Perioperative antinociceptive effects of tramadol. A prospective, randomized, double-blind comparison with morphine

Comparing ultrasound-guided modified thoracoabdominal nerves block through perichondrial approach with oblique subcostal transversus abdominis plane block for patients undergoing laparoscopic cholecystectomy: a randomized, controlled trial

BACKGROUND

Laparoscopic cholecystectomy(LC) causes significant postoperative pain. Oblique subcostal transversus abdominis plane(OSTAP) block was described for postoperative analgesia, especially for upper abdominal surgeries. Modified thoracoabdominal nerves block through perichondrial approach(M-TAPA) block is a new technique defined by the modification of the thoracoabdominal nerves through perichondrial approach (TAPA) block, in which local anesthetics are delivered only to the underside of the perichondral surface. The primary aim of this study was to evaluate the effect of M-TAPA and OSTAP blocks as part of multimodal analgesia on postoperative opioid consumption in patients undergoing LC.

METHOD

The present study was designed as a randomized, controlled, prospective study. Seventy-six adult patients undergoing LC were randomly assigned to receive either bilaterally M-TAPA or OSTAP block after the induction of anesthesia and before surgery using bupivacaine 0.25%, 25 ml. The primary outcome was assessed as postoperative 24 h opioid consumption, between groups were compared. Secondary outcomes were Numerical Rational scale(NRS) scores, time to first opioid analgesia, patient recovery, using the Quality of Recovery-15 (QoR-15) scale, nausea and vomiting, sedation score, metoclopramide consumption, and evaluating the analgesic range of dermatome.

RESULTS

The mean tramadol consumption at the postoperative 24th hour was higher in the group OSTAP than in group M-TAPA (P = 0.047). NRS movement score at 12th hour was statistically significantly lower in group M-TAPA than in group OSTAP (P = 0.044). Dermatomes showed intense sensory analgesia between T7-11 in both groups, and it was determined that there was proportionally more involvement in the group M-TAPA. There were no differences between the groups in terms of other results.

CONCLUSIONS

After the LC surgery, ultrasound-guided M-TAPA block effectively reduced opioid consumption, postoperative pain, and QoR-15 scores similar to OSTAP block.

CLINICAL TRIAL REGISTRATION

The study was registered prospectively at clinicaltrials.gov (trial ID: NCT05108129 on 4/11/2021).

Ultrasound-guided bilateral modified-thoracoabdominal nerve block through a perichondrial approach (M-TAPA) in patients undergoing laparoscopic cholecystectomy: a randomized double-blind controlled trial

Background

Modified thoracoabdominal nerve block through the perichondrial approach (M-TAPA) is a new technique that provides effective analgesia of the anterior and lateral thoracoabdominal walls by administering local anesthesia only to the underside of the perichondral surface. The primary purpose of the present study was to investigate the postoperative analgesic efficacy of M-TAPA block performed before surgery in patients undergoing laparoscopic cholecystectomy (LC).

Method

The present study was designed as a double-blind, randomized, controlled, prospective study. A total of 68 patients were included in the study. In group M-TAPA, M-TAPA block was performed bilaterally after the induction of general anesthesia. No block was performed on the group control. The postoperative pain scores, analgesic use in the first 24 h, antiemetic consumption, sedation, postoperative nausea and vomiting (PONV), and Quality of Recovery-40 (QoR-40) scores were recorded.

Results

Pain scores were significantly lower in group M-TAPA than in the group control, both during resting and motion at all times (p < 0.001 at each time point). The total amount of tramadol consumed in the first 24 h was lower in group M-TAPA [median 100 mg, min-max (0-200)] than in the group control (P < 0.001). Postoperative median QoR-40 scores were higher in group M-TAPA compared with the group control (P < 0.001). There were no differences between the groups in terms of other results.

Conclusion

After the LC surgery, ultrasound-guided M-TAPA block reduced postoperative pain scores and tramadol consumption effectively. It was observed that the quality of recovery was also higher because QoR-40 scores were higher.

The effect of erector spinae plane block on postoperative analgesia and respiratory function in patients undergoing laparoscopic cholecystectomy: A double-blind randomized controlled trial

STUDY OBJECTIVE

Laparoscopic cholecystectomy (LC) causes moderate-to-severe postoperative pain. Postoperative pain is one of the leading contributors to respiratory dysfunction following surgery. This study investigated the effect of erector spinae plane (ESP) block on postoperative analgesia and respiratory function in patients undergoing LC.

DESIGN

Prospective, randomized, controlled trial.

SETTING

University of Health Science.

PATIENTS

Sixty-eight adult patients undergoing LC.

INTERVENTIONS

Both groups received a standardized analgesia protocol. Patients assigned to the ESP block group received an additional bilateral ESP block.

MEASUREMENTS

The primary outcome was assessed as postoperative pain intensity associated with a lower opioid requirement and significant respiratory function improvement.

MAIN RESULTS

Numerical rating scale (NRS) scores both at rest and during coughing were significantly lower in the ESP block group than in the control group at all time intervals (p < 0.001 in each) except for hour 2 postoperatively (p = 0.06 and p = 0.13, respectively). Tramadol consumption at 2 h and 24 h postoperatively was significantly lower in the ESP block group than in the controls (p < 0.001 for each). There was significant preservation in forced expiratory volume in the first second (FEV₁) and forced vital capacity (FVC) in the ESP group in comparison to the control group at 2 and 24 h after surgery (p < 0.05 in each). FEV₁/FVC and peak expiratory flow rate (PEFR) values were similar in each time interval.

