Local anesthetic effect of tramadol, metoclopramide, and lidocaine following intradermal injection

Local anesthesia in oral and maxillofacial surgery: A review of current opinion

Local anesthesia (LA) is the most important pain management process in oral and maxillofacial surgery. Safe and effective LA not only enable patients to obtain high-quality treatment, but also relieve the anxiety of patients when they come to the clinic. The choices of local anesthetic and injection methods determine the success of LA to a great extent. At present, in most countries or regions, common local anesthetics used in oral and maxillofacial surgery belong to amides and they are injected into patients' body mainly through block or infiltration anesthesia. In addition, the operators' technique level, patient's subjective psychology and anatomical variation of maxillofacial structure also have a strong influence on LA in dental clinic. Due to the existence of above factors, the worldwide success rates of LA in oral and maxillofacial surgery is very different. There are no specific LA methods that ensure 100% successful LA rates. Fortunately, the development of new local anesthetic and injection technology are providing us with new ideas to solve this problem. This review mainly report the new research progress on LA in oral and maxillofacial surgery in recent decades and help clinicians with dental LA operation.

Effectiveness of tramadol compared to lignocaine as local anesthesia in the extraction of firm teeth: a randomized controlled trial

Background

The aim of this study was to compare the local anesthetic effect of tramadol with that of lignocaine in the extraction of immobile (grade 0) maxillary first molars.

Methods

This was a randomized, double-blind, equally balanced, controlled trial conducted on a sample population of 116 patients. The patients were randomly divided into two groups: group A (control) and group B (study). Group A and group B participants received 1.8 ml of 2% lignocaine without adrenaline and 1.8 ml of 5% tramadol, respectively through the supra-periosteal infiltration technique before extraction. Intraoperative pain was recorded on the Visual Analog Scale (VAS) and was evaluated using two unpaired t-tests.

Results

Intraoperative pain was evaluated in both the control and study groups. In the control group, the mean VAS score was 0.71 ± 0.81, while in the study group, the mean intraoperative VAS score was 1.21 ± 0.86, with the difference between the two mean values being statistically significant (P = 0.001).

Conclusion

Tramadol has a less potent local anesthetic effect than lignocaine. As a higher dose of tramadol is required to obtain the desired anesthetic effect, it should be used as a supplement to lignocaine in extensive surgical procedures. It can also be used in patients allergic to lignocaine.

Local infiltration of tramadol as an effective strategy to reduce post-operative pain: a systematic review protocol and meta-analysis

OBJECTIVE

The purpose of this review is to evaluate the use and effectiveness of the local administration of tramadol in reducing post-operative pain during surgical interventions.

METHODS

The PubMed, EMBASE and Cochrane Central Register of Controlled Trials (CENTRAL) databases will be searched for this review. This systematic review will include studies evaluating the clinical efficacy of the local infiltration of tramadol, with no study design restrictions. Only studies that present clear descriptions of local tramadol administration are published in peer-reviewed journals in the English, Italian, Spanish, French, Portuguese or German language and are published in full will be taken into consideration. A meta-analysis will be performed when there is sufficient clinical homogeneity among the retrieved studies, and only randomized controlled studies and quasi-randomized controlled studies will be included. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach will be used to assess the certainty in the evidence. If a quantitative analysis cannot be conducted, a qualitative description of the results of the retrieved studies will be provided.

RESULTS

A high-quality synthesis of the current evidence on the local administration of tramadol for managing post-surgical pain will be illustrated using subjective reports and objective measures of performance. The primary outcomes will include the magnitude of post-operative pain intensity improvement, with improvement being as defined by a reduction by at least 2 points in the visual analogue scale (VAS) score or numerical rating scale (NRS) score. The secondary outcomes will be the magnitude of reduction in tramadol rescue doses and in other analgesic drug doses.

CONCLUSION

This protocol will present evidence on the efficacy of tramadol in relieving post-surgical pain.

