlled trials (RCTs) to compare the efficacy and tolerance of ramosetron to prevent PONV after spinal surgery.

METHODS

Medline, Embase, Cochrane Library, and Science Citation Index databases were systematically searched for relevant RCT articles published between January 1979 and November 2020. Full text articles restricted to English language that described RCTs comparing the use of ramosetron with other serotonin antagonists to treat PONV following spinal surgery in adult patients were considered for meta-analysis. Two reviewers independently performed study selection, quality assessment, and data extraction of all articles. Differences were resolved by a third reviewer.

RESULTS

The search identified 88 potentially relevant articles, of which only 3 met our selection criteria. Study drugs were administered at the end of spinal surgery in all 3 included articles. The meta-analysis revealed that ramosetron (0.3 mg) reduced the pain score (mean difference = -0.66; 95% CI -1.02 to -0.30), lowered the risk of PONV (risk ratio = 0.86; 95% CI, 0.76-0.97), and postoperative vomiting (risk ratio = 0.32; 95% CI, 0.17-0.60), and limited the use of rescue antiemetics (risk ratio = 0.66; 95% CI, 0.45-0.96) after spinal surgery. However, there were no significant differences in the incidence of postoperative nausea, the use of rescue pain medications, the number of rescue analgesics required, and the risk of discontinuation of patient-controlled analgesia between ramosetron and palonosetron (0.075 mg) or ondansetron (4 mg). There were no statistically significant differences in the risk of adverse events among the 3 medications.

CONCLUSIONS

This meta-analysis of 3 RCTs showed that ramosetron reduced the risk of PONV and POV, limited the use of rescue antiemetics, reduced the postoperative pain score, and did not increase the risk of discontinuing patient-controlled analgesia compared with palonosetron or ondansetron after spinal surgery in 3 RCTs. Therefore, this meta-analysis indicates that ramosetron is an effective and well tolerated antiemetic that can be used to prevent PONV following spinal surgery in adult patients. PROSPERO identifier: CRD42020223596 (Curr Ther Res Clin Exp. 2022; 83:XXX-XXX)© 2022 Elsevier HS Journals, Inc.

Assessing outcome in postoperative pain trials: are we missing the point? A systematic review of pain-related outcome domains reported in studies early after total knee arthroplasty

ABSTRACT

The management of acute postoperative pain remains suboptimal. Systematic reviews and Cochrane analysis can assist with collating evidence about treatment efficacy, but the results are limited in part by heterogeneity of endpoints in clinical trials. In addition, the chosen endpoints may not be entirely clinically relevant. To investigate the endpoints assessed in perioperative pain trials, we performed a systematic literature review on outcome domains assessing effectiveness of acute pain interventions in trials after total knee arthroplasty. We followed the Cochrane recommendations for systematic reviews, searching PubMed, Cochrane, and Embase, resulting in the screening of 1590 potentially eligible studies. After final inclusion of 295 studies, we identified 11 outcome domains and 45 subdomains/descriptors with the domain "pain"/"pain intensity" most commonly assessed (98.3%), followed by "analgesic consumption" (88.8%) and "side effects" (75.3%). By contrast, "physical function" (53.5%), "satisfaction" (28.8%), and "psychological function" (11.9%) were given much less consideration. The combinations of outcome domains were inhomogeneous throughout the studies, regardless of the type of pain management investigated. In conclusion, we found that there was high variability in outcome domains and inhomogeneous combinations, as well as inconsistent subdomain descriptions and utilization in trials comparing for effectiveness of pain interventions after total knee arthroplasty. This points towards the need for harmonizing outcome domains, eg, by consenting on a core outcome set of domains which are relevant for both stakeholders and patients. Such a core outcome set should include at least 3 domains from 3 different health core areas such as pain intensity, physical function, and one psychological domain.