CONCLUSIONS

Bilateral ESP blocks provides adequate analgesia, allowing for a lower opioid requirement and significant respiratory function improvement after LC; therefore, we concluded that ESP block could be added to the multimodal analgesia protocol in LC.

Intravenous Tramadol is Effective in the Management of Postoperative Pain Following Abdominoplasty: A Three-Arm Randomized Placebo- and Active-Controlled Trial

BACKGROUND AND OBJECTIVE

Oral tramadol, an atypical opioid approved in the United States (US) since 1995 and a Schedule IV controlled substance, has less abuse liability compared to Schedule II conventional opioids. Intravenous (IV) tramadol is not available in the US, but has the potential to fill a gap between non-opioid medications and conventional opioids for treatment of acute pain. This study evaluates IV tramadol in the management of postoperative pain compared to placebo and standard-of-care active control.

METHODS

A phase 3, multicenter, double-blind, three-arm, randomized, placebo- and active-controlled, multiple-dose, parallel-group study was conducted to evaluate the efficacy and safety of 50 mg IV tramadol versus placebo and 4 mg IV morphine over 48 h in patients with postoperative pain following abdominoplasty surgery.

RESULTS

IV tramadol was statistically superior (p < 0.05) to placebo and comparable to IV morphine for the primary and all key secondary efficacy outcomes and demonstrated numerically lower rates for the incidence of most common treatment-emergent adverse events (TEAEs) compared to morphine. No unexpected findings were observed for TEAEs, laboratory tests, vital signs, or electrocardiograms (ECGs). Over 90% of patients completed the study.

CONCLUSION

The study demonstrated that IV tramadol 50 mg is highly effective in the management of postoperative pain following abdominoplasty. The consistency of effects between tramadol and morphine (as compared to placebo) for primary and key secondary endpoints validates the efficacy of tramadol observed. The study also provided direct evidence of improved tolerability of IV tramadol over a standard-of-care conventional Schedule II opioid. IV tramadol may become a useful option in patients where exposure to conventional opioids is not desired.

Evaluation of Ultrasound-Guided Erector Spinae Plane Block and Oblique Subcostal Transversus Abdominis Plane Block in Laparoscopic Cholecystectomy: Randomized, Controlled, Prospective Study

Background:

Oblique subcostal transversus abdominis plane block (OSTAP) is a recently described regional anesthetic technique used in upper abdominal surgeries such as laparoscopic cholecystectomy (LC). Erector spinae plane block (ESPB) has also been reported for postoperative analgesia in LC.

Aim:

We aimed to compare the effectiveness of OSTAP and ESPB in providing postoperative analgesia in patients undergoing these surgeries.

Setting and Design:

This study was designed as a double-blinded, prospective, randomized, efficiency study in a tertiary university hospital, postoperative recovery room, and ward.

Materials and Methods:

A total of 72 patients were recruited and 60 patients were randomized into three equal groups (ESPB, OSTAP, and control group). Pain intensity between groups was compared using Numeric Rating Scale (NRS) scores. In addition, consumption of paracetamol and tramadol and additional rescue analgesic requirement were measured. Standard multimodal analgesia was performed in all groups, while ESPB block was also performed in Group ESPB and OSTAP block was also performed in group OSTAP.

Statistical Analysis Used:

Descriptive statistics were expressed as mean ± standard deviation. Independent t-test, Mann–Whitney U-test, Chi-square test, Fisher's exact test, Shapiro–Wilk test, one-way ANOVA, and post hoc Tukey's analysis were used for statistical analysis.

Results:

NRS was lower in block groups during the first 3 h. There was no difference in NRS scores at other hours. Analgesic consumption and rescue analgesic requirement were lower in groups ESPB and OSTAP when compared to those of control group. Block groups were similar.

Conclusion:

Bilateral ultrasound-guided ESPB and OSTAP performed at the end of LC lead to akin analgesia requirement and improve the quality of multimodal analgesia.

Laparoscopic surgery: a narrative review of pharmacotherapy in pain management

Laparoscopic surgery is widespread, and an increasing number of surgeries are performed laparoscopically. Early pain after laparoscopy can be similar or even more severe than that after open surgery. Thus, proactive pain management should be provided. Pain after laparoscopic surgery is derived from multiple origins; therefore, a single agent is seldom sufficient. Pain is most effectively controlled by a multimodal, preventive analgesia approach, such as combining opioids with non-opioid analgesics and local anaesthetics. Wound and port site local anaesthetic injections decrease abdominal wall pain by 1-1.5 units on a 0-10 pain scale. Inflammatory pain and shoulder pain can be controlled by NSAIDs or corticosteroids. In some patient groups, adjuvant drugs, ketamine and α2-adrenergic agonists can be helpful, but evidence on gabapentinoids is conflicting. In the present review, the types of pain that need to be taken into account while planning pain management protocols and the wide range of analgesic options that have been assessed in laparoscopic surgery are critically assessed. Recommendations to the clinician will be made regarding how to manage acute pain and how to prevent persistent postoperative pain. It is important to identify patients at the highest risk for severe and prolonged post-operative pain, and to have a proactive strategy in place for these individuals.

Efficacy of preventive analgesia with tramadol or lornoxicam for percutaneous nephrolithotomy: a prospective, randomized, double-blind, placebo-controlled study

BACKGROUND

Prevention of postoperative pain provides better and more rapid convalescence for patients.