SYSTEMIC REVIEW REGISTRATION

PROSPERO CRD42018087381.

Inhibition of Fast Nerve Conduction Produced by Analgesics and Analgesic Adjuvants-Possible Involvement in Pain Alleviation

Nociceptive information is transmitted from the periphery to the cerebral cortex mainly by action potential (AP) conduction in nerve fibers and chemical transmission at synapses. Although this nociceptive transmission is largely inhibited at synapses by analgesics and their adjuvants, it is possible that the antinociceptive drugs inhibit nerve AP conduction, contributing to their antinociceptive effects. Many of the drugs are reported to inhibit the nerve conduction of AP and voltage-gated Na⁺ and K⁺ channels involved in its production. Compound action potential (CAP) is a useful measure to know whether drugs act on nerve AP conduction. Clinically-used analgesics and analgesic adjuvants (opioids, non-steroidal anti-inflammatory drugs, ₂-adrenoceptor agonists, antiepileptics, antidepressants and local anesthetics) were found to inhibit fast-conducting CAPs recorded from the frog sciatic nerve by using the air-gap method. Similar actions were produced by antinociceptive plant-derived chemicals. Their inhibitory actions depended on the concentrations and chemical structures of the drugs. This review article will mention the inhibitory actions of the antinociceptive compounds on CAPs in frog and mammalian peripheral (particularly, sciatic) nerves and on voltage-gated Na⁺ and K⁺ channels involved in AP production. Nerve AP conduction inhibition produced by analgesics and analgesic adjuvants is suggested to contribute to at least a part of their antinociceptive effects.

Tramadol hydrochloride: An alternative to conventional local anaesthetics for intraoral procedures- a preliminary study

Purpose

To evaluate and compare the soft tissue anaesthesia produced by tramadol hydrochloride on gingival tissues in maxilla.

Methods

A total of 50 ASA physical status I subjects between 18 and 35 years of age, both male and female were included in the study. Each individual received 0.5 ml of 50 mg tramadol in the soft tissues over maxillary canine tooth as local infiltration on one and 0.5 ml of 20 mg lignocaine on the contralateral side in a double-blinded fashion. After completing the injection, the author recorded pain on injection, the onset of action, duration of anaesthesia, side effects, and feedback from patient.

Results

The mean onset of anaesthesia for tramadol was 172.00 s (standard deviation 39.898) while for lignocaine it was 162.60 s (standard deviation 35.098) and there was no statistically significant difference between the two groups (p = 0.214). The mean duration of anaesthesia for tramadol group was 45.70 min with a standard deviation of 8.512 min whereas for lignocaine group it was 44.70 min with a standard deviation of 8.107 min. There was no statistical relevant difference between the two groups in duration of anaesthesia (p = 0.549). None of the subjects reported any side effect in both the groups. There was no significant difference in pain on injection between the two groups.

Conclusions

Tramadol has a local anaesthetic effect similar to lignocaine when injected as infiltration in oral soft tissues.

Comparison of Local Anaesthetic Efficacy of Tramadol Versus Lignocaine for Extraction of Tooth Under Supraperiosteal Infiltration

Background

Tramadol has been shown to have a local anaesthetic effect when used as infiltration anaesthesia.

Methods

The local anaesthetic efficacy of tramadol was compared with that of lignocaine for the extraction of teeth in terms of their onset of action, duration of action, intraoperative pain, post-operative analgesic effect and adverse reactions. Apart from this, incidence of allergic reaction was also recorded for both the drugs. A total of 100 patients were divided into two groups randomly. Each patient was assigned to receive either a maximum of 2 ml of 5% tramadol (Supridol 50 mg, Neon laboratories), Group T (n = 50), as a local anaesthetic solution for extraction of maxillary premolar for orthodontic reason under supraperiosteal infiltration following strict aseptic precaution or a maximum of 2 ml of 2% lignocaine (Lox 2%, Neon laboratories), Group L (n = 50), in a double-blinded fashion.

