A comparison of the local anesthetic effects of meperidine, fentanyl, and sufentanil on dorsal root axons

The Assessment of Marcaine Versus Meperidine for Spinal Anesthesia in Anorectal Surgery: A Randomized Clinical Trial

Background

Spinal anesthesia (SA) for the surgical management of chronic anal fissures is favored by surgeons as it provides an early return to daily activities; however, the agents applied for SA to achieve the best outcomes with minimized adverse effects are a matter of debate.

Objectives

This study aimed to assess the utility of Marcaine versus meperidine for SA induction of anoderm surgery.

Methods

This randomized clinical trial (RCT) was conducted on 138 patients with chronic anal fissures who were candidates for surgical management in 2020. The patients were randomly assigned to two groups of SA using 2.5 mL of hyperbaric Marcaine 0.5% (n = 69) or 1 mg/kg of meperidine (n = 69). Pain severity (measured via Numerical Rating Scale (NRS)), anal sphincter tone manometry (measured at baseline and the end of the sphincterotomy), and drug-related adverse effects were compared between the groups.

Results

Both agents led to significant pain relief within 24 hours after SA (P < 0.05); nevertheless, pain severity was remarkably lower in meperidine-treated patients in different measurements performed during the first 24 hours after SA (P < 0.05). The sphincteric tone significantly decreased in both groups (P < 0.001), while the postoperative tone was significantly less in the Marcaine-treated patients (65.22 ± 3.02 versus 46.04 ± 1.97, P < 0.001). The two groups did not differ regarding the adverse effects (P > 0.05).

Conclusions

Meperidine for SA in anal fissure surgical management was relatively superior to Marcaine, as postoperative pain control was remarkably better achieved with meperidine. However, anal sphincter tone reached a normal range in Marcaine-treated cases, and the average tone in those anesthetized with meperidine was slightly above the normal limits.

Full Opioid Agonists and Tramadol: Pharmacological and Clinical Considerations

Opioids are mu receptor agonists and have been an important part of pain treatment for thousands of years. In order to use these drugs appropriately and successfully in patients, whether to control pain, to treat opiate-induced side effects, or opiate withdrawal syndromes, a solid understanding of the pharmacology of such drugs is crucial. The most recognized full agonist opioids are heroin, morphine, codeine, oxycodone, meperidine, and fentanyl. Phenanthrenes refer to a naturally occurring plant-based compound that includes three or more fused rings. The opioids derived from the opium plant are phenanthrene derivatives, whereas most synthetic opioids are simpler molecules that do not have multiple rings. Methadone acts as a synthetic opioid analgesic similar to morphine in both quality and quantity; however, methadone lasts longer and in oral form, has higher efficacy, and is considered a diphenylheptane. Fentanyl is a strong synthetic phenylpiperdine derivative that exhibits activity as a mu-selective opioid agonist approximately 50 to 100 times more potent than morphine. Meperidine is another medication which is a phenylpiperdine. Tramadol is considered a mixed-mechanism opioid drug, as it is a centrally acting analgesic that exerts its effects via binding mu receptors and blocking the reuptake of monoamines. Some of the most common adverse effects shared among all opioids are nausea, vomiting, pruritus, addiction, respiratory depression, constipation, sphincter of Oddi spasm, and miosis (except in the case of meperidine). Chronic opioid usage has also established a relationship to opioid-induced hypogonadism and adrenal suppression. Physicians must be stewards of opioid use and use opioids only when necessary.

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.

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.

The Pharmacology of Spinal Opioids and Ziconotide for the Treatment of Non-Cancer Pain

Background

Intrathecal drug delivery has undergone a revitalization following a better understanding of this delivery route and its pharmacokinetics. Driven by patient safety and outcomes, clinicians are motivated to rethink the traditional spinal infusion pump patient selection criteria and indications. We review the current understanding of the pharmacology of commonly employed intrathecal agents and the clinical relevance.

Methods

Search strategies for data acquisition included Medline database, PubMed, Google scholar, along with international and national professional meeting content, with key words including pharmacology of opioids, intrathecal therapy, ziconotide, pharmacokinetics, and intrathecal drug delivery. The search results were limited to the English language.

Results

Over 300 papers were identified. The literature was condensed and digested to evaluate the most commonly used medications in practice, sto serve as a foundation for review. We review on-label medications: ziconotide and morphine, and off label medications including fentanyl, sufentail, and hydromorphine.

Conclusion

Intrathecal therapy has level-one evidence for use for malignant pain and nonmalignant pain, with continued cost savings and improved safety. To most effectively serve our patients, a clear appreciation for the pharmacology of these commonly employed medication is paramount..

