Intra-articular Morphine Research Articles

Intra-articular morphine and postoperative analgesia after knee arthroscopy

The aim of this study was to evaluate the postoperative analgesic effect of intra-articular administration of a low- and a high-dose morphine solution after knee arthroscopy. Thirty patients who underwent diagnostic arthroscopy or arthroscopic meniscectomy were allocated in three groups. At the end of the arthroscopic procedure patients in Group A received intra-articularly 20 ml normal saline (N/S), Group B received 5 mg morphine in 20 ml N/S and Group C received 15 mg morphine in 20 ml N/S. The postoperative pain was assessed using a visual analogue scale for 24 h, while all the patients stayed at hospital. Side effects from the central action of opioids were not detected. Although the pain scores in the group of low-dose morphine were lower than in the control group, we failed to detect any significant differences in pain scores among the three groups. There was evidence that a high-dose can cause hyperalgesia.

Immune Mechanisms in Pain Control

Immune Mechanisms in Pain Control

The effects of morphine on human articular cartilage of the knee: An in vitro study

Purpose: The purpose of this study was to determine the metabolic, histologic, and ultrastructural effects of morphine and its combination with saline and bupivacaine on human articular cartilage. Type of Study: In vitro study. Methods: Nonfibrillated human articular cartilage was harvested and transferred into an experimental culture consisting of a control medium, saline, or a combination of morphine/saline or morphine/saline/bupivacaine for 12, 24, or 72 hours. Each sample was radiolabeled to assess proteoglycan synthesis. Histologic and ultrastructural effects were also examined. Results: We found a significant, dose-related, transient decrease in 35SO4 incorporation in the morphine/saline samples at 12 hours, and in the saline only samples at 24 hours. We found no evidence of histologic or ultrastructural damage to the cartilage. Conclusions: Morphine and saline can both produce a transient decrease in 35SO4 incorporation that normalizes by 72 hours. This study does not suggest any contraindication to the use of intra-articular morphine as a postoperative analgesic.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 18, No 6 (July-August), 2002: pp 631–636

Evaluating analgesia: the challenges.

Decisions must be made when assigning analgesics, and such decisions involve comparing efficacy and adverse effects. The rules for assessing efficacy by systematic review and by large clinical trials are becoming clearer all the time. It is known, for instance, that trials that are not randomized, are not double-blind, or are too small will exaggerate efficacy. These rules are relatively easy to apply to drug interventions, although there are glaring exceptions, such as in early intra-articular morphine studies. The rules may also be less easy to apply for analgesics available over-the-counter (OTC) if the drugs have not been studied in trials of high quality or if the OTC-recommended doses are below the doses studied in the trials. When there are at least 500 patients studied in trials of high quality, credible efficacy estimates for effective drugs can be derived; more patients are needed for less effective drugs. The number needed to treat and the number needed to harm can be used to compare the efficacy and safety of a treatment with placebo or with other treatments. A recent meta-analysis comparing the number needed to treat for paracetamol 1000 mg and paracetamol 600-650 mg in moderate to severe postoperative pain indicated that paracetamol 1000 mg is likely to be more effective than lower doses. Large data sets allow investigation into dose response, gender differences, and whether particular drugs work better for particular painful conditions. Purists would argue that databases of patient experience should not be used for these efficacy analyses. The rules on how to collect and use evidence on adverse effects are less clearly formulated than they are for efficacy. For safety at or above therapeutic dose, the rules of evidence-gathering are necessarily different, and randomized trials are rarely an adequate or sufficient source. Databases of patient experience, with all the caveats, may be the most reliable data from which to work.