Results

In group T, the mean subjective onset of action was 33.66 s, while in group L it was 33.06 s (p = 0.881). In group T, the mean objective onset of action was 3.04 min, while in group L it was 3.18 min (p > 0.05). The mean duration of action in group T was 55.60 min, while in group L it was 57.50 min (p = 0.432). Only 2 patients in group T and 1 patient in group L had nausea (p = 0.245).

Conclusion

We conclude that 5% tramadol has a local anaesthetic efficacy similar to 2% lignocaine but is comparatively a weaker agent.

New Findings on Local Tramadol Use in Oral Surgery

In modern times, all procedures in oral surgery need to be painless and management of postoperative pain needs to be adequate. The surgical extraction of the third molar or alveolectomy of the wisdom tooth is one of the most common surgical procedures carried out in oral surgery and it includes rising a flap, bone removal and suturing. These surgical procedures usually cause swelling, trismus and moderate to severe pain. Third molar surgery is often used as a model in clinical trials that are directed toward reducing postoperative pain and improving its management. Tramadol is a well-known central acting opioid analgesic that produces analgesia against multiple pain conditions such as postsurgical pain, obstetric pain, terminal cancer pain, pain of coronary origin and neuropathic pain. Tramadol is an atypical opioid. When administered locally, it has both analgesic and anesthetic properties. The aim of this paper was to present new findings on local effects of tramadol in oral surgery.

Effects of Addition of Systemic Tramadol or Adjunct Tramadol to Lidocaine Used for Intravenous Regional Anesthesia in Patients Undergoing Hand Surgery

Intravenous regional anesthesia (IVRA) is used in outpatient hand surgery as an easily applicable and cost-effective technique with clinical advantages. The present study aimed to investigate the effects of addition of systemic tramadol or adjunct tramadol to lidocaine for IVRA in patients undergoing hand surgery. American Society of Anesthesiologists (ASA) I-II patients (n = 60) who underwent hand surgery were included. For this purpose, only lidocaine (LDC), lidocaine+adjunct tramadol (LDC+TRA group), or lidocaine+systemic tramadol (LDC+SysTRA group) was administered to the patients for IVRA and the groups were compared in terms of onset and recovery time of sensory and motor blocks, quality of anesthesia, and the degree of intraoperative and postoperative pain. The onset time of sensorial block was significantly shorter in the LDC+TRA group than that in the LDC+SysTRA group. The motor block recovery time was significantly shorter in the LDC+SysTRA group than that in the LDC+TRA and LDC groups. Administration of tramadol as an adjunct showed some clinical benefits by providing a shorter onset time of sensory and motor block, decreasing pain and analgesic requirement, and improving intraoperative conditions during IVRA. It was determined that systemic tramadol administration had no superiority.

Clinical pharmacy intervention post tonsillectomy: a randomized control trial

BACKGROUND

Pain control in pediatric patients undergoing tonsillectomy remains a dilemma. Tramadol and ketamine are reported to be an effective analgesic.

AIM OF THE STUDY

To evaluate the effect of peritonsillar infiltration of tramadol in combination with ketamine versus peritonsillar infiltration of tramadol posttonsillectomy.

SETTING

Specialty hospital in Jordan.

METHOD

Sixty children, aged 7-12 years, selected for tonsillectomy were enrolled in the study. We divided the patients into two groups 30 of each, Group I: received peritonsillar saline and peritonsillar infiltration of tramadol 2 mg/kg, Group II: received peritonsillar infiltration of ketamine 1.0 mg/kg added to peritonsillar tramadol 2 mg/kg.

MAIN OUTCOME MEASURE

Hemodynamic stability, pain scale, first request of analgesia, total analgesics consumption and post-operative nausea and vomiting (PONV) side effects were recorded 24 h after surgery.