OBJECTIVE

The aim of this study was to compare the preventive analgesic effect of tramadol and lornoxicam in the early postoperative period in patients undergoing percutaneous nephrolithotomy (PCNL).

METHODS

Patients who were scheduled for elective PCNL at the Cumhuriyet University Hospital, Sivas, Turkey, were enrolled in this prospective, double-blind, placebo-controlled study. The patients were randomly assigned to 1 of 3 groups: tramadol, lornoxicam, and normal saline (NS). Ten minutes before induction of anesthesia, the tramadol group received tramadol 100 mg IV, the lornoxicam group received lornoxicam 8 mg IV, and the NS group received NS 2 mL IV. Anesthesia was induced using fentanyl 1 μg/kg and thiopental sodium 4 to 7 mg/kg. Vecuronium 0.1 mg/kg was used for muscle relaxation. Desflurane 4% to 6% and 50%:50% oxygen/nitrous oxide were used for maintenance. Oxygen saturation, heart rate, and mean blood pressure were recorded before induction and during the postoperative period. During the postoperative period, visual analogue scale O/AS) scores, time to first analgesic (TFA), total analgesic consumption (TAC), and patient satisfaction scores were determined. Data about postoperative nausea and vomiting and other adverse events and complications were also collected.

RESULTS

Seventy-three patients were assessed for enrollment and 60 (33 women, 27 men; mean [SD] age, 44.69 [11.27] years; age range, 20-62 years) were included in the study. The baseline demographic characteristics and duration of surgery were similar in all 3 groups. The mean (SD) VAS scores in the tramadol group were significantly lower than in the NS group at 15 and 30 minutes and 1, 2, 4, and 12 hours after surgery (all, P < 0.05). The VAS scores in the lornoxicam group were significantly lower than in the NS group at 15 and 30 minutes and 1 hour (all, P < 0.05). The VAS score at 1 hour after surgery was significantly lower in the tramadol group than in the lornoxicam group (18 [8] vs 32 [16]; P < 0.05); however, there were no other significant differences in VAS scores between the active groups. A significantly shorter TFA was associated with the NS group when compared with the tramadol and lornoxicam groups (46 [27] vs 354 [187] and 180 [118], respectively; both, P < 0.05). TFA was significantly shorter in the lornoxicam group when compared with the tramadol roup (180 [118] vs 354 [187]; P < 0.05). TAC was significantly higher in the NS group than in the tramadol and lornoxicam groups (270 [47] vs 115 [74] and 145 [72], respectively; both, P < 0.05). Patient satisfaction score (range) was significantly lower in the NS group when compared with the tramadol and lornoxicam groups (0 [0-1] vs 3 [0-3] and 2 [0-3], respectively; both, P < 0.05). There were no other significant between-group differences observed.

CONCLUSIONS

Tramadol and lornoxicam were more effective than NS in preventing early postoperative pain. The preventive analgesic effect of tramadol was comparable with that of lornoxicam, except at 1 hour when tramadol was more effective among these patients undergoing PCNL. Both drugs were well tolerated.

Pharmacological interventions for prevention or treatment of postoperative pain in people undergoing laparoscopic cholecystectomy

BACKGROUND

While laparoscopic cholecystectomy is generally considered less painful than open surgery, pain is one of the important reasons for delayed discharge after day-surgery and overnight stay following laparoscopic cholecystectomy. The safety and effectiveness of different pharmacological interventions such as non-steroidal anti-inflammatory drugs, opioids, and anticonvulsant analgesics in people undergoing laparoscopic cholecystectomy is unknown.

OBJECTIVES

To assess the benefits and harms of different analgesics in people undergoing laparoscopic cholecystectomy.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Science Citation Index Expanded, and the World Health Organization International Clinical Trials Registry Platform portal (WHO ICTRP) to March 2013 to identify randomised clinical trials of relevance to this review.

SELECTION CRITERIA

We considered only randomised clinical trials (irrespective of language, blinding, or publication status) comparing different pharmacological interventions with no intervention or inactive controls for outcomes related to benefit in this review. We considered comparative non-randomised studies with regards to treatment-related harms. We also considered trials that compared one class of drug with another class of drug for this review.

DATA COLLECTION AND ANALYSIS

Two review authors collected the data independently. We analysed the data with both fixed-effect and random-effects models using Review Manager 5 analysis. For each outcome, we calculated the risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CI).

MAIN RESULTS

We included 25 trials with 2505 participants randomised to the different pharmacological agents and inactive controls. All the trials were at unclear risk of bias. Most trials included only low anaesthetic risk people undergoing elective laparoscopic cholecystectomy. Participants were allowed to take additional analgesics as required in 24 of the trials. The pharmacological interventions in all the included trials were aimed at preventing pain after laparoscopic cholecystectomy. There were considerable differences in the pharmacological agents used and the methods of administration. The estimated effects of the intervention on the proportion of participants who were discharged as day-surgery, the length of hospital stay, or the time taken to return to work were imprecise in all the comparisons in which these outcomes were reported (very low quality evidence). There was no mortality in any of the groups in the two trials that reported mortality (183 participants, very low quality evidence). Differences in serious morbidity outcomes between the groups were imprecise across all the comparisons (very low quality evidence). None of the trials reported patient quality of life or time taken to return to normal activity. The pain at 4 to 8 hours was generally reduced by about 1 to 2 cm on the visual analogue scale of 1 to 10 cm in the comparisons involving the different pharmacological agents and inactive controls (low or very low quality evidence). The pain at 9 to 24 hours was generally reduced by about 0.5 cm (a modest reduction) on the visual analogue scale of 1 to 10 cm in the comparisons involving the different pharmacological agents and inactive controls (low or very low quality evidence).

