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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 17  |  Issue : 4  |  Page : 398-403

Effects of adding morphine to intra-articular dexamethasone injection on postoperative pain after arthroscopic subacromial decompression shoulder surgery


Department of Anesthesia and Intensive Care, Al-Azhar Faculty of Medicine for Male, Al-Azhar University, Cairo, Egypt

Date of Submission19-Sep-2019
Date of Decision22-Sep-2019
Date of Acceptance22-Oct-2019
Date of Web Publication14-Feb-2020

Correspondence Address:
Sameh H Seyam
Department of Anesthesia and Intensive Care, Al-Azhar faculty of Medicine for Male, Al-Azhar University, Cairo, 12992
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AZMJ.AZMJ_129_19

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  Abstract 


Background Arthroscopic shoulder surgery is a common method in the surgical treatment of shoulder diseases. We compared a combination of dexamethasone–bupivacaine–morphine against bupivacaine–morphine, as well as bupivacaine alone following arthroscopic subacromial decompression surgery. The study aimed for better quality of postoperative analgesia and lower pain intensity.
Patients and methods This prospective, randomized, double-blinded controlled study was conducted on 60 patients undergoing arthroscopic shoulder subacromial decompression surgery. The patients were randomly allocated into three equal groups. All medications were injected intra-articularly at the end of the procedure. In the control group, 10 ml of 0.5% bupivacaine+5 ml isotonic saline (total volume, 15 ml) were injected. In the morphine group, 5 mg morphine diluted in 5 ml normal saline+10 ml of 0.5% bupivacaine was injected. In the morphine–dexamethasone group, 5 mg morphine+400 μg/kg weight dexamethasone completed to 5 ml with normal saline+10 ml of 0.5% bupivacaine was injected. Visual analog score, vital signs, time of first analgesic request, need for supplemental analgesic, and adverse effects were recorded.
Results The morphine–dexamethasone group showed a lower visual analog score at rest and movement, delayed time for first analgesic request, more stable vital signs, and less adverse effects as compared with the other groups.
Conclusion Addition of intra-articular morphine to dexamethasone and bupivacaine has a remarkable analgesic efficacy, a much-prolonged postoperative pain control, minimal postoperative analgesic requirement, and better patient compliance with minimal side effects.

Keywords: dexamethasone, local anesthetics, morphine, postoperative analgesia, shoulder arthroscopy


How to cite this article:
Seyam SH, Elsheshtawy K, Abdelmaboud MA. Effects of adding morphine to intra-articular dexamethasone injection on postoperative pain after arthroscopic subacromial decompression shoulder surgery. Al-Azhar Assiut Med J 2019;17:398-403

How to cite this URL:
Seyam SH, Elsheshtawy K, Abdelmaboud MA. Effects of adding morphine to intra-articular dexamethasone injection on postoperative pain after arthroscopic subacromial decompression shoulder surgery. Al-Azhar Assiut Med J [serial online] 2019 [cited 2020 Feb 29];17:398-403. Available from: http://www.azmj.eg.net/text.asp?2019/17/4/398/278393




  Introduction Top


Shoulder pain is a common problem. Yearly, one in every 50 adults in the United Kingdom complain of shoulder pain [1]. Among those people, subacromial pain syndrome or what is called (rotator cuff disease) is the most common finding [2]. Regarding subacromial lesions found in cadaver shoulders, surgeons considered that subacromial pain syndrome can occur due to encroachment of the rotator cuff tendons in between the humeral head and the base of the acromion process [3]. Arthroscopic shoulder surgery is a common method in the surgical treatment of shoulder diseases (such as glenoid labial tear, rotator cuff tear, and subacromial bursitis). Postoperatively, around 45% of patients have severe pain, which results in too much discomfort and postponed discharge [4]. The way of intra-articular drug administration exploits the peripheral receptors and administration of local anesthetics through this route is frequently done after arthroscopic knee surgery. However, in arthroscopic shoulder surgeries, intra-articular analgesics are not commonly used. Earlier studies have reported the use of opioids like morphine, local anesthetics like ropivacaine or bupivacaine, and magnesium sulfate intra-articularly in arthroscopic shoulder surgeries with different periods of analgesia for postoperative pain management [5]. Although a limited number of researches demonstrated the analgesic effect of fixed-dose dexamethasone following arthroscopic shoulder surgeries, in this study, we compared a combination of dexamethasone–bupivacaine–morphine against bupivacaine–morphine, as well as bupivacaine alone following arthroscopic subacromial decompression surgery. We report the extended analgesic effects of adding morphine to dexamethasone following arthroscopic shoulder subacromial decompression surgery.


  Aim Top


To study the efficacy of adding morphine to dexamethasone and bupivacaine injected intra-articularly in patients undergoing arthroscopic shoulder subacromial decompression surgery as regards the primary outcome [visual analog score (VAS) at rest and movement] or secondary outcomes (vital signs, time of first analgesic request, need for supplemental analgesic, and adverse effects).


