ความปลอดภัยและประสิทธิผลของการงดใช้มอร์ฟีนทางช่องน้ำไขสันหลังร่วมกับการสกัดกั้นเส้นประสาทซาฟีนัสภายใต้เครื่องอัลตร้าซาวด์ สำหรับการระงับปวดหลังผ่าตัดเปลี่ยนข้อเข่าเทียม: การศึกษาเชิงเปรียบเทียบแบบไปข้างหน้าในโรงพยาบาลพระนครศรีอยุธยา

Paksiree Changkittirat; Pitsamai  Ruenthana; Sukanya  Pinhom

Authors

Paksiree Changkittirat Anesthesiologist, Phra Nakhon Si Ayutthaya Hospital
Pitsamai Ruenthana Anesthesiology Nursing Division, Phra NaKhon Si Ayutthaya Hospital
Sukanya Pinhom Nursing Research and Development Department, Phra NaKhon Si Ayutthaya Hospital

Keywords:

intrathecal morphine, saphenous nerve block, total knee arthroplasty, postoperative nausea and vomiting, postoperative analgesia

Abstract

Objectives: Postoperative pain following total knee arthroplasty (TKA) is commonly managed with intrathecal morphine (ITM) combined with spinal anesthesia to enhance analgesic efficacy. However, ITM is associated with opioid-related side effects such as postoperative nausea and vomiting (PONV) and pruritus. This study aimed to compare the safety and efficacy of omitting ITM combined with ultrasound-guided adductor canal block versus the use of ITM in patients undergoing TKA. Methods: This prospective controlled clinical study included 60 patients undergoing TKA. Participants were divided into a control group receiving ITM (n = 30) and an experimental group without ITM (n = 30). All patients received spinal anesthesia combined with an ultrasound-guided adductor canal block. Outcomes included the incidence of PONV, pruritus, pain scores, time to first pain, and time to ambulation. Data were analyzed using Chi-square test, Fisher’s exact test, and Mann–Whitney U test, with statistical significance set at p < 0.05. Results: The experimental group demonstrated a significantly lower incidence of PONV and pruritus compared with the control group (p < 0.05). In terms of analgesic efficacy, the control group had a longer pain-free period and lower pain scores within the first 6 hours postoperatively (p < 0.05). However, pain scores at 12 and 24 hours were comparable between the two groups. Additionally, the experimental group achieved earlier postoperative ambulation than the control group (p = 0.01). Patient satisfaction was rated at the highest level in both groups, with no significant difference. Conclusion: Omitting intrathecal morphine in combination with adductor canal block reduces opioid-related side effects and enhances postoperative recovery, while maintaining comparable analgesic efficacy in the later postoperative period. This approach may be considered a safe and effective alternative for postoperative pain management in TKA patients.

References

Brown B, Cheok TS, Worsley D, Kroon HM, Davis N, Jaarsma RL, et al. Comparative efficacy of intrathecal morphine and adductor canal block in the knee arthroplasty population: a retrospective multi-centre cohort study. BMC Anesthesiol 2024;24(1):365.

Andersen HL, Gyrn J, Møller L, Christensen B, Zaric D. Continuous adductor-canal-blockade for adjuvant post-operative analgesia after major knee surgery. Acta Anaesthesiol Scand 2013;57(5):614-23.

Wainwright TW, Gill M, McDonald DA, Middleton RG, Reed M, Sahota O, et al. Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Acta Orthop 2020;91(1):3-19.

AbdelQadir YH, Nabhan AE, Abdelghany EA, Mohamed AG, El Tokhey AS, Elmegeed AA, et al. Efficacy and safety of intrathecal morphine in total knee arthroplasty: a systematic review and meta-analysis. J Opioid Manag 2021;17(5):405-16.

Jungquist CR, Quinlan-Colwell A, Vallerand A, Cooney M, Maly A, Meloche K, et al. American society for pain management nursing guidelines on monitoring for opioid-induced advancing sedation and respiratory depression: revisions. Pain Manag Nurs 2020;21(1):7-25.

Moraitis A, Hultin M, Walldén J. Risk of postoperative nausea and vomiting in hip and knee arthroplasty: a prospective cohort study after spinal anaesthesia including intrathecal morphine. BMC Anesthesiol 2020;20(1):242.

Chinachoti T, Nilrat P, Samarnpiboonphol P. Nausea, vomiting and pruritus induced by intrathecal morphine. J Med Assoc Thai 2013;96(5):589-94.

โสภิต เหล่าชัย, เฉลิมพงศ์ ไพนุพงศ์, อุทัยวรรณ หาญอยู่, จตุพร บุญยืด, ศักดิ์ศรัณย์ ล้ำเลิศ. การสกัดกั้นเส้นประสาทในช่องแอดดักเตอร์ด้วยการฉีดยาชาเพียงครั้งเดียว โดยใช้คลื่นความถี่สูงนำทางร่วมกับการใส่ยามอร์ฟีนในช่องไขสันหลัง สำหรับการระงับปวดหลังผ่าตัดเปลี่ยนข้อเข่าเทียม. วิสัญญีสาร 2564;47(2):93-103.

Gonvers E, El-Boghdadly K, Grape S, Albrecht E. Efficacy and safety of intrathecal morphine for analgesia after lower joint arthroplasty: a systematic review and meta-analysis. Anaesthesia 2021;76(12):1648-58.

Biswas A, Perlas A, Ghosh M, Chin K, Niazi A, Pandher B, et al. Relative contributions of adductor canal block and intrathecal morphine to analgesia and functional recovery after total knee arthroplasty: a randomized controlled trial. Reg Anesth Pain Med 2018;43(2):154-60.

Huang BY, Leslie SW. Postoperative urinary retention. [Internet]. 2023 [cited 2026 Jan 11]. Available from: https://shorturl.asia/lwoWg

Agrawal K, Majhi S, Garg R. Post-operative urinary retention: review of literature. World J Anesthesiol 2019;8(1):1-12.

Janiak M, Kowalczyk R, Gorniewski G, Kowalski M, Nowakowski P, Trzebicki J, et al. Efficacy and side effect profile of intrathecal morphine versus distal femoral triangle nerve block for analgesia following total knee arthroplasty: a randomized trial. J Clin Med 2022;11(23):6945.

Ljungqvist O, Scott M, Fearon KC. Enhanced recovery after surgery: a review. JAMA Surg 2017;152(3):292-8.

American Society of Anesthesiologists Task Force on Prevention, Detection, and Management of Respiratory Depression Associated with Neuraxial Opioid Administration. Practice guidelines for the prevention, detection, and management of respiratory depression associated with neuraxial opioid administration: an updated report. Anesthesiology 2016;124(3):535-52.