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An Economic Evaluation of Bupivacaine Plus Fentanyl Versus Ropivacaine Alone for Patient-Controlled Epidural Analgesia After Total-Knee Replacement Procedure: A Double-Blinded Randomized Study
  1. Siriporn Pitimana-aree, M.D.,
  2. Shusee Visalyaputra, M.D.,
  3. Chulaluk Komoltri, Ph.D.,
  4. Saipin Muangman, M.D.,
  5. Supinya Tiviraj, B.Sc.,
  6. Supranee Puangchan, B.Sc. and
  7. Pattada Immark, B.Sc.
  1. From the Department of Anesthesiology, (S.P., S.V., S.M., S.T.,S.P., P.I.) and the Clinical Epidemiology Unit(C.K.), Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
  1. Reprint requests: Siriporn Pitimana-aree, 2 Prannok Rd., Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkoknoi, Bangkok 10700, Thailand. E-mail: sispm{at}


Background and Objectives Total-knee replacement (TKR) surgery is one of the most painful orthopedic procedures after surgery. Opioid has been commonly combined with a local anesthetic to improve the quality of pain relief, but the treatment has opioid-related side effects. This study compared the cost effectiveness of patient-controlled epidural analgesia (PCEA) with 0.0625% bupivacaine plus fentanyl (BF) 3 μg/mL versus 0.15% ropivacaine alone (R) during the first 48 hours after TKR procedure.

Methods This prospective randomized double-blined study was performed on 70 patients who underwent unilateral TKR procedure and received either BF or R after surgery. Visual analog scale (VAS) pain score at rest and upon movement, side effects, and cost of treatment were compared.

Results Overall pain at rest and upon movement between groups was not significantly different (P = 0.58, 95% CI = 4.4 to −7.8 and P = 0.8, 95% CI = 6.4 to −8.2, respectively). Patients in the BF group experienced more pruritus and had more vomiting episodes than those in the R group (P = .015), whereas no difference occurred in other side effects. Nevertheless, patient satisfaction with pain management was higher in the BF group compared with that in the R group. In addition, pain treatment with bupivacaine and fentanyl was 18% less costly compared with ropivacaine alone.

Conclusions Considering the economic evaluation, we conclude that PCEA with 0.0625% bupivacaine plus fentanyl 3 μg/mL is more cost effective and provides more patient satisfaction than PCEA with ropivacaine alone. However, use of epidural ropivacaine alone causes fewer opioid-related side effects, particularly pruritus and vomiting.

  • Patient-controlled epidural analgesia (PCEA)
  • Total-knee replacement
  • Cost effectiveness
  • Bupivacaine
  • Ropivacaine
  • Fentanyl

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  • Support by a Siriraj Grant for Research Development and Medical Education.