No pain, no gain: clinical excellence and scientific rigour – lessons learned from IA morphine

The effectiveness of intra-articular (IA) morphine in arthroscopic procedures of the knee joint was analysed in all randomised and controlled trials that included injections of morphine and placebo into the knee joint, and where the data were analysable. Sensitivity of the studies and effectiveness were analysed for three different periods: immediate (0–2 h), early (2–6 h) and late (6–30 h). Sensitivity for each period was assumed if pain intensity was at least 30% of the maximum of 100 on the visual analogue scale in the placebo group. Six different doses (1–10 mg) of IA morphine were compared with placebo. The injections were made at the end of surgery, before the arthroscope was removed from the joint. In the immediate period 7/15 sensitive trials were positive, in the early period 8/12 sensitive trials were positive and in the late period 10/13 sensitive trials were positive. Most positive studies had used higher doses (3–5 mg) compared with negative studies that had mainly used 1 mg. Two studies using patient controlled analgesia consumption of analgesics as an outcome were also positive. The only sensitive study of four dose–response comparisons indicated that 5 mg of IA morphine was more effective than 1 mg. The only sensitive study of three cross-route comparisons showed no difference between 5 mg of IA and 5 mg of intra-muscular morphine. All insensitive trials, including placebo (except two individual comparisons), cross-route and dose–response comparisons, were negative. The analysis of sensitive studies indicates that 5 mg of IA morphine injected into the knee joint provides postoperative pain relief for up to 24 h. A minimum of 30% of the maximum possible pain intensity is needed for an analgesic effect to be detected in a study.

Does intraarticular morphine improve pain control with femoral nerve block after anterior cruciate ligament reconstruction? (Vanderbilt University Medical Center, Nashville, TN) American Journal of Sports Medicine 2001;29:327-332.

In a prospective, randomized, double-blinded manner, the authors of this study compared the effects of a preoperative intraarticular injection of morphine (5 mg) or a placebo, combined with a postoperative femoral nerve block, on postoperative pain. Sixty-two patients underwent an arthroscopically assisted anterior cruciate ligament reconstruction using patellar tendon autograft under general anesthesia. No statistical difference between the 2 groups was evident in terms of age, sex, weight, operative time, volume of bupivacaine received with the femoral nerve block, or tourniquet use or tourniquet time. A comparison of the visual analog pain scale scores revealed no statistical difference between the groups at any point after the operation. Both groups had a significant decrease in visual analog scale scores after the femoral nerve block. No significant difference in postoperative narcotic medication use was evident in the recovery room or at home. A post hoc analysis revealed that the study power reached 87% with a significance level of 5%. Conclude that the postoperative femoral nerve block was effective and intraarticular morphine provided no additional benefit. Comment by Alan David Kaye, M.D., Ph.D., and Erin Bayer, M.D. This prospective, randomized, double blinded study compared the effects of preoperative intraarticular injection of morphine or a placebo along with postoperative femoral “three-in-one” block on postoperative pain. 62 patients underwent arthroscopic ACL reconstruction under general anesthesia. After induction of anesthesia, patients were injected with either morphine 5 mg or placebo along with local anesthetics intraarticularly. Femoral nerve blocks were performed in the recovery room with a total of 3 mg/kg bupivacaine. The VAS of pain was assessed immediately postoperatively and at six time points afterward up to 24 hours. This study concluded that there were no statistical differences between the two groups comparing VAS. Also no significant difference was observed in postoperative narcotic use in the recovery room or at home. The study included antiemetics; however, the results did not include if the morphine group had a larger incidence of nausea or vomiting postoperatively. Finally, the authors suggest that there are no advantages to use of intraarticular morphine with a femoral nerve block post-operatively. A future study employing preoperative femoral nerve block with or without use of intraarticular morphine might be interesting to see on arthroscopic ACL repairs to obtain adequate analgesia as the authors suggested.

