Nalbuphine for postoperative pain treatment in children

A randomized, double-blind study to compare the efficacy and safety of nalbuphine nasal spray and injectable solution in patients after orthopaedic interventions and traumatological procedures

AIMS

Our previous 3-period crossover study in healthy volunteers comparing the pharmacokinetics of nalbuphine nasal spray Apain with parenteral nalbuphine solution demonstrated high bioavailability of the nasal spray and close similarity of pharmacokinetic profiles after intranasal and intramuscular administration, especially within 30 min postdose. The aim of the present study was a noninferiority assessment of nalbuphine nasal spray vs. intramuscular injection for pain relief in postoperative patients.

METHODS

Ninety orthopaedic and traumatology patients were enrolled in this double-blind, randomized study of the effectiveness and tolerance of a single 10.5 mg dose of nalbuphine nasal spray vs. 10 mg intramuscular injection. The summed pain intensity difference (SPID0-6) calculated using visual analogue scale scores was the primary study endpoint.

RESULTS

Of 90 subjects enrolled, the per-protocol efficacy population comprised 79 patients; 6 patients in the reference group and 5 patients in the test group were excluded due to remedication. The mean values of study endpoints with 95% confidence interval were as follows in reference and test groups, respectively: SPID0-6 = 228.08 (205.73-250.43) vs. 248.73 9 (225.83-271.63), time to pain relief onset = 0.28 h (0.25-0.31) vs. 0.27 h (0.25-0.29), duration of analgesia = 5.55 h (5.17-5.93) vs. 5.51 h (5.10-5.92), area under the curve = 119.30 (91.17-147.43) vs. 99.81 (74.52-107.10). No statistically significant differences were revealed.

CONCLUSION

Nalbuphine nasal spray Apain has been proven to be a safe, noninvasive alternative to intramuscular nalbuphine to relieve severe postoperative pain. Designed for self-administration and dose-adjusting, the noncontrolled opioid analgesic nalbuphine spray can be used for patient-controlled analgesia in out-of-hospital, field and home settings.

Comparison of postoperative analgesia and side effects in pediatric laparoscopic surgery with morphine and nalbuphine

There is currently no consensus on the optimal perioperative pain management strategy involving specific opioids. This study aims to compare the postoperative analgesia, the associated side effects between nalbuphine and morphine in children undergoing laparoscopic surgery. One hundred ninety children were randomly assigned to nalbuphine (0.2 mg/kg) or morphine (0.2 mg/kg). Nalbuphine's analgesic effect was non-inferior to morphine, with similar total rescue analgesic consumption during PACU stay (0.03 ± 0.05mg vs. 0.04 ± 0.06 mg, p > 0.05). Nalbuphine group had a lower incidence of respiratory depression (RR ≤ 10/min) (4.8% vs. 38.6%, p < 0.001), PONV (2.4% vs. 18.1%, p = 0.002), and pruritus (0% vs. 16.9%, p < 0.001) than morphine. Additionally, nalbuphine showed a shorter laryngeal mask airway removal time (13.9 [12.7, 15.1]) compared with morphine (17.0 [15.1, 18.9], p = 0.011). Nalbuphine provides equipotent analgesia with significantly lower incidences of respiratory depression, PONV, and pruritus compared with morphine in pediatric laparoscopic surgery.

Nalbuphine's Hemodynamic Impact in Ear, Nose, and Throat (ENT) Surgeries: A Comprehensive Review

Nalbuphine, a semi-synthetic opioid, has gained attention for its analgesic properties, but its specific impact on hemodynamics in ear, nose, and throat (ENT) surgeries remains a subject of exploration. This comprehensive review aims to systematically analyze existing literature to understand the nuanced hemodynamic effects of nalbuphine during ENT procedures. Nalbuphine demonstrates promise as an analgesic agent in ENT surgeries with generally stable hemodynamic profiles. However, the variability in study designs and outcomes necessitates a cautious interpretation. The review underscores the need for standardized protocols and further research to elucidate patient-specific considerations, ensuring optimal utilization of nalbuphine in enhancing overall perioperative care for ENT patients.