Effects of preoperative, scheduled administration of antiemetics in reducing postoperative nausea and vomiting in patients undergoing total knee arthroplasty

There is no established protocol regarding the timing of administration of antiemetics in patients undergoing total knee arthroplasty (TKA). The purpose of this study was to determine whether preoperative, rather than postoperative administration of an antiemetic could reduce postoperative nausea and vomiting (PONV) in patients undergoing TKA, and whether there was a difference in postoperative pain, patient satisfaction and complications after TKA between the 2 different administration times.The included patients (N = 101) either received intravenous administration of the ramosetron 1 hour before surgery (N = 50) or at the end of surgery (N = 51) consecutively order. The incidence of PONV and the frequency of rescue medicine use were recorded until 48 hours postoperatively. The severity of postoperative pain and patient satisfaction were assessed using the visual analogue scale. The incidence of complications associated with use of antiemetic was assessed.Preoperative administration of ramosetron did not decrease PONV during the first 48 hours. There was no significant difference in the incidence of nausea and vomiting, use of rescue antiemetics, and the severity of nausea (P > .05). Postoperative pain, satisfaction scores, and the incidence of complications were not different between the 2 groups (P > .05).Preoperative administration of ramosetron did not show clinical advantage in reducing POVN, postoperative pain and improving patient satisfaction. However, the outcomes of complications were not inferior to those of postoperative administration. Therefore, under the current protocol of multimodal therapies, timing of administration of pre-emptive antiemetic did not have significant effect on PONV.

Repeat Doses of Dexamethasone up to 48 Hours Further Reduce Pain and Inflammation After Total Hip Arthroplasty: A Randomized Controlled Trial

BACKGROUND

The optimal dose regimen of dexamethasone in total hip arthroplasty (THA) is unclear. This study was conducted to compare the effects among 1-dose, 2-dose, and 3-dose dexamethasone in THA.

METHODS

One hundred fifty patients were randomized to receive a single preoperative dose of 10-mg dexamethasone (group A, 50 patients), or another dose of 10-mg dexamethasone 24 hours later (group B, 50 patients), or another 2 doses of 10-mg dexamethasone 24 and 48 hours later (group C, 50 patients). The primary outcome was postoperative pain level. The use of analgesic and antiemetic rescue; incidence of postoperative nausea and vomiting; C-reactive protein and interleukin-6 levels; range of motion; and complications were also compared.

RESULTS

The dynamic pain scores were lower for groups B and C compared to group A on postoperative days 2 and 3. Such difference was also detected between groups B and C on postoperative day 3. C-reactive protein and interleukin-6 levels were lower in groups B and C than in group A at 48 and 72 hours postoperatively. Such difference was also observed between groups B and C at 72 hours postoperatively. Patients in groups B and C had reduced rescue analgesic use, and improved range of motion compared to patients in group A. There were no differences among 3 groups regarding the rescue antiemetic use, postoperative nausea and vomiting occurrence, and complications.

CONCLUSION

Additional administrations of dexamethasone after THA could provide sustained pain relief and inflammatory control. Besides, the 3-dose regimen was more effective than the 2-dose regimen in terms of the analgesic and anti-inflammatory effects.

LEVEL OF EVIDENCE

I.

Is a split-dose intravenous dexamethasone regimen superior to a single high dose in reducing pain and improving function after total hip arthroplasty? A randomized blinded placebo-controlled trial

Aims

Intravenous dexamethasone has been shown to reduce immediate postoperative pain after total hip arthroplasty (THA), though the effects are short-lived. We aimed to assess whether two equivalent perioperative split doses were more effective than a single preoperative dose.

Methods

A total of 165 patients were randomly assigned into three groups: two perioperative saline injections (Group A, placebo), a single preoperative dose of 20 mg dexamethasone and a postoperative saline injection (Group B), and two perioperative doses of 10 mg dexamethasone (Group C). Patients, surgeons, and staff collecting outcome data were blinded to allocation. The primary outcome was postoperative pain level reported on a ten-point Numerical Rating Scale (NRS) at rest and during activity. The use of analgesic and antiemetic rescue, incidence of postoperative nausea and vomiting (PONV), CRP and interleukin-6 (IL-6) levels, range of motion (ROM), length of stay (LOS), patient satisfaction, and the incidence of surgical site infection (SSI) and gastrointestinal bleeding (GIB) in the three months postoperatively, were also compared.

Results

The pain scores at rest were significantly lower in Groups B and C than in Group A on postoperative days 1 and 2. The dynamic pain scores and CRP and IL-6 levels were significantly lower for Groups B and C compared to Group A on postoperative days 1, 2, and 3. Patients in Groups B and C had a lower incidence of PONV, reduced use of analgesic and antiemetic rescue, improved ROM, shorter LOS, and reported higher satisfaction than in Group A. Patients in Group C had significantly lower dynamic pain scores and IL-6 and CRP levels on postoperative days 2 and 3, and higher ROM and satisfaction on postoperative day 3 than in Group B. No SSI or GIB occurred in any group.