The use of intra-articular opioids and bupivacaine for analgesia following temporomandibular joint arthroscopy: A prospective, randomized trial

Purpose: This investigation evaluated the efficacy of using intra-articular morphine, bupivacaine, or a combination of both in the management of postarthroscopy temporomandibular joint (TMJ) pain. Materials and Methods: Thirty-two consecutive patients with internal derangements of the TMJ and persistent pain underwent TMJ arthroscopy. The patients were randomized equally into 4 groups. Group 1 received a sterile saline solution (control), group 2 received bupivacaine alone, group 3 received only a morphine solution, and group 4 received morphine mixed with bupivacaine. The patients recorded postarthroscopy pain using a visual analog scale (VAS), as well as analgesic consumption for 24 hours. The VAS and analgesic consumption were compared in the 4 groups. Results: Group 3 (bupivacaine alone) consumed, on average, 5.1 fewer analgesic equivalents than did group 1 (control) over the 24-hour period of study (P <.05). Otherwise, there was no significant difference in the number of analgesic equivalents consumed by the 4 groups. Patients treated with bupivacaine alone and those with morphine alone had significantly lower pain scores than the controls. However, there was no significant difference between the pain scores of the morphine and bupivacaine groups at any time. Patients treated with the mixture of morphine and bupivacaine showed no significant difference from controls at any time. Conclusions: Bupivacaine alone provides a better analgesic effect than morphine alone or the combination of morphine and bupivacaine. Morphine alone has a longer time of onset, with less effect on the pain scores during the 24-hour observation period. © 2001 American Association of Oral and Maxillofacial Surgeons

A systematic review of the peripheral analgesic effects of intraarticular morphine.

The analgesic effects of intraarticular morphine are controversial. To systematically evaluate the effects, we performed a review of the literature and a metaanalysis of the peripheral effects of morphine injected intraarticularly. Research databases were searched to identify articles in which peripheral analgesic effects of morphine were studied in patients undergoing arthroscopic knee procedures under local, regional, or general anesthesia. The review was performed on three issues: does morphine injected intraarticularly produce analgesia, is it a dose-dependent effect, and, if so, is the effect systemic or mediated via peripheral opioid receptors? Visual analog score (VAS) and analgesic consumption were studied during the early phase (0-2 h), intermediate phase (2-6 h), and late phase (6-24 h) postoperatively after injection of morphine intraarticularly. Metaanalysis of these effect variables was performed by the weighted-analysis technique, and the essential homogeneity assumption was tested by the chi(2) test. Forty-five articles could be identified in which the effects of morphine were studied in a prospective, randomized manner, and 32 of these studies included a placebo control. Pooled analyses of data from 19 studies suitable for metaanalysis showed an improvement in analgesia after morphine compared with placebo in the order of 12-17 mm on the VAS during all three phases of treatment. Studies with high quality scores showed somewhat smaller improvements. Total analgesic consumption could not be analyzed statistically, but the number of studies showing decreased analgesic consumption or no differences between groups was identical (six and six). No clear dose-response effect was seen when VAS was used as a measure of pain, but it was seen when area under the curve was used as a measure of pain. A systemic effect of peripherally-injected morphine was not possible to exclude because of the very limited data available. We conclude from this metaanalysis that intraarticularly administered morphine has a definite but mild analgesic effect. It may be dose dependent, and a systemic effect cannot be completely excluded.