Impact of intravenous administration of nalbuphine at different time points for postoperative analgesia and sedation in adenotonsillectomized children: a prospective, randomized controlled trial

Objective

To compare the efficacy of intravenous administration of nalbuphine at different time points for postoperative analgesia and sedation in adenotonsillectomized children.

Methods

Patients with obstructive sleep apnea syndrome scheduled for adenotonsillectomy were randomly divided into group A (patients received intravenous nalbuphine 0.2 mg/kg before anesthesia induction), group B (patients received intravenous nalbuphine 0.2 mg/kg 10 min before the end of surgery), and group C (patients did not receive nalbuphine injection). The time points for measuring outcomes were before anesthesia induction (T0), extubation (T1), and 0, 15, 30, or 45 min in the postanesthesia care unit (PACU) (T2-T5, respectively).

Results

There were 40 patients in group A, 41 patients in group B and 39 patients in group C. Patients in group B had significantly lower FLACC (Face, Legs, Activity, Cry, Consolability) pain scores at T2-T5 than those in group C (all p<0.05). Patients in group B had higher Ramsay Sedation Score at T2-T4 than those in group C (all p<0.05). The proportion of patients who received remedial analgesia in the PACU in group A (17.5%, p=0.008) and group B (9.8%, p<0.001) was significantly lower than that in group C (46.2%).

Conclusion

Intravenous administration of nalbuphine 10 min before the end of adenotonsillectomy in children could decrease pain intensity and increase sedation levels during the recovery period with the reduction of remedial analgesia in the PACU.Trial registration number ChiCTR2200060118.

Efficacy of intravenous nalbuphine for managing post-anaesthesia shivering: A systematic review and meta-analysis of randomised controlled trials with trial sequential analysis

Background and Aims

Post-anaesthesia shivering is distressing and is observed after spinal and general anaesthesia. Nalbuphine, a partial mu-opioid receptor antagonist with kappa-opioid receptor agonist properties, has been successfully used to manage post-anaesthesia shivering.

Methods

After registering the review with the International Prospective Register of Systematic Reviews (PROSPERO), we searched PubMed/Medline, Scopus, Ovid, Cochrane Library and clinicaltrials.gov with keywords for randomised controlled trials. The risk of bias-2 (RoB-2) scale was used to assess the quality of evidence. We also used Grading of Recommendations, Assessment, Development and Evaluations (GRADE) guidelines to evaluate the strength of evidence and trial sequential analysis to validate the conclusions.

Results

Of the 240 articles, 10 were considered eligible for review (700 patients, 350- nalbuphine, 350- control or placebo). When compared to placebo, the success rate of nalbuphine controlling shivering was significantly better (risk ratio [RR]: 2.37, 95% confidence interval [CI]:1.91, 2.94; P = 0.04, I² = 94%), but comparable to the control group drugs (opioids, dexmedetomidine, ondansetron, pethidine). Compared to placebo, shivering recurrence was significantly less with nalbuphine than with placebo (RR: 0.47, 95% CI: 0.26, 0.83; P = 0.01, I² = 61%), but comparable with the control group. The incidence of postoperative nausea/vomiting (PONV) was significantly less with nalbuphine when compared to the control group (RR: 0.67, 95% CI: 0.47, 0.95; P = 0.02, I² = 37%), but PONV in the nalbuphine group was comparable to placebo (RR: 1.20, 95% CI: 0.68, 2.12; P = 0.54, I² = 0%). Other outcomes, like the grade of shivering and hypotension, were comparable between the nalbuphine and control groups.

Conclusion

Nalbuphine successfully controls post-anaesthesia shivering and reduces the recurrence of shivering.