Conclusion

Perioperative dexamethasone provides short-term advantages in reducing pain, PONV, and inflammation, and increasing range of motion in the early postoperative period after THA. A split-dose regimen was superior to a single high dose in reducing pain and inflammation, and increasing ROM, with better patient satisfaction. Level of evidence: I Cite this article: Bone Joint J 2020;102-B(11):1497–1504.

Effect of periarticular morphine injection for total hip arthroplasty: a randomised, double-blind trial

BACKGROUND

The periarticular multimodal cocktail injection is currently commonly used to treat postoperative pain after total hip arthroplasty (THA). Despite its analgesic effect, it is frequently reported to cause nausea and vomiting, which are adverse effects of opioids. This study aimed to assess the efficacy of morphine as a component of a multimodal cocktail injection for providing postoperative analgesia and alleviating swelling in patients who underwent THA.

MATERIALS AND METHODS

This was a prospective, single-centre, randomised controlled trial involving 100 patients scheduled for unilateral THA. A mixture of steroids, local anaesthetics, NSAIDs, and epinephrine with or without morphine (0.1 mg/kg), was injected into randomly assigned patients. Postoperative assessment was performed with all attending personnel and patients blind to group assignment. Visual analogue scale (VAS) of pain, range of motion (ROM), nausea numerical rating scale (NRS), the total dose of antiemetic drugs used and thigh swelling were compared between groups on postoperative days.

RESULTS

Pain VAS scores both at rest and on motion did not differ between the 2 groups at any postoperative time-point. The nausea NRS scores during the postoperative period from 0 minutes to 1 hour and the total dose of antiemetic drugs administered were significantly higher in the morphine group. The thigh girth showed no difference between groups on any of the postoperative days.

CONCLUSIONS

The results of this study suggested that addition of morphine to the multimodal cocktail injection after THA is not effective for relieving postoperative pain, alleviating swelling, or improving ROM, and results in nausea and vomiting. Randomised controlled trial registration number UMIN000022668.

Duloxetine Reduces Pain and Improves Quality of Recovery Following Total Knee Arthroplasty in Centrally Sensitized Patients: A Prospective, Randomized Controlled Study

BACKGROUND

Unexplained postoperative pain is one of the most feared complications of total knee arthroplasty (TKA). A persistent noxious peripheral stimulus, such as the pain of chronic knee osteoarthritis, can cause central sensitization in which the central nervous system becomes hyperexcitable, resulting in hypersensitivity to both noxious and non-noxious stimuli. Patients with central sensitization may be more susceptible to unexplained pain after TKA. Duloxetine, a selective serotonin norepinephrine reuptake inhibitor (SNRI), can ameliorate the pain associated with central sensitization, and we aimed to determine whether it could reduce postoperative pain and improve quality of recovery after TKA in patients with central sensitization.

METHODS

Patients undergoing TKA were screened for central sensitization preoperatively with use of the Central Sensitization Inventory (CSI). Among 464 patients with primary osteoarthritis who were scheduled for primary unilateral TKA, 80 were identified as being centrally sensitized and were included in the study. Forty patients were randomly assigned to the duloxetine group (30 mg 1 day before surgery and for 6 weeks after surgery), and 40 were randomized to the control group (no duloxetine). Pain and quality of recovery were assessed with use of the Brief Pain Inventory (BPI), the Short Form-36 (SF-36), the Measure of Intermittent and Constant Osteoarthritis Pain (ICOAP), and the Hamilton Depression Scale. The prevalence of adverse medication effects was also noted.

RESULTS

The patients in the duloxetine group had better performance across pain metrics during the initial 2 to 12-week postoperative period (p < 0.05). The duloxetine group also had a superior quality of recovery 2 weeks after TKA, as indicated by emotional and physical functioning (all p < 0.05). There was no difference between groups in the prevalence of adverse events.

CONCLUSIONS

A substantial number of patients are centrally sensitized before TKA. Surgeons should consider selective incorporation of duloxetine into the multimodal postoperative analgesic protocol, according to the severity of central sensitization, to minimize the possibility of persistent pain following TKA.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Perioperative multiple low-dose Dexamethasones improves postoperative clinical outcomes after Total knee arthroplasty

Background

The purpose of this study was to investigate the efficacy and safety of multiple low-dose dexamethasones in primary total knee arthroplasty (TKA).

Methods

One hundred fifty patients were equally randomized into 3 groups: Group A (n = 50) received 2 doses of normal saline only; Group B (n = 50) received with 1 dose of intravenous dexamethasone and 1 dose of normal saline; Group C (n = 50) received with 2 doses of intravenous dexamethasone. The clinical outcomes and complications were assessed.