RESULTS

The analysis of data showed that Group II had significantly lower face pain scale, longer time for first request of analgesia, and better hemodynamic stability than GI (p < 0.001). On the other hand the total analgesics requirements, time of surgery, and PONV showed no significant differences between the two groups.

CONCLUSION

Combined use of peritonsillar infiltration of ketamine 1.0 mg/kg with tramadol 2 mg/kg provided prolong analgesic effects, less pain with no side effect, and better hemodynamic stability compared with using tramadol alone in patients undergoing tonsillectomy.

Prevention of propofol injection pain in children: a comparison of pretreatment with tramadol and propofol-lidocaine mixture

BACKGROUND

The pain on propofol injection is considered to be a common and difficult to eliminate problem in children. In this study, we aimed to compare the efficacy of pretreatment with tramadol 1 mg.kg(-1)and propofol-lidocaine 20 mg mixture for prevention of propofol induced pain in children.

METHODS

One hundred and twenty ASA I-II patients undergoing orthopedic and otolaryngological surgery were included in this study and were divided into three groups with random table numbers. Group C (n=39) received normal saline placebo and Group T (n=40) received 1 mg.kg(-1) tramadol 60 sec before propofol (180 mg 1% propofol with 2 ml normal saline) whereas Group L (n=40) received normal saline placebo before propofol-lidocaine mixture (180 mg 1% propofol with 2 ml %1 lidocaine). One patient in Group C was dropped out from the study because of difficulty in inserting an iv cannula. Thus, one hundred and nineteen patients were analyzed for the study. After given the calculated dose of propofol, a blinded observer assessed the pain with a four-point behavioral scale.

RESULTS

There were no significant differences in patient characteristics and intraoperative variables (p>0.05) except intraoperative fentanyl consumption and analgesic requirement one hr after surgery among the groups (p<0.05). Both tramadol 1 mg.kg(-1) and lidocaine 20 mg mixture significantly reduced propofol pain when compared with control group. Moderate and severe pain were found higher in control group (p<0.05). The incidence of overall pain was 79.4% in the control group, 35% in tramadol group, 25% in lidocaine group respectively (p<0.001).

CONCLUSIONS

Pretreatment with tramadol 60 sec before propofol injection and propofol-lidocaine mixture were significantly reduced propofol injection pain when compared to placebo in children.

Percutaneous sciatic nerve block with tramadol induces analgesia and motor blockade in two animal pain models

Local anesthetic efficacy of tramadol has been reported following intradermal application. Our aim was to investigate the effect of perineural tramadol as the sole analgesic in two pain models. Male Wistar rats (280-380 g; N = 5/group) were used in these experiments. A neurostimulation-guided sciatic nerve block was performed and 2% lidocaine or tramadol (1.25 and 5 mg) was perineurally injected in two different animal pain models. In the flinching behavior test, the number of flinches was evaluated and in the plantar incision model, mechanical and heat thresholds were measured. Motor effects of lidocaine and tramadol were quantified and a motor block score elaborated. Tramadol, 1.25 mg, completely blocked the first and reduced the second phase of the flinching behavior test. In the plantar incision model, tramadol (1.25 mg) increased both paw withdrawal latency in response to radiant heat (8.3 ± 1.1, 12.7 ± 1.8, 8.4 ± 0.8, and 11.1 ± 3.3 s) and mechanical threshold in response to von Frey filaments (459 ± 82.8, 447.5 ± 91.7, 320.1 ± 120, 126.43 ± 92.8 mN) at 5, 15, 30, and 60 min, respectively. Sham block or contralateral sciatic nerve block did not differ from perineural saline injection throughout the study in either model. The effect of tramadol was not antagonized by intraperitoneal naloxone. High dose tramadol (5 mg) blocked motor function as well as 2% lidocaine. In conclusion, tramadol blocks nociception and motor function in vivo similar to local anesthetics.