Oxycodone vs. tramadol in postoperative parent-controlled intravenous analgesia in children: a prospective, randomized, double-blinded, multiple-center clinical trial

BACKGROUND

Management of acute postoperative pain is one of the major challenges in pediatric patients. Oral oxycodone has shown good pain relief in postoperative pain relief in children, but no studies have investigated intravenous oxycodone in this context.

OBJECTIVE

whether oxycodone PCIA can provide adequate and safe postoperative pain relief, in comparison to tramadol as reference opioid drug.

DESIGN

a randomized, double-blind, parallel, multi-center clinical trial.

SETTING

five university medical centers and three teaching hospitals in China.

PARTICIPANTS

patients aged 3-month-old to 6-year-old undergoing elective surgery under general anesthesia.

INTERVENTION

patients were randomly allocated to either tramadol (n = 109) or oxycodone (n = 89) as main postoperative opioid analgesic. Tramadol or oxycodone were administered with a loading dose at the end of surgery (1 or 0.1 mg.kg^-1, respectively), then with a parent-controlled intravenous device with fixed bolus doses only (0.5 or 0.05 mg.kg-1, respectively), and a 10-min lockout time.

OUTCOMES

the primary outcome was adequate postoperative pain relief, defined as a face, legs, activity, cry, and consolability (FLACC) score < 4/10 in the post-anesthesia care unit (PACU), with no need for an alternative rescue analgesia. FLACC was measured 10 min after extubation then every 10 min until discharge from PACU. Analgesia was currently conducted with the boluses of either tramadol or oxycodone if FLACC was ≥ 3, up to three bolus doses, after what rescue alternative analgesia was administered.

RESULTS

tramadol and oxycodone provided a similar level of adequate postoperative pain relief in PACU and in the wards. No significant differences were either noted for the raw FLACC scores, the bolus dose demand in PACU, the time between the first bolus dose and discharge from PACU, analgesic drug consumption, bolus times required in the wards, function activity score, or the parents' satisfaction. The main observed side effects in both groups were nausea and vomiting, with no difference between groups. However, patients in the oxycodone group showed less sedation levels and had a shorter stay in the PACU, compared with the tramadol group.

CONCLUSIONS

an adequate postoperative analgesia can be achieved with intravenous oxycodone, this with less side effects than tramadol. It can therefore be a choice for postoperative pain relief in pediatric patients.

TRIAL REGISTRATION

The study was registered at www.chictr.org.cn (Registration number: ChiCTR1800016372; date of first registration: 28/05/2018; updated date:06/01/2023).

Intraoperative administration of intravenous flurbiprofen axetil with nalbuphine reduces postoperative pain after orbital decompression: a single-center, prospective randomized controlled trial

Purpose

This study aimed to investigate postoperative analgesia achieved with intraoperative administration of intravenous flurbiprofen axetil and nalbuphine in patients undergoing orbital decompression.

Methods

Sixty-three patients undergoing orbital decompression under general anesthesia at the Zhongshan Ophthalmic Center at Sun Yat-sen University (Guangzhou, China) were randomly allocated into one of the following three groups (1:1:1): intraoperative flurbiprofen axetil 100 mg (Group 1); intraoperative nalbuphine 0.1 mg/kg (Group 2); or intraoperative flurbiprofen axetil 100 mg combined with nalbuphine 0.1 mg/kg (Group 3). The primary end point was mean postoperative pain intensity during the first 24 hours. The secondary efficacy end points were the intensity of pain and discomfort at 0, 2, 6, 10, and 24 hours after surgery and side effects at 24 hours after surgery.

Results

The demographic characteristics were similar among the three groups. Mean and peak postoperative pain scores during the first 24 hours in Group 3 were lower than those in Group 1 (P=0.007 and P=0.003, respectively) and Group 2 (P=0.001 and P=0.000, respectively). Additionally, the pain scores in Group 3 were significantly lower than those in Group 1 during the first 6 hours after surgery (P=0.003, 0.002, and 0.022 at 0, 2, and 6 hours, respectively) and those in Group 2 during the first 10 hours after surgery (P=0.008, 0.000, 0.001, and 0.019 at 0, 2, 6, and 10 hours, respectively). Discomfort scores were not significantly different among the three groups during the observation period, except at 2 hours after surgery, at which time the scores in Group 3 were significantly lower than those in Group 2 (P=0.033). Postoperative adverse effects and analgesic requirements were similar among the three groups.