Evidence Based Resource in Anaesthesia and Analgesia

Evidence Based Resource in Anaesthesia and Analgesia MARTIN TRAMÈR (ed.) BMJ Books: London, UK, 2000, 225 pp. Price £30.00. To make a good soup you need good ingredients, and the complexities and controversies surrounding Evidence Based Medicine definitely lend themselves to a quality intellectual soup. Martin Tramèr sets out his objectives quite clearly. His aim is not to publish another conventional textbook. He has succeeded. This book attempts both to address the philosophical controversies and to explain the statistical and practical complexities involved in performing systematic reviews and meta-analyses. The book is in two parts. The first attempts a balanced discourse of the various aspects of evidence based medicine and the second looks at a few poignant topics. The book starts with an eloquent philosophical preamble by Neville Goodman looking at the various comments made in the medical literature by often polarized protagonists. Things then start in earnest with detailed discussion on the state of anaesthetic literature, the methods involved in systemic reviews and the statistics involved in meta-analysis. These chapters describe clearly, although occasionally repetitively, the difficulties in extracting useful information from often poorly performed and reported primary research. As such, this section makes invaluable reading for any potential researcher over and above any concerns about meta-analysis. We need well-conducted reliable research for all sorts of reasons, and aspiring researchers who want to get their work published would do well to heed the methodological quality lessons which attempting to combine primary studies have taught us. The contributions in the second half of the book vary in style. Chapter 6 is an annotated summary of six systematic reviews, whilst Chapter 7 is a single review in itself (dealing with the effects of intra-articular morphine). Chapter 8 gives a fascinating insight into how the Oxford canon of systematic reviews in postoperative nausea and vomiting were conducted, noteworthy because they considered potential harms as well as benefits. The final chapter considers the control of perioperative bleeding. These areas are all put through the meta-scope, the multiple systemic reviews are dissected and analysed, before concluding where the state of the science is, which is frequently and refreshingly inconclusive. The Editor’s aim of providing a balanced appraisal of evidence based medicine is clearly met, and although the authors include most of the major luminaries of evidence based medicine within anaesthesia, their accounts reflect both its shortcomings and merits. The claim in the title to be a resource is also achieved with a comprehensive list of systemic reviews with brief comment, in the appendix, and several useful websites are also detailed. Unfortunately, the publishers’ claim that there will be regular electronic updates is not expanded upon. Also, because of the lag time between the book’s preparation and its publication, there is no mention of the Cochrane Anaesthesia Review Group, which was formed early in 2000. This book has something for everyone – both reviewers learnt a lot from it, although one is an editor within the Cochrane Collaboration and one a relative novice in the field. We expect this book, and its subsequent editions, will become a favourite for trainees seeking knowledge, and is a must when they start designing their research project, but maybe also for ‘old timers’ to reassure them that science has not yet taken away their art. What it does not do, however, is solve the problem of articulating to nonmedics what we should practise instead of Evidence Based Medicine. We hope subsequent courses live up to this most appetizing starter.

Intraarticular morphine versus dexamethasone in chronic arthritis

Intraarticular morphine inhibits pain after knee surgery without overt toxicity. This study examined intraarticular morphine in chronic arthritis. We undertook a randomized double-blind comparison between intraarticular morphine (3 mg), dexamethasone (4 mg) and saline (3 ml) in 44 patients with chronic inflammatory arthritis or osteoarthritis of the knee. Pain (the primary outcome measure) was assessed at rest and during activity for 6 days using a visual analog scale (VAS) and the McGill pain questionnaire. Before drug injections and on day 6 synovial leukocyte counts (the secondary outcome measure) were taken. During the first 6 h after injection both morphine and dexamethasone significantly reduced VAS and pain rating indices (PRI) in comparison to saline. Both substances also produced a significant reduction of PRI compared to saline during the subsequent 5 days. No patient displayed untoward side effects. Synovial leukocyte counts were lower after morphine than after saline. In conclusion, intraarticular morphine produces analgesia of similar magnitude to dexamethasone and it may have antiinflammatory actions in chronic arthritis.

Use of intra-articular morphine for postoperative analgesia following TMJ arthroscopy

Recent studies have suggested that giving opioids locally into inflamed tissue may cause analgesia. This antinociceptive effect has been attributed to the interaction of the drug with opioid receptors upregulated by inflammation in the peripheral tissues. We have compared the analgesic effect of intra-articular morphine with that of normal saline and a combination of morphine and its antagonist naloxone after arthroscopy of the temporomandibular joint (TMJ). Twenty-one patients took part in a randomized controlled double-blind trial and received one of these three solutions at the end of operation.The pain scores, time to the first request for analgesia, and the analgesic consumption of the patients in the three groups did not differ significantly at any time during the study period.

Intraarticular and periarticular opioid binding in inflamed tissue in experimental canine arthritis.