AUTHORS' CONCLUSIONS

There is evidence of very low quality that different pharmacological agents including non-steroidal anti-inflammatory drugs, opioid analgesics, and anticonvulsant analgesics reduce pain scores in people at low anaesthetic risk undergoing elective laparoscopic cholecystectomy. However, the decision to use these drugs has to weigh the clinically small reduction in pain against uncertain evidence of serious adverse events associated with many of these agents. Further randomised clinical trials of low risk of systematic and random errors are necessary. Such trials should include important clinical outcomes such as quality of life and time to return to work in their assessment.

Pharmacokinetics, safety and tolerance of single- and multiple-dose of a novel compound tramadol hydrochloride injection (35 mg tramadol hydrochloride, 45 mgl promethazine hydrochloride) in Chinese healthy subjects

The pharmacokinetics of Tramadol and Promethazine after a single dose of 40, 80 and 120 mg intramuscular injecting CTHI was evaluated in healthy volunteers. Physical exam, vital signs, clinical laboratory tests and electrocardiogram measurements were monitored to assess the safety and tolerance of the drug. The plasma levels of Tramadol and Promethazine in serial samples were measured by a validated HPLC-MS method. No subject showed any drug-related clinically significant changes on physical examination, vital signs or laboratory tests.

[Influence of the fascia iliaca compartment block on postoperative cognitive status in the elderly]

OBJECTIVE

The aim of this study was to assess the influence of a regional analgesia technique on the incidence of postoperative cognitive dysfunction (POCD) after hip surgery, in elderly patients.

PATIENTS AND METHODS

Patients, aged over 65 years, were assigned in two groups according to the anaesthesia technique: group NKT (general anaesthesia with target concentration infusion of propofol and remifentanil, with a 0.1 mg/kg-bolus of morphine at the end of surgery), group KT (preoperative iliaca compartment block with catheter and then general anaesthesia without bolus of morphine). Postoperative analgesia was similar in both groups: paracetamol, tramadol, and subcutaneous morphine if verbal pain scale equal or greater than 2 (0.1 mg/kg). POCD was defined as a decrease in Mini Mental Status (MMSE) equal or greater than 2 points and was monitored during 2 days. Consumption of opioids, pain scores and side effects were recorded.

RESULTS

Sixty-five patients were included: 34 in NKT group and 31 in KT group. MMSE scores were higher in the KT group at day 1 and day 2 (p=0.01 and 0.0004, respectively). POCD was less frequent in group KT at day 2 (6 % vs 41 % ; p=0.001) and pain scores were lower during the first 48 hours (p=0.03). Remifentanil consumption was lower in KT group (0.43+/-0.18 mg vs 0.61+/-0.25 mg, p=0.002). Total amount of morphine, including the bolus in NKT group, was significantly lower in KT group (7 [5-17] mg vs 0 [0-5] mg, p<10(-6)).

CONCLUSION

Postoperative analgesia by iliaca compartment block with catheter seems to provide a decrease in the incidence of POCD after hip surgery in elderly patients.

STUDY DESIGN

Prospective, observational study.

Ultra low-dose naloxone and tramadol/acetaminophen in elderly patients undergoing joint replacement surgery: a pilot study

OBJECTIVE

A pilot study was conducted to assess whether both the rationale and feasibility exist for future randomized clinical trials to evaluate the combined use of naloxone infusion and tramadol/acetaminophen as opioid-sparing drugs in elderly patients undergoing lower extremity joint replacement surgery.

DESIGN

Ten patients 70 years of age or older undergoing either total knee (n=7) or total hip (n=3) arthroplasty were treated prospectively. Each patient received two tablets of tramadol/acetaminophen (Tramacet; Janssen-Ortho Inc, Canada) preoperatively and every 6 h postoperatively, as well as a naloxone infusion started preoperatively at 0.25 microg/kg/h and continued up to 48 h postoperatively. In addition, standard intraoperative care was provided with 0.2 mg of intrathecal morphine, 1.4 mL of 0.75% bupivacaine, and an intra-articular infiltration of 100 mL of 0.3% ropivacaine and 30 mg of ketorolac, as well as standard postoperative morphine via patient-controlled analgesia orders and celecoxib 200 mg twice daily for five days.

OUTCOME MEASURES

Compared with seven historical controls, also 70 years of age or older, who had undergone either a total knee (n=4) or total hip (n=3) arthroplasty, postoperative opioid use was reduced by 80%. Except for transient nausea and vomiting in 40% and 20% of patients, respectively, the 10 patients on tramadol/acetaminophen and naloxone tolerated the new regimen without difficulty.

CONCLUSION

Consequently, a randomized, double-blinded clinical trial comparing standard therapy versus standard therapy plus these two drugs seems warranted. In such a trial, it would require approximately 20 subjects per treatment arm to detect a 80% decrease in morphine use.