  Patients and methods Top


This prospective, randomized, double-blinded controlled study was conducted on 60 patients of both sexes, after approval of the ethics committee of Al-Azhar University Hospitals and obtaining informed written consent. The study was conducted in Al-Azhar University Hospitals from June 2015 to October 2016. Inclusion criteria were as follows: age between 21 and 60 years, American Society of Anesthesiologists I and II physical status, and scheduled for subacromial decompression arthroscopic shoulder surgeries.

Patients with evidence of any major systemic illness, history of allergy to any of the drugs in the study, morphine addiction, or history of convulsive disorders were excluded from the study. General anesthesia was given to all patients. On arrival to the operating room, routine monitors were applied (Nihon Kohden, Tokyo, Japan). Anesthesia was induced by intravenous fentanyl 1 µg/kg and propofol 2 mg/kg. Cuffed endotracheal tube of appropriate size was inserted after complete muscle relaxation by atracurium hydrochloride 0.8 mg/kg. Anesthesia was maintained by sevoflurane 2% (1 MAC) in 100% oxygen. Patients were randomly allocated by computer-generated programs and sealed opaque envelopes into three equal groups according to the studied groups, 20 patients in each group.

Group 1 (control group, B), 10 ml of 0.5% bupivacaine (Markyrene 0.5%; Sigmatec Pharmaceuticals Industries Co. packed by Al-Debeiky Pharma, Obour City, Egypt) and 5 ml isotonic saline (total volume 15 ml) were injected. Group 2 (morphine group, MB), 5 mg morphine (morphine sulfate 20 mg/ml; Misr Company for Pharmaceuticals, Abo Zaabal, Qalubia, Egypt) diluted in 5 ml normal saline+10 ml of 0.5% bupivacaine was injected. Group 3 (morphine–dexamethasone, MDB), 5 mg morphine+400 μg/kg weight dexamethasone completed to 5 ml with normal saline+10 ml of 0.5% bupivacaine was injected.

All solutions were injected at the end of the operation. Preoperatively, the patients were instructed to report their pain using the VAS with ‘0’ representing ‘no pain,’ whereas ‘10 cm’ representing the ‘worst imaginable pain.’ Postoperative pain at rest and movement was assessed by VAS at the following postoperative periods: time of full recovery, 1, 2, 3, 4, 6, 12, 18, and 24 h. The patients were monitored postoperatively for a period of 24 h for the following parameters: heart rate, mean arterial blood pressure, respiratory rate, SpO2, time of first analgesic request (usually associated with VAS >3), and need for supplemental analgesic. Supplemental analgesia was provided with (pethidine) 50 mg if VAS of greater than 3 and total consumption was recorded over 24 h. Adverse effects like nausea, vomiting, pruritus, respiratory, and depression were recorded. The study drugs were prepared by one anesthesiologist and injected by another anesthesiologist who was blinded to the study drugs. The nurse who was observing the patient and recoding the postoperative study parameters was blinded to the study drugs.


  Results Top


As regards demographic data, American Society of Anesthesiologists, type, and duration of surgery, there was no significant differences among all groups as shown in [Table 1] (P>0.05).
Table 1 Patient characteristics and duration of surgery

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As regards VAS scores for pain at rest and movement, it was significantly lower in the MB group in comparison with the control group for the first 6 postoperative hours (P<0.0001). VAS scores at rest and movement were significantly lower in the MDB group compared with the control (B) and MB groups for the first 12 postoperative hours (P<0.0001) and was comparable among groups at other periods of measurement as shown in [Table 2] and [Figure 1].
Table 2 Visual analog scale scoring at recovery and 24 h postoperatively

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Figure 1 VAS scoring at recovery and 24 h postoperatively. VAS, visual analog scale.

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As regards time for first analgesic demand, it was significantly prolonged in the MB group (6.32±0.90 h) and MDB group (19.02±1.43 h) compared with the control group (4.72±0.77 h) (P<0.0001) and significantly prolonged in the MDB group compared with the MB group (P<0.01) as shown in [Table 3].
Table 3 Analgesia duration and total analgesic requirement in 24 h

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The total consumption of pethidine was highly significantly lower in the MB group (45.38±11.34 mg) and MDB group (21.34±5.56 mg) compared with the control group (80.52±14.12 mg) (P<0.001) and significantly lower in the MDB group compared with the MB group (P<0.0001) as shown in [Table 3].

The heart rate, MABP, SpO2, and respiratory rate showed no statistically significant difference among all groups in the intraoperative and postoperative periods (P>0.05) as shown in [Table 4] and [Table 5].
Table 4 Heart rate before and for 24 h after surgery

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Table 5 Mean arterial blood pressure before and for 24 h after surgery

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As regards the complications, the number of patients with pruritus was 4/20 (20%) patients, in the MB group and 3/20 (15%) patients in the MDB group, with no statistically significant difference (P>0.05) and 0/20 (0%) patients in the control group. There were no recorded cases of respiratory depression, nausea, or vomiting in the three groups.


  Discussion Top


In this study we attempted to improve the mode of recovery after shoulder arthroscopic surgery by implementing prolonged and effective postoperative analgesia. Our aim in the present study was to prolong analgesia, decrease VAS for pain (at rest and movement), and to decrease analgesic consumption by adding dexamethasone to intra-articular morphine after shoulder arthroscopic surgeries.

