Anesth Analg 2001;92:625-628
© 2001 International Anesthesia Research Society
AMBULATORY ANESTHESIA
Intraarticular Sufentanil Administration Facilitates Recovery After Day-Case Knee Arthroscopy
Jan H. Vranken, MD,
Kris C. P. Vissers, MD*,
Raf de Jongh, MD*, and
Rene Heylen, MD, PhD*
Department of Anesthesiology, Academic Medical Center, University of Amsterdam, 1100 DD Amsterdam, The Netherlands; and *Department of Anesthesiology, Ziekenhuis Oost-Limburg, 3600 Genk, Belgium
Address correspondence and reprint requests to Jan H. Vranken, MD, Department of Anesthesiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands. Address e-mail to jannekevranken{at}hotmail.com
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Abstract
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We evaluated the efficacy of intraarticular sufentanil in the prevention of postoperative pain after day-case arthroscopic procedures. Sixty patients were randomly assigned to receive either intraarticular sufentanil, 5 or 10 µg, and saline IV, or intraarticular saline and sufentanil 5 µg IV (control). All study medication was administered in a double-blinded fashion. Postoperatively and the day after surgery, pain levels at rest and during movement (i.e., active flexion of the knee), measured by a visual analog scale, were significantly lower in the Sufentanil groups compared with the Control group. Moreover, intraarticular sufentanil significantly reduced the postoperative consumption of analgesics. The time until discharge from the postanesthesia care unit (assessed by the Aldrete score) was significantly shorter in the patients receiving sufentanil intraarticularly. There were no significant differences between the two Sufentanil groups either in the intensity of postoperative pain or in discharge times from the postanesthesia care unit. We conclude that intraarticular sufentanil in arthroscopic knee procedures is a simple, effective, safe and well-tolerated analgesic technique for outpatients undergoing arthroscopic procedures. Increasing the dose sufentanil from 5 to 10 µg intraarticularly offered no additional advantage. Intraarticular sufentanil (5–10 µg) administration improves postoperative management after day-case diagnostic arthroscopic knee procedures.
Implications: Intraarticular sufentanil (5–10 µg) administration improves postoperative management after day-case diagnostic arthroscopic knee procedures.
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Introduction
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Opioids administered intraarticularly produce conflicting data with respect to their analgesic efficacy (1). Some reports showed intraarticular opioids to be ineffective (1,2); others reported a significant positive effect on postoperative analgesia (3). The choice for sufentanil was made on the basis of its greater lipophilic characteristics, which should provide for a faster onset of analgesia than morphine (4). The aim of this study was to evaluate the effect of intraarticular administration of sufentanil on postoperative pain, and oral analgesic requirements after day-case arthroscopic knee procedures.
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Methods
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After approval by the local ethical committee, informed patient consent was obtained from all study patients. Sixty unpremedicated ASA physical status I patients scheduled for outpatient diagnostic arthroscopic knee procedures were enrolled in this study. Exclusion criteria included relevant drug allergy, need for a surgical debridement or synovectomy and the need for arthrotomy or postoperative intraarticular drainage.
In all patients, anesthesia was induced with propofol 2.5 mg · kg-1 and alfentanil 25 µg · kg-1. Tracheal intubation was facilitated with vecuronium 0.1 mg · kg-1, and anesthesia was maintained with propofol 6 mg · kg-1 · h-1 and nitrous oxide 65% in oxygen. All patients received paracetamol 15 mg · kg-1 IV intraoperatively. If pain relief was insufficient postoperatively, oral paracetamol was given on request. At the end of the operation, before the arthroscope was removed, patients were randomized using a random number table and sealed envelopes into three groups and the following solutions were administered simultaneously: Group IAS5 (n = 20) received sufentanil 5 µg in 20 mL of normal saline intraarticularly and 5 mL of normal saline IV; Group IAS10 (n = 20) received sufentanil 10 µg in 20 mL of normal saline intraarticularly and 5 mL of normal saline IV; and Group IVS (n = 20), the control group, received 20 mL saline intraarticularly and 5 µg sufentanil in 5 mL of normal saline IV. Two coded sterile syringes were prepared for each patient by the hospital pharmacist; the contents of these syringes were unknown to the anesthesiologist and surgeon who performed the surgery. The codes were not revealed until completion of the study.
Pain levels, at rest and during movement (active flexion of the knee), were assessed using a visual analog scale (VAS). Before anesthesia, all patients received instructions as to the use of a 100-mm VAS with 0 = no pain to 100 = unbearable pain. VAS scores were recorded preoperatively (T0), and at 30 min (T1) and 90 min (T2) after the intraarticular injection. In addition, patients also recorded scores at hospital discharge (T3) and on the morning after surgery (T4). At the same time, oral analgesic consumption (paracetamol) was recorded.
After discontinuation of anesthesia, the time required to achieve eligibility for discharge from the postanesthesia care unit (PACU) was measured and recorded using the Aldrete Post-Anesthesia Recovery Score (5), with a score of 
8 required without complaints of moderate to severe pain or nausea or vomiting. Occurrences of side effects such as nausea, vomiting, pruritus, or somnolence were recorded for each patient.
Data analysis was performed by the Kruskal-Wallis test, the Bonferroni post hoc test, and the 
2 test as appropriate. In all cases, P < 0.05 was considered to be significant. All data are presented as mean ± SD, or median with range for nonparametric data.