Small-dose (1 mg) intraarticular morphine has been used successfully in many studies to provide long-lasting analgesia after arthroscopic knee surgery. We used radioligand binding to determine whether these effects could be mediated by opioid binding sites in the joint, particularly after the induction of inflammation. Inflammation was induced by the injection of oleyl alcohol (20 microL) in sterile peanut oil (0.25 mL) into the left radiocarpal joint of 27 dogs, and the dogs were euthanized at 12 h. The articular and periarticular tissues from both treated and control joints were collected, and membranes were prepared for equilibrium binding assays. The density of specific opioid binding was markedly enhanced (P < 0.05) in homogenates prepared from the treated relative to those from the control joint. The binding affinities (KD values) for morphine and naloxone (mean +/- SEM) were approximately one one-hundredth (79 +/- 17 nM and 124 +/- 5.5 nM, respectively) that of the corresponding published affinities in brain tissue. However, the binding site densities were approximately one hundred times larger (Bmax = 1032 +/- 265 and 543 +/- 51 fmol/mg of protein) than the respective published values in brain tissue. These findings imply that the opioid binding sites, found in the inflamed articular and periarticular tissues in this study, are similar to those of putative mu 3-opioid binding sites that appear to be present on cultured thymocytes and in the airways of rats and humans. The high density of opioid binding sites found in inflamed canine joint tissue supports the clinical use of intraarticular opioids in the treatment of postoperative and chronic inflammatory joint pain.

Intraarticular and Periarticular Opioid Binding in Inflamed Tissue in Experimental Canine Arthritis

Small-dose (1 mg) intraarticular morphine has been used successfully in many studies to provide long-lasting analgesia after arthroscopic knee surgery. We used radioligand binding to determine whether these effects could be mediated by opioid binding sites in the joint, particularly after the induction of inflammation. Inflammation was induced by the injection of oleyl alcohol (20 [micro sign]L) in sterile peanut oil (0.25 mL) into the left radiocarpal joint of 27 dogs, and the dogs were euthanized at 12 h. The articular and periarticular tissues from both treated and control joints were collected, and membranes were prepared for equilibrium binding assays. The density of specific opioid binding was markedly enhanced (P < 0.05) in homogenates prepared from the treated relative to those from the control joint. The binding affinities (KD values) for morphine and naloxone (mean +/- SEM) were approximately one one-hundredth (79 +/- 17 nM and 124 +/- 5.5 nM, respectively) that of the corresponding published affinities in brain tissue. However, the binding site densities were approximately one hundred times larger (Bmax = 1032 +/- 265 and 543 +/- 51 fmol/mg of protein) than the respective published values in brain tissue. These findings imply that the opioid binding sites, found in the inflamed articular and periarticular tissues in this study, are similar to those of putative [micro sign]3-opioid binding sites that appear to be present on cultured thymocytes and in the airways of rats and humans. Implications: The high density of opioid binding sites found in inflamed canine joint tissue supports the clinical use of intraarticular opioids in the treatment of postoperative and chronic inflammatory joint pain. (Anesth Analg 1999;89:409-15)

Dose-dependency of intra-articular morphine analgesia

We have examined if the analgesic effects of intra-articular morphine are dose-dependent in patients undergoing elective arthroscopic knee surgery. At the end of surgery, patients were allocated randomly to one of four groups to receive intra-articular saline (n = 22), or morphine 1 mg (n = 24), 2 mg (n = 21) or 4 mg (n = 19). After operation, patients remained in hospital overnight and pain intensity was assessed using a visual analogue scale at 1, 2, 3, 6, 9, 12, 18 and 24 h after intra-articular injection. Patients requesting additional analgesia received a loading dose of piritramide 0.1 mg kg-1 i.v. and were connected to a PCA device using the same drug. Increasing doses of intra-articular morphine were associated with greater analgesic effects and less supplementary analgesic requirements.

