Stein C, Comisel K, Haimerl E, Yassouridis A, Lehrberger K, Herz A, Peter K
Department of Anesthesiology, Ludwig-Maximilians-Universität München, Germany.
N Engl J Med. 1991 Oct 17;325(16):1123-6. doi: 10.1056/NEJM199110173251602.
Opioids can produce potent antinociceptive effects by interacting with local opioid receptors in inflamed peripheral tissue. In this study we examined the analgesic effects of the intraarticular, as compared with intravenous, administration of morphine after arthroscopic knee surgery.
In a double-blind, randomized trial, we studied 52 patients who had received one of four injections at the end of surgery. The patients in group 1 (n = 18) received 1 mg of morphine intraarticularly and saline intravenously; those in group 2 (n = 15), saline intraarticularly and 1 mg of morphine intravenously; those in group 3 (n = 10), 0.5 mg of morphine intraarticularly and saline intravenously; and those in group 4 (n = 9), 1 mg of morphine and 0.1 mg of naloxone intraarticularly and saline intravenously. The volume of the intraarticular injections was 40 ml, and that of the intravenous injections was 1 ml. After 1, 2, 3, 4, 6, and 24 hours, postoperative pain was assessed with a visual-analogue scale, a numerical-rating scale, and the McGill pain questionnaire. The need for supplemental analgesic agents, the patients' vital signs, and the occurrence of side effects were monitored.
All pain scores were lower in group 1 than in group 2 at all times. The differences were significant (P less than 0.05) at three, four, and six hours (mean [+/- SD] visual-analogue score at six hours, 9 +/- 13 mm vs. 37 +/- 31 mm). The mean (+/- SD) consumption of supplemental analgesic medication per 24 hours was significantly lower in group 1 (36 +/- 51 mg of diclofenac and 1.2 +/- 3.4 mg of meperidine) than in group 2 (75 +/- 42 mg of diclofenac and 14 +/- 18 mg of meperidine, P less than 0.05). The visual-analogue scores in group 3 were slightly but not significantly higher than those in group 1 at all times except 6 and 24 hours after injection. The visual-analogue scores were significantly higher in group 4 than in group 1 one to four hours after injection (P less than 0.05), indicating that the analgesic effect of intraarticular morphine was reversible by naloxone.
Low doses of intraarticular morphine can significantly reduce pain after knee surgery through an action specific to local opioid receptors that reaches its maximal effect three to six hours after injection.
阿片类药物可通过与炎症外周组织中的局部阿片受体相互作用产生强效的抗伤害感受作用。在本研究中，我们比较了关节镜下膝关节手术后关节内注射与静脉注射吗啡的镇痛效果。
在一项双盲、随机试验中，我们研究了52例在手术结束时接受四种注射之一的患者。第1组（n = 18）患者关节内注射1 mg吗啡，静脉注射生理盐水；第2组（n = 15）患者关节内注射生理盐水，静脉注射1 mg吗啡；第3组（n = 10）患者关节内注射0.5 mg吗啡，静脉注射生理盐水；第4组（n = 9）患者关节内注射1 mg吗啡和0.1 mg纳洛酮，静脉注射生理盐水。关节内注射体积为40 ml，静脉注射体积为1 ml。在1、2、3、4、6和24小时后，用视觉模拟评分法、数字评分法和麦吉尔疼痛问卷评估术后疼痛。监测补充镇痛药的需求、患者的生命体征和副作用的发生情况。
第1组在所有时间的所有疼痛评分均低于第2组。在3、4和6小时时差异显著（P < 0.05）（6小时时平均[±标准差]视觉模拟评分为9±13 mm，而第2组为37±31 mm）。第1组每24小时补充镇痛药的平均（±标准差）消耗量（双氯芬酸36±51 mg和哌替啶1.2±3.4 mg）显著低于第2组（双氯芬酸75±42 mg和哌替啶14±18 mg，P < 0.05）。除注射后6和24小时外，第3组在所有时间的视觉模拟评分均略高于第1组，但差异不显著。第4组在注射后1至4小时的视觉模拟评分显著高于第1组（P < 0.05），表明关节内吗啡的镇痛作用可被纳洛酮逆转。
低剂量关节内注射吗啡可通过局部阿片受体特异性作用显著减轻膝关节手术后的疼痛，该作用在注射后3至6小时达到最大效果。