The perioperative management of pain from intracranial surgery

Analgesic therapy following intracranial procedures remains a source of concern and controversy. Although opioids are the mainstay of the "balanced" general anesthetic techniques frequently used during intracranial procedures, neurosurgeons and others have been reluctant to administer opioid analgesics to patients following such procedures. This practice is supported by the concern that the sedation and miosis associated with opioid administration could mask the early signs of intracranial catastrophe, or even exacerbate it through decreased ventilatory drive, elevated arterial carbon dioxide levels, and increased cerebral blood flow. This reluctance to use opioids following intracranial surgery is enabled by decades of training and anecdote emphasizing that pain is minimal following these procedures. However, recent data suggests otherwise, and raises the question of how to provide safe and effective analgesia for these patients. Here, this data is reviewed along with the relevant pain pathways, analgesic drugs and techniques, and the available data on their use following intracranial surgery. Although pain following intracranial surgery appears to be more intense than initially believed, it is readily treated safely and effectively with techniques that have proven useful following other types of surgery, including patient-controlled administration of opioids. The use of multimodal analgesic therapy is emphasized not only for its effectiveness, but to reduce dosages and, therefore, side effects, primarily of the opioids, that could be of legitimate concern to physicians and affect the comfort of their patients.

Pre-emptive analgesic effect of tramadol after mandibular third molar extraction: a pilot study

PURPOSE

We compared the efficacy of tramadol given before or immediately after surgical extraction of an impacted mandibular third molar under local anesthesia.

MATERIALS AND METHODS

In this prospective, randomized, controlled, double-blind pilot study, 3 groups of 20 patients each were included: tramadol preoperative, 100 mg intramuscularly (IM) 1 hour before surgery (group A); tramadol postoperative, 100 mg IM immediately after surgery (group B); and saline (group C). We evaluated intensity of pain and analgesic consumption as was requested.

RESULTS

The analgesic efficacy measured as complete relief of pain at 24 hours was 86% in the preemptive tramadol compared with 70% and 36% for postoperative tramadol administration and control group. A significant reduction in the consumption of analgesics was seen in preoperative group as compared with the postoperative and control groups. Adverse events were minimal and similar in all groups.

CONCLUSIONS

This study suggests the preemptive use of tramadol as an alternative for the acute pain treatment after the removal of an impacted mandibular third molar carried out under local anesthesia.

The addition of tramadol to morphine via patient-controlled analgesia does not lead to better post-operative pain relief after total knee arthroplasty

BACKGROUND

Tramadol is used as an analgesic in post-operative pain treatment. Intravenous tramadol is often combined with morphine to achieve better pain relief and less side-effects after orthopaedic surgery. However, the available evidence is insufficient to support this combination. For this reason, we conducted the present non-commercial, randomized, double-blind clinical trial.

METHOD

Sixty-three patients with osteoarthritis of the knee, selected for primary total knee arthroplasty (TKA), were randomized to receive saline or tramadol 100 mg/ml intravenously every 6 h during the first post-operative day (total, 400 mg/24 h). All patients had access to morphine via a patient-controlled analgesia (PCA) pump.

RESULTS

Neither during the 6 h after the first dose nor during the first post-operative day could we detect any statistically significant difference with regard to pain intensity, sedation and nausea between patients treated with tramadol and the placebo group. However, the withdrawal rate caused by insufficient pain relief was greater in the tramadol group (7/31) than in the saline group (2/32). This difference did not reach statistical significance. In the group of patients who remained in the study for 24 h ('per protocol'), those randomized to receive tramadol had a significantly (P < 0.05) lower morphine consumption (20 mg or 31%) than the placebo group.

CONCLUSION

Our study does not support the combination of tramadol and morphine via PCA for post-operative pain relief after primary TKA. In addition, our study indicates that morphine via PCA as the sole means of post-operative analgesia does not provide sufficient pain relief after TKA. Thus, other means of post-operative analgesia should be used following TKA.

Postoperative effects of opioid analgesics administered via continuous perfusion and patient controlled analgesia after open heart surgery

Critical care nurses and physicians are familiar with the principles of patient controlled analgesia and the opioid analgesics' regimens and observations necessary for pain control in the postoperative cardiac surgical patients. The objective of the study was to compare the effects of morphine, fentanyl, meperidine, remifentanil and tramadol which were administered by patient controlled analgesia and continuous intravenous infusion combination on the various parameters. This study was designed as prospective randomised trial. Fifty patients undergone open heart surgery with sternotomy were entered equally into five randomized groups. Visual analog scale was used by researcher nurse to assess the patient' pain status. Respiratory rate, heart rate and blood gases (pO2, pCO2, SaO2), radial arterial blood pressures were measured in the first 24 hrs postoperatively. Bolus requirements were determined by physicians and side effects of the analgesics were documented. Fentanyl group showed statistically higher levels of mean pO2 (p=0.002). Meperidine had the lowest number of bolus doses (p=0.001). There were no significant differences between the groups for pain management except higher visual analog scales on tramadol. Headache, stomach-ache and, palpitations were observed in our patients. Remifentanil, meperidine, fentanyl and morphine showed similar effect with each other for pain relief except tramadol.

A comparison of the postoperative analgesic efficacy of single-dose epidural tramadol versus morphine in children

BACKGROUND

The aim of this study was to compare epidural administration of single-dose tramadol with morphine in children undergoing urological surgery with respect to preoperative haemodynamic effects, postoperative analgesia and side-effects.

METHODS

Eighty children aged between 7 and 14 undergoing urological surgery were included in the study. After intubation, in the lateral decubitus position, a single dose of morphine 0.1 mg kg(-1) in isotonic saline 0.2 ml kg(-1) (morphine group) and tramadol 2 mg kg(-1) in isotonic saline 0.2 ml kg(-1) (tramadol group) was administered epidurally. During the 24-h postoperative period, heart rate, systolic blood pressure, respiration rate, pain score and sedation level of the patients were monitored. A modified objective pain score of 3 or lower was accepted as an indicator of inadequate analgesia and these patients were given 20 acetaminophen mg kg(-1) rectally or orally. Time to first analgesia was noted. Sedation level was evaluated with a four-point sedation scale.