An early granulocyte colony-stimulating factor treatment attenuates neuropathic pain through activation of mu opioid receptors on the injured nerve

Several studies have shown that the mu opioid receptor (MOR) located in the peripheral nerves can be activated after nerve injury and that it attenuates peripheral nociceptive signals to the spinal dorsal horn. Various cytokines and phosphorylated-p38 (p-p38) activation in the dorsal horn also play an important role in neuropathic pain development. Granulocyte-colony stimulating factor (GCSF) is a growth factor that can stimulate granulocyte formation and has been shown to exert an analgesic effect on neuropathic pain through recruiting opioid-containing leukocytes to the injured nerve. However, the underlying mechanisms are not well understood. Herein, the results of behavior tests in addition to MOR levels in the injured sciatic nerve and the levels of p-p38 and various cytokines in the spinal dorsal horn were studied in vehicle-treated or GCSF-treated chronic constriction injured (CCI) rats at different time points (i.e., 1, 3, and 7 days, respectively) after nerve injury. The results showed that a single early systemic GCSF treatment after nerve injury can up-regulate MORs in the injured nerve, which can decrease peripheral nociceptive signals. Thereafter, those changes suppress the pro-inflammatory cytokine IL-6 but enhance the anti-inflammatory cytokine IL-4, followed by decreases in p-p38 in the dorsal horn, and thus further attenuate neuropathic pain.

The effect of intra-articular meperidine and bupivacaine 0.5% on postoperative pain of arthroscopic knee surgery; a randomized double blind clinical trial

Background:

Arthroscopic knee surgeries have a painful postoperative course, which often necessitates acute pain management. Among different analgesia techniques, Intra-articular injection is the technique of choice for many pain specialists, based on its confined effect to the surgical site (knee), lack of systemic effects and promotion of safe early ambulation.

Objectives:

The aim of this study was to compare analgesic effects of intra-articular meperidine, bupivacaine 0.5% or their combination after knee arthroscopic surgery.

Patients and Methods:

Sixty ASA class I-II patients’ candidates for arthroscopy knee surgery enrolled in a randomized double blind study to receive either 20 mL of bupivacaine 0.5%; 100 mg meperidine (diluted in normal saline) or bupivacaine 0.5% along with 100 mg meperidine. A written informed consent was obtained from all patients. Postoperative analgesia duration, VAS at 2, 6, 12 and 24 hours, the first analgesic request time, total fentanyl consumption in first 24 hours, patients’ satisfaction and adverse effects were recorded.

Results:

The bupivacaine-meperidine group had better duration of postoperative analgesia (P = 0.001), latter first analgesic request (P ≤ 0.001), lower total fentanyl consumption in first 24 hours after the operation (P = 0.001), less mean VAS at 2 hours (P = 0.001) and more patients’ overall satisfaction (P = 0.01) compared with each medication alone. VAS at 6, 12 and 24 postoperative hours were not different between the groups of study. No adverse effects were observed.

Conclusions:

Although postoperative intra-articular meperidine is a better alternative for bupivacaine, their combination could improve their analgesic effects compared with each other alone.

Efficacy of tramadol as a preincisional infiltration anesthetic in children undergoing inguinal hernia repair: a prospective randomized study

Background

Preincisional local anesthetic infiltration at the surgical site is a therapeutic option for postoperative pain relief for pediatric inguinal hernia. Additionally, tramadol has been used as an analgesic for postoperative pain in children. Recently, the local anesthetic effects of tramadol have been reported. The aim of this study was to determine both the systemic analgesic and the local anesthetic effects of tramadol and to determine how it differs from bupivacaine when administered preincisionally.

Methods

Fifty-two healthy children, aged 2–7 years, who were scheduled for elective herniorrhaphy were randomly allocated to receive either preincisional infiltration at the surgical site with 2 mg/kg tramadol (Group T, n=26) or 0.25 mL/kg 0.5% bupivacaine (Group B, n=26). At the time of anesthetic administration, perioperative hemodynamic parameters were recorded. The pain assessments were performed 10 minutes after the end of anesthesia and during the first 6-hour period, using pain scores. The time of first dose of analgesia and need for additional analgesia were recorded.

Results

Between T and B groups, the anesthesia time, perioperative hemodynamic changes, and pain scores were not statistically different. However, in group B, the postoperative analgesic requirement was higher than in group T.

Conclusion

Tramadol shows equal analgesic effect to bupivacaine and decreases additional analgesic requirement, when used for preincisional infiltration anesthesia in children undergoing inguinal herniorrhaphy.

Evaluation of analgesic effect of two different doses of fentanyl in combination with bupivacaine for surgical site infiltration in cases of modified radical mastoidectomy: A double blind randomized study

Background:

Limited evidence supports the efficacy of peripheral route fentanyl and local anesthetic combination for postoperative analgesia. Our study was therefore designed to demonstrate the analgesic efficacy of two different doses of fentanyl in combination with bupivacaine for surgical site infiltration in patients undergoing modified radical mastoidectomy (MRM).