Results

The CRP and IL-6 were significantly lower in Group C and B than Group A at 24, 48, and 72 h postoperatively (P < 0.001 for all). The intensity of postoperative nausea and vomiting (PONV) in Group C was lower than Group A at 24 (P < 0.001, P = 0.002), 48 (P = 0.005, P = 0.041) and 72 h (P = 0.017, P = 0.031) postoperatively and Group B at 24 h (P = 0.027, P = 0.019) postoperatively. Pain were significantly less in Group C than Group A at 24 (P < 0.001), 48 h (P = 0.037) postoperatively and Group B 24 h (P = 0.030) postoperatively. Patients in Group C had better range of motion (ROM) and satisfaction than Group A (P < 0.001, P = 0.002) and B (P = 0.001, P = 0.043). No differences were found in complications.

Conclusions

The administration of 10 mg dexamethasone 1 h before the surgery, and repeated at 6 h postoperatively can significantly reduce the level of postoperative CRP and IL-6 and the incidence of PONV, relieve pain, achieve an additional analgesic effect, and improve the early ROM compared with the other two groups in TKA.

Level of Evidence

Therapeutic Level I.

Trial registration

The Chinese Clinical Trial Registry (ChiCTR1800017036). Registered on July 9, 2018.

Effects of palonosetron for prophylaxis of postoperative nausea and vomiting in high-risk patients undergoing total knee arthroplasty: A prospective, randomized, double-blind, placebo-controlled study

Background

The preemptive multimodal pain protocols used in total knee arthroplasty (TKA) often cause emesis postoperatively. We investigated whether palonosetron prophylaxis reduces postoperative nausea and vomiting (PONV) in high-risk patients after TKA.

Methods

We randomized 120 female patients undergoing TKA to receive either palonosetron (0.075 mg, intravenous) or no antiemetic prophylaxis (0.9% saline, control group). All patients were given spinal anesthesia, a continuous femoral nerve block, and fentanyl-based intravenous patient controlled analgesia. Patients undergoing staged bilateral TKA were assigned to one group for the first knee and the other group for the second knee. The overall incidence of PONV, the incidences of both nausea and vomiting, severity of nausea, complete response, requirement for rescue antiemetics, pain level, opioid consumption, and satisfaction scores were evaluated during three periods: 0–2, 2–24, and 24–48 h postoperatively. We also compared PONV and pain between the first and second TKA.

Results

The incidence of PONV during the first 48 h was lower in the palonosetron group compared with the controls (22 vs. 41%, p = 0.028), especially 2–24 h after surgery, as was the nausea and vomiting respectively. The severity of nausea was lower in the palonosetron group (p = 0.010). The complete response rate (93 vs. 73%, p = 0.016) and satisfaction score (84 ± 12 vs. 79 ± 15, p = 0.032) were higher in the palonosetron group during 2–24 h after surgery. Patients who underwent a second operation complained of more severe pain, and consumed more opioids than those of the first operation. There was no difference in the incidence of PONV between the first and second operations.

Conclusions

Palonosetron prophylaxis reduced the incidence and severity of PONV in high-risk patients managed with multimodal pain protocol for 48 h, notably 2–24 h after TKA.

Effect of Periarticular Morphine Injection for Total Knee Arthroplasty: A Randomized, Double-Blind Trial

BACKGROUND

The periarticular multimodal cocktail injection including morphine is currently commonly used to treat postoperative pain after total knee arthroplasty (TKA). Despite its analgesic effect, it is frequently reported to cause nausea and vomiting, which are adverse effects of opioids. This study aimed to assess the efficacy of morphine as a component of a multimodal cocktail injection for providing postoperative analgesia and alleviating swelling in patients who underwent TKA.

METHODS

This is a prospective, single-center, randomized controlled trial involving 102 patients scheduled for unilateral TKA. A mixture of steroids, local anesthetics, nonsteroidal anti-inflammatory drugs, and epinephrine with or without morphine (10 mg) was injected to randomly assigned patients. Postoperative assessment was performed with all attending personnel and patients blinded to group assignment. Visual analog scale of pain, range of motion, nausea numerical rating scale, number of patients with vomiting, total dose of antiemetic drugs used, thigh swelling, the Western Ontario and McMaster Universities Osteoarthritis Index score, and adverse outcomes were compared between groups on postoperative days.