The Effect of Intraarticular Morphine and Clonidine on Postoperative Analgesia after Knee Surgery

The Effect of Intraarticular Morphine and Clonidine on Postoperative Analgesia after Knee Surgery

The safety and efficacy of intrabursal oxycodone and bupivacaine in analgesia after shoulder surgery

Background and Objectives. Peripherally administered opioids, e.g., intra-articular morphine, exert their analgesic action on local opioid receptors. The present study investigated the safety and efficacy of intrabursal oxycodone and bupivacaine in comparison with bupivacaine infiltration and interscalene brachial plexus block in conjunction with shoulder surgery. Methods. A prospective, randomized study was conducted in 45 patients (15 per group) undergoing elective shoulder surgery during general anesthesia. At the end of the surgery, patients received either 10 mL 0.5% bupivacaine (group B) or 5 mg oxycodone and 10 mL 0.5% bupivacaine (group OB) in the subacromial bursa; interscalene plexus blocks were performed preoperative (group IPB). Postoperative analgesia was provided by patient-controlled analgesia, and the amount of intravenous fentanyl used during the total perioperative period was recorded. Postoperative pain was assessed by a visual analog scale. Results. The total fentanyl consumption was lower in groups OB and IPB than in group B, and the difference reached statistical significance for both groups ( P = .045 and P = .006, respectively). However, the groups OB and IPB did not differ in respect to their fentanyl requirements ( P = 1.000). Visual analog scores for pain were lowest in group IBP during the first 6 postoperative hours. The incidence of adverse effects was similar in all groups; serious adverse effects did not occur. Conclusions. According to the present study, intrabursal oxycodone and bupivacaine offer an acceptable and efficient method for postoperative analgesia after shoulder surgery.

Analgesic effect of intra-articular morphine after arthroscopic knee surgery

Objectives: To assess the analgesic effect of intra-articular morphine. To establish the optimal dose of morphine as well as the best volume of solution to obtain an adequate analgesic effect. Patients and methods: Prospective, randomized, double blind study of 120 patients undergoing elective arthroscopic meniscectomy. Patients were randomly allocated to one of the following five groups: In group A1 ( n=28) and B1 ( n=20) patients received 1 and 5 mg of intra-articular morphine, respectively; in both groups morphine was diluted in 20 ml of saline. Another two groups, groups A2 ( n=22) and B2 ( n=26) received 1 and 5 mg of intra-articular morphine, respectively, that was diluted in 40 ml of saline. Finally, the control group, group C ( n=26), received 20 ml of saline without morphine. The intensity of the pain was evaluated by visual analog scale of 1 to 10 points at 30 min and at 1, 2, 3, 6, 12 and 24 h after arthroscopic surgery. Needs for complementary analgesia and side effects related to morphine were also recorded. Results: With respect to the control group there was a significant improvement in pain scores in those patients that were treated with morphine ( p<0.05). The best morphine dose to improve pain was 5 mg. The amount of analgesic therapy required by the patients within the first 24 h after surgery was lower in groups B1 and B2. No important side effects or complications of therapy were seen in any of the groups. Conclusions: Intra-articular morphine is effective in the postoperative period after arthroscopic meniscectomy. This method of administration provides a safe way to control the postoperative pain after arthroscopic ambulatory surgery of knee. In our experience a morphine dose of 5 mg disolved in 20 ml of saline constitutes the best therapeutic approach to reduce postoperative pain after arthroscopic meniscectomy.

Lower Doses of Intra-Articular Morphine are More Effective for Pain Control on Arrival to PACU after Arthroscopic ACL Repair

Lower Doses of Intra-Articular Morphine are More Effective for Pain Control on Arrival to PACU after Arthroscopic ACL Repair

Analgesic effects of intra-articular morphine during and after knee arthroscopy: a comparison of two methods