Conclusion

Intraoperative administration of a combination of intravenous flurbiprofen axetil and nalbuphine is superior to single-dose flurbiprofen axetil or nalbuphine in patients undergoing orbital decompression.

The application of nalbuphine in patient-controlled intravenous analgesia for patients undergoing subtotal gastrectomy

The aim of the present study was to investigate the analgesic effect and safety of the application of different doses of nalbuphine in patient-controlled intravenous analgesia (PCIA) for patients undergoing subtotal gastrectomy. A total of 120 patients, who underwent subtotal gastrectomy at our hospital between May, 2015 and January, 2017 under combined spinal epidural combined anesthesia, were selected. The patients received PCIA after surgery. The patients were randomly divided into four groups, including the morphine (MOP group), nalbuphine 60 mg (N60 group), nalbuphine 80 mg (N80 group) and nalbuphine 100 mg (N100 group). The first dose of PCIA treatment was 2 ml, the background dose was 2 ml/h, PCIA dose was 0.5 ml, and the lockout time was 15 min. Postoperative vital signs and adverse reactions (bleeding, fullness and aching of upper abdomen and vomiting) were recorded. The visual analogue scale (VAS) and Ramsay sedation score of patients were evaluated. The number of PCIA and analgesia-related complications during analgesia were recorded. No significant differences in general data were found among the four groups (P>0.05). The VAS score of the three nalbuphine groups was lower than that of the MOP group, but the differences were not significant. All postoperative Ramsay sedation scores of the four groups showed appropriate sedation, but no significant differences were found between the groups. Compared with the MOP group, the use of postoperative PCIA was significantly delayed and the number of PCIA was significantly smaller in the three nalbuphine groups (P<0.05). The results show that the analgesic effect and safety of the use of PCIA for patients undergoing subtotal gastrectomy were satisfactory.

Comparison of single-dose nalbuphine versus tramadol for postoperative pain management in children: a randomized, controlled trial

Background

Acute postoperative pain control in children is an essential component of postoperative care, particularly in daycare procedures. Giving patients continuous narcotic analgesics can be risky; however, a single dose may be sufficient.

Methods

This study used a prospective, randomized controlled design and was conducted at the Pediatric Surgery Unit, Services Hospital, Lahore. In total, 150 patients who underwent inguinal herniotomy (age range: 1–12 years) were randomly assigned to two groups: group A (nalbuphine) and group B (tramadol). Patients were given a single dose of either nalbuphine (0.2 mg/kg) or tramadol (2 mg/kg) immediately after surgery and pain was measured at 0, 1, 2, 4, and 8 h.

Results

The demographic characteristics were similar between the two groups. The mean pain score was lower in group A than in group B at 0 and 1 h (P < 0.05). However, at 4 h and 8 h, the pain scores in group A were still lower, but not significantly. In all, 9 patients (12.0%) required rescue analgesics in group A compared to 16 patients (21.3%) in group B (P = 0.051). The mean time for requirement of rescue analgesics was 6.5 ± 0.5 h in group A and 5.3 ± 1.7 h in group B (P = 0.06).

Conclusions

A single dose of nalbuphine is sufficient, and superior to tramadol, for postoperative pain management in children who have undergone daycare procedures.

Tramadol for postoperative pain treatment in children

BACKGROUND

According to current recommendations a multimodal approach is believed to be the gold standard for postoperative pain treatment in children. However, several surveys in the last few years demonstrated that postoperative pain in children is still a serious problem, mainly because opioids are avoided. One of the reasons for this is the fear of severe adverse events following opioid administration. Tramadol is a weak mu-opioid agonist and inhibits reuptake of noradrenaline and serotonin (5HT). Because of a relatively wide therapeutic window and a ceiling effect with a lower risk for severe adverse events (for example respiratory depression) tramadol is a widely used opioid in children. However, the exact efficacy and occurrence of adverse events following tramadol (in comparison with placebo or other opioids) for postoperative pain treatment in children and adolescents are currently not clear.