Arthroscopic subacromial decompression is often followed by severe postoperative pain as a result of soreness of free nerve endings of the synovial tissue and joint capsule during surgical excision, insertion of hard wires, removal of bone or soft tissue distension from the irrigation fluid [6].

Good and early postoperative rehabilitation depends on postoperative pain management and early mobilization. Local and regional anesthesia has greatly developed as a solution for postoperative pain relief although its intra-articular administration method following shoulder arthroscopy is not yet in routine clinical practice.

Our study recorded the postoperative analgesic effect of adding morphine 5 mg to dexamethasone at a dose of 400 μg/kg weight as an adjunct to bupivacaine following arthroscopic subacromial decompression. We observed a lengthy analgesic period and decreased analgesics requirement postoperatively with a better patient compliance and satisfaction.

These results correspond with the results of Panigrahi et al. [7]. In that study they used dexamethasone intra-articularly following arthroscopic Bankart repair. The patients were randomly assigned into three groups, the first group (1) received 20 ml normal saline, the second group (2) received 20 ml 0.2% ropivacaine, and the third group (3) received 15 ml 0.2% of ropivacaine and dexamethasone at a dose of 300 μg/kg intra-articularly. Variables checked was the VAS score, time to first postoperative analgesic request, and total analgesics required during the first 24 h postoperatively. They noticed that group 3 has significant lower pain scores for more than 24 h as compared with groups 2 and 1. Time to first analgesic request was the longest in group 3 (1562.2±79.10 min) (P<0.01). Strength of pain and total analgesic requirement were also significantly less in group 3 (32.2±23.83 mg) (P<0.01) compared with groups 2 and 1.Dexamethasone was selected in our study because of its highly strong anti-inflammatory properties with few mineralocorticoid activity [8].

Earlier studies report significant pain control for up to 12 h postshoulder arthroscopic procedures in patients receiving intra-articular ropivacaine with decreased analgesic requirement [9]. On the other side, there was some reported side effects like nausea and vomiting for up to 12 h postoperatively in those who did not receive dexamethasone, whereas we observed significant pain-free periods up to 24 h in our study in patients receiving intra-articular dexamethasone 400 μg/kg weight with 15 ml of bupivacaine compared with normal saline and bupivacaine injections alone.

We reported a significant prolongation of analgesia and the time to first analgesic request postoperatively (19.02±1.43 min, P<0.01), a significant reduction in analgesia consumption of (21.34±5.56 mg, P<0.01), and a significantly lower pain VAS score in the first 24 h in dexamethasone groups as compared with dexamethasone devoid groups. We attribute these results to the distinct combination of morphine and dexamethasone.


  Conclusion Top


Intra-articular morphine as an adjuvant to dexamethasone and bupivacaine has a remarkable analgesic efficacy, a much-prolonged postoperative pain control, minimal postoperative analgesic requirement, and better patient compliance with minimal side effects.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Urwin M, Symmons D, Allison T. Estimating the burden of musculoskeletal disorders in the community: the comparative prevalence of symptoms at different anatomical sites, and the relation to social deprivation. Ann Rheum Dis 1998; 57:649–655.  Back to cited text no. 1
    
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Mitchell C, Adebajo A, Hay E. Shoulder pain: diagnosis and management in primary care. BMJ 2005; 331:1124–1128.  Back to cited text no. 2
    
3.
Codman EA, Akerson IB. The pathology associated with rupture of the supraspinatus tendon. Ann Surg 1931; 93:348–359.  Back to cited text no. 3
    
4.
de Mulder K, Petré D, Declercq G. Arthroscopy of the shoulder. Current concepts review. Acta Orthop Belg 1999; 65:447–457.  Back to cited text no. 4
    
5.
Doss NW, Splain SH, Crimi T, Michael R, Abadir AR, Gintautas J. Intra-articular morphine, ropivacaine and morphine/ ropivacaine for pain control after arthroscopy. Preliminary observation. Proc West Pharmacol Soc 2001; 44:195–196.  Back to cited text no. 5
    
6.
Ruiz-Suarez M. Postoperative pain control after shoulder arthroscopy. Orthopaedics 2008; 31:1130.  Back to cited text no. 6
    
7.
Panigrahi R, Roy R, Prasad A, Mahapatra AK, Priyadarshi A, Palo N. Intraarticular dexamethasone in pain management following arthroscopic Bankart repair. Anaesth Pain Intensive Care 2015; 19:4.  Back to cited text no. 7
    
8.
Johanson A, Hao J, Sjölund B. Local corticosteroid application blocks transmission in normal nociceptive C-fibres. Acta Anaesthsiol Scand 1990; 34:335–338.  Back to cited text no. 8
    
9.
Rodolà F, Vagnoni S, D’Avolio S, Vurchio M, Micci D, Chierichini A. Intra-articular analgesia following arthroscopic surgery of the shoulder. Eur Rev Med Pharmacol Sci 2001; 5:143–146.  Back to cited text no. 9
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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