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Results
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Demographic data and duration of anesthesia are summarized in Table 1. No significant differences among groups regarding body weight, age, gender or duration of anesthesia were observed. VAS scores at rest and during movement are shown in Figures 1 and 2, respectively. Postoperatively and the day after surgery, pain scores were significantly lower in the two intraarticular sufentanil groups (versus the control group). Supplementary analgesic consumption was significantly increased in the control group ( Fig. 3). There were no differences in VAS scores or in postoperative paracetamol consumption between the two sufentanil groups.
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Figure 1. Visual analog scale (VAS) pain scores (median and range) at rest as a function of time: preoperatively (T0), at 30 min postoperatively (T1), and at 90 min postoperatively (T2), at hospital discharge (T3), and on the morning after surgery (T4). IVS = sufentanil 5 µg IV (control group); IAS5 = sufentanil 5 µg intraarticular; IAS10 = sufentanil 10 µg intraarticular. *P < 0.05 control compared with sufentanil 5 or 10 µg.
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Figure 3. Oral paracetamol (mean ± SD) given at 30 min postoperatively (T1), and at 90 min postoperatively (T2), at hospital discharge (T3), and on the morning after surgery (T4). IVS = sufentanil 5 µg IV (control group); IAS5 = sufentanil 5 µg intraarticular; IAS10 = sufentanil 10 µg intraarticular. *P < 0.05 control compared with sufentanil 5 or 10 µg.
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Figure 2. Visual analog scale (VAS) pain scores (median and range) during movement as a function of time: preoperatively (T0), at 30 min postoperatively (T1), and at 90 min postoperatively (T2), at hospital discharge (T3), and on the morning after surgery (T4). IVS = sufentanil 5 µg IV (control group); IAS5 = sufentanil 5 µg intraarticular; IAS10 = sufentanil 10 µg intraarticular. *P < 0.05 control compared with sufentanil 5 or 10 µg.
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The average time (± SD) from discontinuation of anesthesia to achieving eligibility for discharge from the PACU (Aldrete Post-Anesthesia Recovery Score of at least 8 and pain, nausea, or vomiting under control) was significantly shorter (P < 0.05) in the 5 µg (13.1 ± 1.8 min) and 10 µg (12.8 ± 1.6 min) sufentanil groups compared with the control group (19.7 ± 2.2 min). However, there were no significant differences between the two sufentanil groups.
No adverse side effects were noted after the administration of intraarticular sufentanil. All patients were discharged from the hospital on the day of surgery and no side effects were recorded during the first 24 h postoperatively.
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Discussion
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Antinociceptive effects of opioids have been attributed primarily to an activation of receptors located in the central nervous system. However, animal studies revealed the existence of peripheral opioid binding sites, which appear to become especially active in the presence of inflammation (6–7). These first observations were later confirmed in human clinical trials (8–12). It was also found that this peripheral effect of the stimulation of opioid binding sites could be inhibited by naloxone (8). In the present study, we found an analgesic effect of sufentanil administered intraarticularly after diagnostic arthroscopic knee procedures as evidenced by both the lower VAS-scores and by the reduced requirement for paracetamol in the postoperative period.
As a result of its lipophilicity, sufentanil could theoretically avoid the delayed onset associated with intraarticular morphine (3). In our study, we detected a fast onset of analgesia with the effect lasting until the morning after surgery. In contrast, the analgesic effect after intraarticular administration of a local anesthetic, particularly bupivacaine, lasts a shorter period (13). The combination of morphine and bupivacaine administered intraarticularly results in a controversial analgesic effect (11,14). Intraarticular administration of opioids such as fentanyl or meperidine did not result in a significant analgesic effect as compared to intraarticular morphine (15).
This study also demonstrated that administration of sufentanil for day-case arthroscopic knee procedures resulted in measurable analgesic activity. Moreover, intraarticular sufentanil significantly attenuated postoperative pain leading to a faster eligibility for discharge from the PACU. The shortened stay in the postoperative care unit, could substantially improve operating room management in a busy day-case hospital. Moreover, faster recovery from anesthesia could theoretically result in considerable cost-savings if more patients can bypass the PACU (16).
Although sufentanil is an extremely lipophilic opioid, possibly enabling a fast penetration through the synovium into the bloodstream (4), a systemic analgesic effect of intraarticular sufentanil could be excluded because the control group had less pain relief postoperatively. Moreover, the analgesic effect of intraarticularly administered sufentanil lasted until the morning after surgery. A drawback of the study is that plasma concentrations of sufentanil were not measured after the intraarticular administration.
The intraarticular administration of sufentanil 10 µg offered no advantage compared with sufentanil 5 µg. This may be explained by at least two factors. First, diagnostic arthroscopic knee procedures elicit only a minimal release of inflammatory mediators by the injured tissue (17,18). A second reason might relate to the fact that diagnostic knee arthroscopies were studied, resulting in low to moderate postoperative pain scores (19). Based on these results, the use of 10 µg sufentanil intraarticularly cannot be recommended as it does not offer any demonstrable advantages over 5 µg and the chances of systemic absorption may be increased.
We conclude that intraarticular administration of sufentanil 5 µg after outpatient diagnostic arthroscopic knee procedures is a simple, effective, safe and well-tolerated analgesic technique offering superior postoperative pain control to sufentanil 5 µg IV
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Accepted for publication November 20, 2000.
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Abstract
Introduction