RESULTS

In the postoperative period, pain scores and the average time for analgesic requirement were similar in the two groups. However, the incidences of allergic rash, itching, sedation and respiratory depression and sedation score were greater in the morphine group than in the tramadol group.

CONCLUSION

Greater epidural use of tramadol may be preferred to morphine for postoperative analgesia under these circumstances.

A procedure-specific systematic review and consensus recommendations for postoperative analgesia following laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy has advantages over the open procedure for postoperative pain. However, a systematic review of postoperative pain management in this procedure has not been conducted.

METHODS

A systematic review was conducted according to the guidelines of the Cochrane Collaboration. Randomized studies examining the effect of medical or surgical interventions on linear pain scores in patients undergoing laparoscopic cholecystectomy were included. Qualitative and quantitative analyses were performed. Recommendations for patient care were derived from review of these data, evidence from other relevant procedures, and clinical practice observations collated by the Delphi method among the authors.

RESULTS

Sixty-nine randomized trials were included and 77 reports were excluded. Recommendations are provided for preoperative analgesia, anesthetic and operative techniques, and intraoperative and postoperative analgesia.

CONCLUSIONS

A step-up approach to the management of postoperative pain following laparoscopic cholecystectomy is recommended. This approach has been designed to provide adequate analgesia while minimizing exposure to adverse events.

The median effective dose of tramadol and morphine for postoperative patients: a study of interactions

Tramadol is a centrally-acting analgesic drug. In a search of an effective balanced analgesia technique with a morphine-sparing component, we studied the median effective analgesic doses (ED(50)) of tramadol, morphine, and their combination to determine the nature of their interaction using an isobolographic analysis. In this double-blind, randomized, two-stage prospective study, 90 postoperative patients were enrolled in one of three groups. The dose of tramadol and morphine received by a particular patient was determined using an up-down allocation technique. Initial doses and increments were, respectively, 100 mg and 10 mg in the tramadol group and 5 mg and 1 mg in the morphine group. In the second part, a 40:3 tramadol:morphine dosing ratio was used. The threshold of effective analgesia was defined as 3 or less on a numerical pain score (0-10). Isobolographic analysis was subsequently applied. The ED(50) values (95% confidence interval) of tramadol and morphine were, respectively, 86 mg (57-115 mg) and 5.7 mg (4.2-7.2 mg). The ED(50) of the combination was 72 mg (62-82 mg) for tramadol and 5.4 mg (4-6.6.2 mg) for morphine. The combination of tramadol and morphine was infra-additive and thus not recommended for postoperative analgesia.

Clinical pharmacology of tramadol

Tramadol, a centrally acting analgesic structurally related to codeine and morphine, consists of two enantiomers, both of which contribute to analgesic activity via different mechanisms. (+)-Tramadol and the metabolite (+)-O-desmethyl-tramadol (M1) are agonists of the mu opioid receptor. (+)-Tramadol inhibits serotonin reuptake and (-)-tramadol inhibits norepinephrine reuptake, enhancing inhibitory effects on pain transmission in the spinal cord. The complementary and synergistic actions of the two enantiomers improve the analgesic efficacy and tolerability profile of the racemate. Tramadol is available as drops, capsules and sustained-release formulations for oral use, suppositories for rectal use and solution for intramuscular, intravenous and subcutaneous injection. After oral administration, tramadol is rapidly and almost completely absorbed. Sustained-release tablets release the active ingredient over a period of 12 hours, reach peak concentrations after 4.9 hours and have a bioavailability of 87-95% compared with capsules. Tramadol is rapidly distributed in the body; plasma protein binding is about 20%. Tramadol is mainly metabolised by O- and N-demethylation and by conjugation reactions forming glucuronides and sulfates. Tramadol and its metabolites are mainly excreted via the kidneys. The mean elimination half-life is about 6 hours. The O-demethylation of tramadol to M1, the main analgesic effective metabolite, is catalysed by cytochrome P450 (CYP) 2D6, whereas N-demethylation to M2 is catalysed by CYP2B6 and CYP3A4. The wide variability in the pharmacokinetic properties of tramadol can partly be ascribed to CYP polymorphism. O- and N-demethylation of tramadol as well as renal elimination are stereoselective. Pharmacokinetic-pharmacodynamic characterisation of tramadol is difficult because of differences between tramadol concentrations in plasma and at the site of action, and because of pharmacodynamic interactions between the two enantiomers of tramadol and its active metabolites. The analgesic potency of tramadol is about 10% of that of morphine following parenteral administration. Tramadol provides postoperative pain relief comparable with that of pethidine, and the analgesic efficacy of tramadol can further be improved by combination with a non-opioid analgesic. Tramadol may prove particularly useful in patients with a risk of poor cardiopulmonary function, after surgery of the thorax or upper abdomen and when non-opioid analgesics are contraindicated. Tramadol is an effective and well tolerated agent to reduce pain resulting from trauma, renal or biliary colic and labour, and also for the management of chronic pain of malignant or nonmalignant origin, particularly neuropathic pain. Tramadol appears to produce less constipation and dependence than equianalgesic doses of strong opioids.