Intravenous regional anesthesia: a review of common local anesthetic options and the use of opioids and muscle relaxants as adjuncts

Purpose

To provide a review of local anesthetic (LA) agents and adjuncts, opioids and muscle relaxants, and their intraoperative effects and postoperative outcomes in intravenous regional anesthesia (IVRA).

Source

A search for prospective, double-blind, randomized controlled trials evaluating LA agents, opioids and muscle relaxants as adjuvants for IVRA, was conducted (MEDLINE^®, Embase). Intraoperative benefits (onset/recovery of sensory and motor block, intraoperative analgesia, tourniquet pain), postoperative benefits (pain score, analgesic consumption, time to first analgesia), and side effects were recorded. A conclusion for overall benefit was made based on statistical significance and clinical relevance.

Findings

Thirty-one studies were evaluated, with data collected on 1523 subjects. LA agents evaluated were lidocaine, ropivacaine, and prilocaine. Adjuncts evaluated were opioids ( morphine, fentanyl, meperidine, sufentanil, tramadol) and muscle relaxants (pancuronium, atracurium, mivacurium, cisatacurium). There was good evidence that ropivacaine provided effective IVRA and improved postoperative analgesia. Lidocaine and prilocaine were effective LA agents, however they lacked postoperative benefits. Morphine, fentanyl, and meperidine as sole adjuncts did not demonstrate clinically significant benefits or result in an increased risk of side effects. Sufentanil data was limited, but appeared to provide faster onset of sensory block. Tramadol provided faster onset of sensory block and tourniquet tolerance, however postoperative benefits were not consistent and the risk of minor side effects increased. Muscle relaxants improved the quality of motor block, but at the expense of delayed motor recovery. The combination of fentanyl and muscle relaxants can achieve an equivalent quality of IVRA with 50% reduction in LA dose, but at the expense of a potentially slower onset of sensory block.

Conclusion

Ropivacaine is effective for IVRA and improves postoperative analgesia. Muscle relaxants enhance the motor block and when combined with fentanyl allow for an equivalent quality of IVRA with 50% reduction in LA dose.

The maternal and neonatal effects of adding tramadol to 2% lidocaine in epidural anesthesia for cesarean section

Background:

Opioid analgesics are commonly added to epidural local anesthetics to improve analgesia during surgery.

Objectives:

The goal of this study was to evaluate the maternal and neonatal effects of adding different doses of tramadol to 2% lidocaine in the epidural anesthesia for cesarean section.

Patients and Methods:

Ninety pregnant patients who were candidates for cesarean section under epidural anesthesia were randomly categorized into three groups. Group L received 2% lidocaine. In the LT50 and LT100 groups, 50 and 100 mg of tramadol were added to epidural 2% lidocaine. For additional analgesia during surgery, 2% lidocaine through epidural catheter or IV sufentanil were administered. Analgesia after surgery was provided by IV injection of meperidine. Onset and duration of sensory and motor blockades, total drug consumption, neonatal Apgar score, and complications were recorded.

Results:

In the LT100 group, onset of complete sensory and motor blockade at T6 was less than in the two other groups, but the highest level of sensory blockade and two segment regression and duration of motor blockades between the LT50 and LT100 groups were not significantly different, although they were higher and more prolonged than in the L group. Average lidocaine and sufentanil consumption during surgery between the LT50 and LT100 groups were not significantly different but were lower than in the L group. The incidence of maternal complications and neonatal Apgar scores were not significantly different between the three groups. In the LT50 and LT100 groups, the time until the first request for analgesics after surgery was prolonged, and average meperidine consumption was less than in the L group.

Conclusions:

The addition of tramadol to epidural 2% lidocaine offers advantages in cesarean section.

Analgesic efficacy of topical tramadol in the control of postoperative pain in children after tonsillectomy

PURPOSE

Pain control after tonsillectomy is still a controversial issue. Topical approaches have the advantage of pain control with good patient acceptability. Therefore, this study was conducted to evaluate the effects of topical tramadol on postoperative pain and morbidity in children undergoing tonsillectomy.