The objective of this study was to compare the analgesic effects of intra-articularly administered bupivacaine with bupivacaine/morphine during and after therapeutic knee arthroscopy. In a prospective, randomized study, 50 patients with clinical signs of medial meniscal injury were allocated to two groups, A and B. The patients in group A received 40 mL of 0.25% bupivacaine while the same dose of bupivacaine combined with 1 mg of morphine sulphate was administered in group B. Pain was estimated using the visual analogue scale (VAS) during surgery and at 2, 4, 6, and 24 hours after the operation was completed. Supplementary analgesic requirements were also registered, as well as the patients' overall rating of the entire procedure. The pain scores were significantly lower in Group B throughout the whole postoperative observation period. However, no significant differences were found between the two groups in terms of intraoperative pain scores, supplementary analgesic requirements, or the overall rating of the procedure. This study provides evidence that arthroscopic surgery can be performed in a safe manner after intra-articularly administered bupivacaine with or without low-dose morphine. The combination of low- dose morphine and bupivacaine did, however, produce a superior postoperative analgesic effect during the 24 hours following knee arthroscopy compared with bupivacaine alone. Arthroscopy 1998 Mar;14(2):192-6

ANESTHESIA CLINICAL PATHWAYS FOR SAME-DAY ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION DECREASE TIMES TO DISCHARGE HOME

S22 Understanding which activities add value to patient care will likely decrease costs generated by process variability. A useful indicator of the cost-effectiveness of an anesthetic in the ambulatory setting is the recovery time, or the time from OR exit to discharge from the facility. In studying this quality indicator, we developed anesthesia clinical pathways (CP) in conjunction with surgeons who routinely care for outpatients undergoing anterior cruciate ligament (ACL) reconstruction of the knee. We demonstrate that these CPs decrease the total time for phase I and phase II recovery, when compared with time data for historical controls who underwent non-standardized anesthesia and postoperative care plans. Methods: After IRB approval, we reviewed the medical records of consecutive outpatients undergoing ACL reconstruction from July 1995 to June 1997. Patients in academic year (AY) 1995-96 were not subjected to standardized anesthesia care. AY 1996-97 patients (in whom no contraindications existed) selected epidural anesthesia (EA), general anesthesia (GA), or GA with femoral nerve block (GFNB). EA consisted of lumbar epidural catheters placed preoperatively after sedation with fentanyl and midazolam, epidural dosing with lidocaine and fentanyl, and intraoperative sedation with propofol. Both GA and GFNB included induction with propofol and muscle relaxation with succinylcholine; maintenance with endotracheal desflurane, nitrous oxide, and oxygen; and opioid analgesia with fentanyl. Intraoperative fentanyl doses were decreased in the GFNB patients, who had femoral nerve blocks (with bupivacaine) placed preoperatively. All CP patients were given intraarticular morphine (10 mg) and bupivacaine (0.5%, 30cc) at the end of the surgical procedure. Patients at risk by history for postoperative nausea/vomiting (PONV) were given empiric droperidol and metoclopramide intraoperatively, and patients with refractory PONV were given a sequence of metoclopramide, droperidol, ondansetron, and perphenazine postoperatively before admission was considered. Duration of recovery data from these patients were compared with historical controls, who had a non-standardized intraoperative and postoperative anesthesia care plan. The only similarity between the historical controls and the CP patients was the intraarticular injection at the end of the procedure. Recovery time values were analyzed using one-way analysis of variance (ANOVA), with significant differences in pairwise comparisons determined by independent-sample t-tests. P < 0.05 was considered statistically significant. Results: Time data from 150 ACL anesthesia CP patients (31 CP-GA, 62 CP-EA, 57 CP-GFNB) and 122 historical (H) controls (26 regional, 96 general) were examined. Patients who were known in advance to be admitted postoperatively, who were admitted because of an extension of the surgical procedure, or who were admitted for intractable pain or PONV were excluded from this analysis. CP patients (207 +/- 20 min, mean +/- std. error of mean) were discharged home 35 minutes sooner than were historical controls (242 +/- 14 min, P = 0.008). No significant differences in discharge times were seen within the CPs. Discussion: For ACL reconstruction, the anesthesia process influenced recovery times. Whether anesthesia CP for other surgical procedures would benefit or adversely affect recovery times, and whether decreases in recovery times would create scheduling opportunities with respect to recovery nurse staffing, [1] requires further study.