Efficacy of tramadol versus meperidine for pain relief and safe recovery after adenotonsillectomy

BACKGROUND AND OBJECTIVE

Adequate relief of pain after tonsillectomy is a common problem. We compared meperidine and tramadol when given at induction of anaesthesia with respect to their effects on postoperative pain relief and emergence characteristics after adenotonsillectomy in children.

METHODS

Fifty children aged 4-7 yr undergoing tonsillectomy were randomly assigned to receive either tramadol 1 mg kg(-1) (n = 25) or meperidine 1 mg kg(-1) (n = 25) before commencement of the surgical procedure. Anaesthesia was induced with propofol (with cis-atracurium for muscle relaxation) and maintained with sevoflurane in oxygen and nitrous oxide. Postoperative pain was scored by a blinded observer using a facial pain scale in the recovery room at 0 (at arrival of the patient in the postoperative care unit) and at 10, 20 and 45 min thereafter. Agitation scores were also assessed by the same observer at 0 min. Heart rate and mean arterial pressure were recorded at regular intervals. The time to recovery to spontaneous respiration and the incidence of postoperative nausea and vomiting were noted.

RESULTS

Facial pain scale scores were increased in the tramadol group at 0, 10 and 20 min (P < 0.05). No difference was observed in scores at the 45th min postoperation. Agitation scores were higher in the tramadol group than in the meperidine group. No statistical difference was found between the two groups. Heart rates and mean arterial pressures were similar in both groups. The time to recovery to spontaneous respiration was delayed with meperidine compared with tramadol (P < 0.05). The incidence of nausea and vomiting was not statistically different between groups.

CONCLUSIONS

Meperidine was more effective for pain relief and provides better emergence characteristics than tramadol after tonsillectomy in children.

Preemptive use of gabapentin significantly decreases postoperative pain and rescue analgesic requirements in laparoscopic cholecystectomy

PURPOSE

To evaluate the comparative preemptive effects of gabapentin and tramadol on postoperative pain and fentanyl requirement in laparoscopic cholecystectomy.

METHODS

Four hundred fifty-nine ASA I and II patients were randomly assigned to receive 300 mg gabapentin, 100 mg tramadol or placebo in a double-blind manner two hours before laparoscopic cholecystectomy under general anesthesia. Postoperatively, patients' pain scores were recorded on a visual analogue scale every two hours for the initial 12 hr and thereafter every three hours for the next 12 hr. Patients received fentanyl 2 micro g*kg(-1) intravenously on demand. The total fentanyl consumption for each patient was recorded.

RESULTS

Patients in the gabapentin group had significantly lower pain scores at all time intervals (2.65 +/- 3.00, 1.99 +/- 1.48, 1.40 +/- 0.95, 0.65 +/- 0.61) in comparison to tramadol (2.97 +/- 2.35, 2.37 +/- 1.45, 1.89 +/- 1.16, 0.87 +/- 0.50) and placebo (5.53 +/- 2.22, 3.33 +/- 1.37, 2.41 +/- 1.19, 1.19 +/- 0.56). Significantly less fentanyl was consumed in the gabapentin group (221.16 +/- 52.39 micro g) than in the tramadol (269.60 +/- 44.17 micro g) and placebo groups (355.86 +/- 42.04 micro g; P < 0.05). Sedation (33.98%), nausea/retching/vomiting (24.8%) were the commonest side effects in the gabapentin group whereas respiratory depression (3.9%) was the commonest in the tramadol group and vertigo (7.8%) in the placebo group.

CONCLUSION

Preemptive use of gabapentin significantly decreases postoperative pain and rescue analgesic requirement in laparoscopic cholecystectomy.

A comparison of preoperative tramadol and morphine for the control of early postoperative pain in canine ovariohysterectomy

OBJECTIVE

To compare morphine with tramadol for the management of early postoperative pain following ovariohysterectomy after pyometra in dogs.

STUDY DESIGN

Prospective randomized blinded clinical trial.

ANIMALS

Thirty female dogs, 2-14 years old.

METHODS

Animals were randomly divided into two equal groups. Group 1 received 0.2 mg kg-1 of morphine IV and group 2 received 2 mg kg-1 of tramadol IV after the induction of anesthesia. The dogs were premedicated with acepromazine, and anesthesia was induced with intravenous midazolam and ketamine. Isoflurane was used for the maintenance of anesthesia. The variables measured were: analgesia; sedation; cardiac and respiratory rates; arterial blood pressure; end-tidal isoflurane and carbon dioxide (Pe'CO2); oxyhemoglobin saturation (SpO2); plasma catecholamines; serum cortisol and glucose concentrations; pH and blood gases. The animals were monitored for 6 hours after the administration of the analgesic agent.

RESULTS

There were no differences between the two groups with regard to analgesia, sedation, SpO2, pH and blood gases, cardiovascular variables, glucose, catecholamine and cortisol concentrations. Forty minutes postopioid administration, the end-tidal isoflurane concentration was significantly lower in the morphine-treated group as compared to the tramadol group. At 30 minutes following opioid injection, Pe'CO2 was significantly higher in the morphine group than in the tramadol group. Two dogs in the tramadol group and one in the morphine group were given morphine postoperatively because of increasing pain scores.

CONCLUSION AND CLINICAL RELEVANCE

Morphine and tramadol, administered preemptively can be used safely in dogs to control early pain after ovariohysterectomy without significant adverse effects.