METHODS

A prospective, randomized, double-blind, controlled clinical study was designed. Forty children aged between 4 and 15 years, ASA I-II, scheduled for elective tonsillectomy and/or adenoidectomy were randomized into two groups. For patients in Group T (n = 20) swabs soaked with 2 mg/kg tramadol diluted in 10 ml saline were applied to both of their tonsillar fossa for 5 min; in the control group (n = 20) swabs soaked with 10 ml saline were applied. Postoperative pain scores, bleeding, nausea, vomiting, abdominal discomfort, constipation, pain in the throat, painful swallowing, fever, otalgia, trismus, and halitosis were recorded at the first, fifth, thirteenth, seventeenth, twenty-first, and twenty-fourth postoperative hours and the week after tonsillectomy.

RESULTS

Pain scores were found to be significantly lower at the 21st hour and on postoperative day seven in the tramadol group compared with the control group (p < 0.05). Mean daily pain scores ranged from Day 1: 0.34 (±0.21) to Day 7: 0.11 (±0.08) in the tramadol group and Day 1: 0.53 (±0.14) to Day 7: 0.42 (±0.15) in the control group. There were no significant differences in morbidity between the groups (p > 0.05).

CONCLUSION

Topical 5% tramadol with its local anesthetic effect seems to be an easy, safe, and comfortable approach for pain management in children undergoing tonsillectomy.

Tramadol, but not its major metabolite (mono-O-demethyl tramadol) depresses compound action potentials in frog sciatic nerves

BACKGROUND AND PURPOSE

Although tramadol is known to exhibit a local anaesthetic effect, how tramadol exerts this effect is not understood fully.

EXPERIMENTAL APPROACH

The effects of tramadol and its metabolite mono-O-demethyl-tramadol (M1) on compound action potentials (CAPs) were examined by applying the air-gap method to frog sciatic nerves, and the results were compared with those of other local anaesthetics, lidocaine and ropivacaine.

KEY RESULTS

Tramadol reduced the peak amplitude of the CAP in a dose-dependent manner (IC50=2.3 mM). On the other hand, M1 (1-2 mM), which exhibits a higher affinity for mu-opioid receptors than tramadol, did not affect CAPs. These effects of tramadol were resistant to the non-selective opioid receptor antagonist naloxone and the mu-opioid receptor agonist, DAMGO, did not affect CAPs. This tramadol action was not affected by a combination of the noradrenaline uptake inhibitor, desipramine, and the 5-hydroxytryptamine uptake inhibitor, fluoxetine. Lidocaine and ropivacaine also concentration-dependently reduced CAP peak amplitudes with IC50 values of 0.74 and 0.34 mM, respectively.

CONCLUSIONS AND IMPLICATIONS

These results indicate that tramadol reduces the peak amplitude of CAP in peripheral nerve fibres with a potency which is less than those of lidocaine and ropivacaine, whereas M1 has much less effect on CAPs. This action of tramadol was not produced by activation of mu-opioid receptors nor by inhibition of noradrenaline and 5-hydroxytryptamine uptake. It is suggested that the methyl group present in tramadol but not in M1 may play an important role in producing nerve conduction block.

Local anesthesia in hair transplantation

BACKGROUND

Safe and effective use of local anesthesia is essential in hair transplantation.

OBJECTIVE

To review the agents and techniques of local anesthesia as applied to hair transplantation.

METHODS

Information was retrieved from texts, journal articles found by MEDLINE searches, and related references.

RESULTS

Agents, vasoconstrictors, maximum dosages, toxicity, and techniques are discussed.

CONCLUSION

Effective local anesthesia can be maintained throughout hair transplantation. Care must be exercised to minimize discomfort through proper technique and to minimize toxicity through judicious use of vasoconstrictors and nerve blocks and by monitoring total dosage. Constant monitoring for toxicity is required, as is early intervention in the unlikely event that warning signs should appear.