title: Preoperative intra-articular morphine and bupivacaine for pain control after outpatient arthroscopic anterior cruciate ligament reconstruction.
abstract: OBJECTIVE
  The purpose of this study was to determine whether intra-articular injection of bupivacaine, morphine, or a combination prior to surgery provided pain control after arthroscopic anterior cruciate ligament (ACL) reconstruction.
  
  
  METHODS
  These data were collected as a two-stage prospective, randomized, blinded observer study. All patients received a standard general anesthetic, which included an intra-articular injection 20 minutes prior to incision. In phase I, three solutions were assigned randomly in a 60-mL volume. Group 1 was saline, group 2 was 0.25% bupivacaine, and group 3 was 0.25% bupivacaine with 1 mg morphine sulfate (MS). Phase II was identical to phase I in technique and had four groups. Group 1 was 0.25% bupivacaine, group 2 was 1 mg MS in saline, group 3 was 0.25% bupivacaine with 1 mg MS, and group 4 was 0.25% bupivacaine with 3 mg MS. All groups in phases I and II contained 1:200,000 epinephrine, freshly added. Pain scores were evaluated at 0, 30, 60, 90, 120, and 240 minutes postoperative using a visual analog scale. For pain scores of 5 or greater, 50 microg fentanyl was administered at 5-minute intervals until pain was controlled. After transition from phase I to phase II of the postanesthesia care unit (PACU), hydrocodone/acetaminophen tablets were used.
  
  
  RESULTS
  Thirty patients were entered into phase I of the study. Both treatment groups (2 and 3) had significant (P < .05) pain reduction on arrival to the PACU. Group 3 had significantly (P < .05) reduced need for fentanyl during the PACU stay. Forty-nine patients entered phase II of the study. In phase II, group 3 had the lowest pain scores on arrival to the PACU. At 120 and 240 minutes, pain scores were lower in groups 3 and 4. Fentanyl and hydrocodone uses were significantly lower during the PACU stay in groups 3 and 4.
  
  
  CONCLUSIONS
  Presurgical injection of a solution of 0.25 % bupivacaine, morphine, and epinephrine provided pain control and decreased opioid use in the PACU. Increasing the morphine dose did not improve the clinical result.
authors.affiliation: Department of Anesthesiology, The Cleveland Clinic Foundation, Ohio 44195, USA.
authors.forename: J E
authors.initials: JE
authors.lastname: Tetzlaff
authors.forename: J A
authors.initials: JA
authors.lastname: Dilger
authors.forename: J
authors.initials: J
authors.lastname: Abate
authors.forename: R D
authors.initials: RD
authors.lastname: Parker
mesh_terms: D000082:Acetaminophen / Q000627:therapeutic use; D000556:Ambulatory Surgical Procedures / Q000009:adverse effects / Q000379:methods; D018712:Analgesics, Non-Narcotic / Q000627:therapeutic use; D000701:Analgesics, Opioid / Q000008:administration & dosage* / Q000627:therapeutic use; D000779:Anesthetics, Local / Q000008:administration & dosage*; D016118:Anterior Cruciate Ligament / Q000601:surgery*; D001182:Arthroscopy / Q000379:methods; D002045:Bupivacaine / Q000008:administration & dosage*; D004338:Drug Combinations; D004359:Drug Therapy, Combination; D005283:Fentanyl / Q000627:therapeutic use; D006801:Humans; D006853:Hydrocodone / Q000627:therapeutic use; D007270:Injections, Intra-Articular; D009020:Morphine / Q000008:administration & dosage*; D010045:Outpatients; D010149:Postoperative Pain / Q000188:drug therapy / Q000209:etiology / Q000517:prevention & control*; D011300:Preoperative Care; D011446:Prospective Studies; D019651:Plastic Surgery Procedures / Q000009:adverse effects* / Q000379:methods*; D016037:Single-Blind Method
chemical_list: D018712:Analgesics, Non-Narcotic; D000701:Analgesics, Opioid; D000779:Anesthetics, Local; D004338:Drug Combinations; D000082:Acetaminophen; D006853:Hydrocodone; D009020:Morphine; D005283:Fentanyl; D002045:Bupivacaine