Pre-emptive analgesic efficacy of tramadol compared with morphine after major abdominal surgery

BACKGROUND

Studies of pre-emptive analgesia in humans have shown conflicting results. This prospective, randomized, double-blind, controlled study was designed to test the hypothesis that a reduction in postoperative morphine consumption can be achieved by tramadol administered after induction of anaesthesia.

METHODS

Ninety patients were allocated randomly to receive i.v. tramadol (1 mg kg(-1)) (Group T), morphine (0.1 mg kg(-1)) (Group M) or saline 2 ml (Group S) after induction of anaesthesia. At peritoneal closure, a standardized (0.1 mg kg(-1)) morphine loading dose was given to all patients for postoperative pain management. Patients were allowed to use a patient-controlled analgesia (PCA) device giving bolus doses of morphine 0.025 mg kg(-1). Discomfort, sedation, pain scores, cumulative morphine consumption, and side-effects were recorded at 1, 2, 6, 12 and 24 h after the start of PCA.

RESULTS

There were no significant differences between groups in mean pain, discomfort, and sedation scores at any study period. Cumulative morphine consumption was significantly lower in Group M at 12 and 24 h after starting the PCA than in Group S. In Group T, it was lower only after 24 h (28% less in Group M and 17% less in Group T; P<0.017). There were no significant differences in morphine consumption between Groups T and M.

CONCLUSIONS

Tramadol (1 mg kg(-1)), administered after induction of anaesthesia, offered equivalent postoperative pain relief, and similar recovery times and postoperative PCA morphine consumption compared with giving morphine 0.1 mg kg(-1). These results also suggest that presurgical exposure to systemic opioid analgesia may not result in clinically significant benefits .

Tramadol--present and future

The atypical opioid, tramadol, has recently been introduced into Australia and New Zealand. Tramadol's efficacy in a wide range of acute and chronic pain states, its multi-formulation availability, and its low serious side-effect potential at high doses and in prolonged therapy, combine to bestow on it a user-friendly profile, for short- and long-term use in hospitals and communities. This paper reviews the following: its formulation and routes of administration; its unique enantiomeric biochemistry and metabolism; its triple mechanisms of action; its pharmacokinetics and pharmacodynamics; its analgesic efficacy compared with other opioids; the indications for its clinical use in a variety of acute and chronic (including cancer) painful states; its specific use in the elderly, in paediatric and in obstetric patients; its adverse event (including drug interaction) and safety profile; its advantages in terms of its relative lack of respiratory depression, major organ toxicity and histamine release, and dependence and abuse potential. The review looks at new uses for this drug and what can be expected in this area in the future.

Wound closure tramadol administration has a short-lived analgesic effect

PURPOSE

To evaluate the effects of tramadol administration at wound closure on postoperative pain and analgesic requirements in patients undergoing laparoscopic cholecystectomy.

METHODS

In a prospective, randomized, double-blind study 80 patients were allocated into two groups (n = 40 in each) to receive either 200 mg tramadol or placebo i.v. at the time of wound closure. Postoperatively, all patients received tramadol from a patient-controlled analgesia (PCA) device. Pain, analgesic consumption, vital signs and side effects were recorded postoperatively for 24 hr.

RESULTS

Administration of 200 mg tramadol at the time of wound closure was associated with a short-lived (60 min) reduction in pain scores and PCA consumption compared with placebo. Although the time to first request for analgesia after surgery was longer in patients who received tramadol at wound closure, there was no difference between the two groups with respect to pain scores or to the requirements of postoperative analgesia over the next 23 hr. The cumulative PCA consumption of tramadol in 24 hr was 139.4+/-108 and 102.4+/-106 mg in the placebo and tramadol groups, respectively (P = 0.06).

CONCLUSIONS

Wound closure administration of 200 mg tramadol had a short-lived (60 min) analgesic effect but did not affect the long-term pain scores or analgesic requirements after laparoscopic cholecystectomy.

Tramadol: a review of its use in perioperative pain

Tramadol is a synthetic, centrally acting analgesic agent with 2 distinct, synergistic mechanisms of action, acting as both a weak opioid agonist and an inhibitor of monoamine neurotransmitter reuptake. The 2 enantiomers of racemic tramadol function in a complementary manner to enhance the analgesic efficacy and improve the tolerability profile of tramadol. In several comparative, well designed studies, oral and parenteral tramadol effectively relieved moderate to severe postoperative pain associated with surgery. Its overall analgesic efficacy was similar to that of morphine or alfentanil and superior to that of pentazocine. Tramadol provided effective analgesia in children and in adults for both inpatient and day surgery. Tramadol was generally well tolerated in clinical trials. The most common adverse events (incidence of 1.6 to 6.1%) were nausea, dizziness, drowsiness, sweating, vomiting and dry mouth. Importantly, unlike other opioids, tramadol has no clinically relevant effects on respiratory or cardiovascular parameters at recommended doses in adults or children. Tramadol also has a low potential for abuse or dependence.

CONCLUSIONS

The efficacy of tramadol for the management of moderate to severe postoperative pain has been demonstrated in both inpatients and day surgery patients. Most importantly, unlike other opioids, tramadol has no clinically relevant effects on respiratory or cardiovascular parameters. Tramadol may prove particularly useful in patients with poor cardiopulmonary function, including the elderly, the obese and smokers, in patients with impaired hepatic or renal function, and in patients in whom nonsteroidal anti-inflammatory drugs are not recommended or need to be used with caution. Parenteral or oral tramadol has proved to be an effective and well tolerated analgesic agent in the perioperative setting.