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44600 - THE EFFECT OF COMBINED USE OF NALOXONE AND TRAMACET ON POSTOPERATIVE ANALGESIA IN ELDERLY PATIENTS UNDERGOING JOINT REPLACEMENT SURGERY: A PROSPECTIVE FEASIBILITY STUDY

¹ St. Josephs Health Care London, London, ON, Canada
² St Josephs Health Care London
³ St Josephs Health Care London
⁴ St Josephs Health Care London

Abstract

CAS Abstract: The effect of the combined use of naloxone and tramacet on postoperative analgesia in elderly patients having joint replacement surgery: a prospective feasibility study.

Introduction

This is a prospective feasibility study to determine opioid use during combined use of naloxone infusion and tramacet in patients 70 years and above scheduled for joint replacement surgery. Tramacet is a combination of tramadol and acetaminophen. Tramadol exerts its analgesic effects by opioid and non-opiod mechanism. The majority of its analgesic effect occurs by inhibition of the pre-synaptic uptake of the neurotransmitters norepinephrine and serotonin, inhibiting pain perception¹.

Naloxone, when given as an ultra low dose infusion (0.25ug/kg/hr), is analgesic, opioid-sparing, and also may reverse opioid side effects.^2,3,4

Methods

Following Research Ethics Board approval and written informed consent, 6 patients > 70 years scheduled for knee or hip arthroplasty were recruited. All patients received two tablets of tramacet preoperatively and 6 hourly thereafter for 5 days and Morphine via standardized PCA orders. All subjects received a spinal anesthetic with intrathecal morphine 0.2mg, 1.4ml 0.75% bupivacaine and intra-articular infiltration of 100ml ropivacaine 0.3% plus ketorolac 30mg intra-operatively. A naloxone infusion was started preoperatively at 0.25ug/kg/hr and continued for the duration of the patient’s stay in hospital. Celebrex 200mg twice daily for 5days was administered postoperatively. The Visual Analogue scale, Ramsey Sedation Score and the Mini Mental State Exam were used to assess pain, sedation, and confusion respectively every 6 hours. For comparison morphine use / day was collected in 6patients >70 years undergoing knee/hip arthroplasty who had received a similar multimodal analgesic regimen.

Results

The mean number of mg of morphine-equivalents /day in the knee arthroplasty group was 27± 7.1 mg. versus was 2.9± 2.8mg in the study patients ( P = 0.005) The mean number of mg of morphine-equivalents in the hip arthroplasty group was 13mg± 11.5 versus 1.8mg± 1.6 in the study group (p =0.15).

Sedation or confusion did not occur in any of the patients , and earlier independent ambulation was noted.

Conclusion

Post-joint replacement opioid use has been reduced substantially by this regime. There was no episode of sedation or respiratory depression and an unanticipated finding of greatly improved mobility postoperatively. This is a very small group, and the study is not blinded but the results of this analgesic regimen are highly encouraging.

The next step is to to undertake a prospective blinded randomized control trial to verify these results.

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