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PAIN MEDICINE

Intrathecal Clonidine Added to a Bupivacaine-Morphine Spinal Anesthetic Improves Postoperative Analgesia for Total Knee Arthroplasty

Brian D. Sites, MD^*, Michael Beach, MD PhD^*, Russell Biggs, MD^*, Christopher Rohan, MD^*,, Christopher Wiley, MD^*, Athos Rassias, MD^*, Janice Gregory, RN^*, and Gilbert Fanciullo, MD^*

Departments of Anesthesiology, *Dartmouth Medical School, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; and Central Vermont Medical Center, Berlin, Vermont

Address correspondence and reprint requests to Brian D. Sites, MD, Department of Anesthesiology, Dartmouth-Hitchcock Medical Center, 1 Medical Center Dr., Lebanon, NH 03756. Address e-mail to brian.sites{at}hitchcock.org

Postoperative pain after total knee arthroplasty (TKA) is severe and can complicate early physical therapy. We tested the hypothesis that intrathecal clonidine would improve postoperative analgesia for TKA using a hyperbaric bupivacaine spinal anesthetic. In a double-blinded, placebo-controlled protocol, 81 ASA physical status I–III patients undergoing either a single or bilateral TKA were randomized into 4 groups with the following 2-mL solutions added to 15 mg of hyperbaric bupivacaine: 1) sterile saline, 2) morphine (250 µg), 3) morphine (250 µg) with clonidine (25 µg), and 4) morphine (250 µg) with clonidine (75 µg). At 1, 2, 4, 6, 12, and 24 h postoperatively, we measured visual analog scales (VAS), cumulative IV morphine consumption, hemodynamics, nausea, ancillary drugs, and side effects. Our primary comparison was between the clonidine with morphine groups versus the morphine group. We found that the combined administration of intrathecal clonidine and morphine decreased 24 h IV morphine consumption by 13 mg (P = 0.028) when compared with intrathecal morphine alone. This corresponded to a decrease in the VAS score of 1.3 cm at 24 h postoperatively (P = 0.047). Adverse side effects were similar among all groups with the exception of more relative hypotension in the clonidine groups through postoperative hour 6. We conclude that the coadministration of intrathecal clonidine and morphine decreases the 24-h IV morphine consumption and improves the 24-h VAS score when compared with intrathecal morphine alone.

IMPLICATIONS: In this prospective, randomized, double-blinded, and placebo-controlled trial, we identify an effective postoperative analgesic approach in total knee replacement surgery. Intrathecal morphine (250 µg) combined with clonidine (25 or 75 µg) provided superior analgesia compared with intrathecal morphine alone.

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