RESULTS

Visual analog scale scores did not differ between the 2 groups at any postoperative time point. The nausea numerical rating scale scores during the postoperative period from 30 min to 9 h, the number of vomiting episodes, and the total dose of antiemetic drugs administered were significantly higher in the morphine group. The thigh girth, Western Ontario and McMaster Universities Osteoarthritis Index, and the incidence of complications were not different between groups.

CONCLUSION

The results of this study suggested that addition of morphine to the multimodal cocktail injection is not effective for relieving postoperative pain, alleviating swelling, or improving range of motion, and results in nausea and vomiting.

Comparison of Ramosetron With Ondansetron for Prevention of Intrathecal Morphine-Induced Nausea and Vomiting After Primary Total Knee Arthroplasty: A Randomized Control Trial

BACKGROUND

Spinal anesthesia with intrathecal morphine is a reliable, easy to apply, and cost effective method for controlling pain after total knee arthroplasty (TKA). However, postoperative nausea and vomiting (PONV) is a major concern. 5-Hydroxytryptamine receptor 3 (5-HT₃) antagonists like ondansetron and ramosetron are commonly used for preventing PONV, but the optimal choice remains unclear. We conducted a study to assess the effectiveness of ramosetron and ondansetron, hypothesizing that the longer acting ramosetron may be better than ondansetron in the first 48 hours after TKA, performed with spinal anesthesia and intrathecal morphine.

METHODS

Patients were randomized preoperatively to either intravenous ondansetron (8 mg) or ramosetron (0.3 mg). The primary outcomes were the incidence rates of PONV. Secondary outcomes were the need for a rescue antiemetic (metoclopramide), pain score, patient satisfaction, and adverse drug reactions (ADRs) at 0-6, 6-12, 12-24, and 24-48 hours.

RESULTS

Ninety patients were evaluable; 45 patients/arm. Compared with ondansetron, ramosetron was associated with significantly lower incidence rates of nausea at: (1) 12-18 hours: 3/45 vs 11/45 (P = .016), (2) 18-24 hours: 1/45 vs 9/45 (P = .005), and vomiting at 18-24 hours: 1/45 vs 6/45 (P = .044). There were no significant differences in the use of rescue-antiemetic medicine, pain score, patient satisfaction, and ADRs.

CONCLUSION

Preoperative ramosetron provided more prolonged PONV prophylaxis than ondansetron after TKA in our setting, and had a similar ADR profile. Other trials are needed to confirm our results before ramosetron is adopted widely.

Preemptive low-dose dexamethasone reduces postoperative emesis and pain after TKA: a randomized controlled study

BACKGROUND

Dexamethasone is a potent analgesic and antiemetic. However, the benefit of dexamethasone after TKA is unclear, as is the efficacy in a current multimodal regime.

QUESTIONS/PURPOSES

We determined (1) whether the addition of dexamethasone to a protocol including ramosetron further reduces postoperative emesis compared with ramosetron alone; (2) whether it reduces postoperative pain; and (3) whether it increases the risk for wound complications in a current multimodal regime after TKA.

METHODS

We randomized 269 patients undergoing TKAs to receive dexamethasone (10 mg) 1 hour before surgery and ramosetron immediately after surgery (Dexa-Ra group, n = 135), or ramosetron alone (Ra group, n = 134). We recorded the incidence of postoperative nausea and vomiting (PONV), severity of nausea, incidence of antiemetic requirement, complete response, pain level, and opioid consumption. Patients were assessed 0 to 6, 6 to 24, 24 to 48, and 48 to 72 hours postoperatively. In addition, patients were evaluated for wound complications and periprosthetic joint infections at a minimum of 1 year after surgery.

RESULTS

The Dexa-Ra group had a lower incidence of PONV during the entire 72-hour evaluation period and experienced less severe nausea for the first 6 hours after TKA, although not between 6 to 72 hours. Overall use of a rescue antiemetic was less frequent, and complete response was more frequent in the Dexa-Ra group. Patients in the Dexa-Ra group experienced lower pain and consumed less opioids during the 6- to 24-hour period and during the overall study period. No differences were found in wound complications between the groups, and each group had one case of periprosthetic joint infection.

CONCLUSIONS

Patients who received prophylactic dexamethasone in addition to ramosetron had reduced postoperative emesis and pain without increased risks for wound complications, compared with patients who received ramosetron alone in patients managed using a multimodal regimen after TKA.