OBJECTIVES

To assess the effectiveness and side effect profile of tramadol for postoperative pain relief in children and adolescents undergoing different surgical procedures.

SEARCH METHODS

We searched the following electronic databases: the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2014, Issue 6), MEDLINE via PubMed (January 1966 to July 2014) and EMBASE via Ovid (January 1947 to July 2014). There were no restrictions regarding language or date of publication. The reference lists of all included trials were checked for additional studies.

SELECTION CRITERIA

All randomised controlled clinical trials investigating the perioperative administration of tramadol compared to placebo or other opioids for postoperative pain treatment in children and adolescents were included.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed the study eligibility, performed the data extraction and assessed the risk of bias of included trials.

MAIN RESULTS

Twenty randomised controlled trials involving 1170 patients were included in this systematic review. The overall risk of bias in included trials was assessed as unclear, because concealment of allocation processes and blinding of outcome assessors were poorly described. Due to inconsistent outcome reporting, data from 17 included trials could be pooled for some endpoints only. Eight trials compared tramadol administration with placebo and five trials found that the need for rescue analgesia in the postoperative care unit (PACU) was reduced in children receiving tramadol (RR 0.40; 95% CI 0.20 to 0.78; low quality evidence). Only one trial investigated the number of patients with moderate to severe pain, but a non-validated pain scale was used (very low quality evidence). Four trials compared morphine with tramadol administration. There was no clear evidence of difference in the need for rescue analgesia in the PACU (RR 1.25; 95% CI 0.83 to 1.89; low quality evidence) with tramadol compared with morphine. No trials could be pooled for the outcome 'number of patients with moderate to severe pain'. Three trials were included for the comparison of tramadol with nalbuphine. There was no clear evidence for the need for rescue analgesia in the PACU (RR 0,63; 95% CI 0.16 to 2.45; low quality evidence). Only one trial reported the number of patients with moderate to severe pain, but used a non-validated pain scale (very low quality evidence). Two out of six included trials, which compared pethidine with tramadol, reported the number of children with a need for rescue analgesia within the PACU and showed no clear evidence (RR 0.93; 95% CI 0.43 to 2.02; very low quality evidence). Two trials reported the number of patients with moderate to severe pain and showed a lower RR in patients treated with tramadol (RR 0.64; 95% CI 0.36 to 1.16; low quality evidence). Only one trial was included, which compared tramadol with fentanyl, reporting the number of patients with the need for rescue analgesia (very low quality evidence). Generally, adverse events were poorly reported. Most data could be pooled for the comparison with placebo focusing on the RR for postoperative nausea and vomiting (PONV) in the postoperative care unit and 24 h postoperation. Children treated with tramadol, compared to placebo, did not show clear evidence of benefit for PONV in the postoperative care unit (RR 0.84; 95% CI 0.28 to 2.52; moderate quality evidence) and 24 h postoperation (RR 0.78; 95% CI 0.54 to 1.12; moderate quality evidence).

AUTHORS' CONCLUSIONS

The overall evidence regarding tramadol for postoperative pain in children is currently low or very low and should be interpreted with caution due to small studies and methodological problems (different validated and non-validated pain scales with different pain triggers, missing sample size calculations and missing intention-to-treat analysis). Nevertheless, we demonstrated that tramadol administration might provide appropriate analgesia when compared to placebo; this is based on results showing reduced rescue analgesia in children treated with tramadol compared to placebo. In contrast, the evidence regarding the comparison with other opioids (for example morphine) was uncertain. Adverse events were only poorly reported, so an accurate risk-benefit analysis was not possible.