Materials and Methods:

60 patients undergoing MRM under general anesthesia were randomly allocated into two groups, first group receiving 0.5% bupivacaine at a dose of 2 mg/kg body weight with 50 μg fentanyl and second group receiving bupivacaine 0.5% at a dose of 2 mg/kg body weight with 100 μg fentanyl as infiltration of operative field in and around the incision site, after the incision and just before completion of surgery. In postoperative period pain, nausea-vomiting and sedation was recorded at 0 hr, 2, 4, 6, 12 and 24 hrs.

Results:

Both the combinations of bupivacaine and fentanyl (Group I and Group II) were effective for postoperative analgesia. In both the groups the Visual Analogue Scale (VAS) score was less than 3 at each time interval. None of the patients required rescue analgesia. The comparison of VAS scores at different intervals showed that group II had lower VAS scores at all time points.

Conclusions:

Fentanyl and bupivacaine combinations in doses of 50 and 100 μg along with 0.5% bupivacaine at a fixed dose of 2 mg/kg body weight are effective in the management of postoperative pain. Patients who received 100 μg fentanyl (Group II) had lower VAS scores as compared to the patients who received 50 μg fentanyl (Group I) with similar side effects.

Local loperamide injection reduces mechanosensitivity of rat cutaneous, nociceptive C-fibers

Loperamide reverses signs of mechanical hypersensitivity in an animal model of neuropathic pain suggesting that peripheral opioid receptors may be suitable targets for the treatment of neuropathic pain. Since little is known about loperamide effects on the responsiveness of primary afferent nerve fibers, in vivo electrophysiological recordings from unmyelinated afferents innervating the glabrous skin of the hind paw were performed in rats with an L5 spinal nerve lesion or sham surgery. Mechanical threshold and responsiveness to suprathreshold stimulation were tested before and after loperamide (1.25, 2.5 and 5 µg in 10 µl) or vehicle injection into the cutaneous receptive field. Loperamide dose-dependently decreased mechanosensitivity in unmyelinated afferents of nerve-injured and sham animals, and this effect was not blocked by naloxone pretreatment. We then investigated loperamide effects on nerve conduction by recording compound action potentials in vitro during incubation of the sciatic nerve with increasing loperamide concentrations. Loperamide dose-dependently decreased compound action potentials of myelinated and unmyelinated fibers (ED50 = 8 and 4 µg/10 µl, respectively). This blockade was not prevented by pre-incubation with naloxone. These results suggest that loperamide reversal of behavioral signs of neuropathic pain may be mediated, at least in part, by mechanisms independent of opioid receptors, most probably by local anesthetic actions.

Anesthetic efficacy of lidocaine/meperidine for inferior alveolar nerve blocks

The authors, using a crossover design, randomly administered, in a single-blind manner, inferior alveolar nerve blocks using 36 mg of lidocaine with 18 microg of epinephrine or a combination of 36 mg of lidocaine with 18 microg epinephrine plus 36 mg meperidine with 18 microg of epinephrine, at 2 separate appointments, to 52 subjects. An electric pulp tester was used to test for anesthesia, in 4-minute cycles for 60 minutes, of the molars, premolars, and central and lateral incisors. Anesthesia was considered successful when 2 consecutive 80 readings were obtained within 15 minutes and the 80 reading was continuously sustained for 60 minutes. Using the lidocaine solution, successful pulpal anesthesia ranged from 8 to 58% from the central incisor to the second molar. Using the lidocaine/meperidine solution, successful pulpal anesthesia ranged from 0 to 17%. There was a significant difference (P < .05) between the lidocaine and lidocaine/meperidine solutions for the lateral incisors through the second molars. We conclude that the addition of meperidine to a standard lidocaine solution does not increase the success of the inferior alveolar nerve block.

Does tramadol wound infiltration offer an advantage over bupivacaine for postoperative analgesia in children following herniotomy?

BACKGROUND

It has been demonstrated that tramadol is an effective analgesic. We aimed to compare postoperative analgesic effects of wound infiltration with tramadol (T) or bupivacaine (B) and intramuscular tramadol (I) after herniotomy in children.

METHODS

In this study, 75 children were randomly assigned to group T, group B and group I. Wound infiltration was performed to the patients in group T (2 mg.kg-1 tramadol in 0.2 ml.kg-1 saline) and group B (0.2 ml.kg-1 0.25% bupivacaine) into the surgical incision. Twenty minutes before the end of the surgery 2 mg.kg-1 tramadol was injected i.m. in group I. Faces pain scale was used for assessing pain severity. Patients with pain score>2 were treated with paracetamol. The frequency of side effects and analgesic use were recorded. Patients were discharged on the next day.

RESULTS

No side effects were recorded in any group. The pain scores of the patients at the first, fourth and eighth hours were significantly higher in group B and group I than group T (P<0.05). The pain scores of the patients at the first hour were significantly higher in group I compared with group B (P<0.05). Average time to first analgesic requirement was significantly longer in group T (6.72+/-4.09 h after herniotomy than both group I (4.49+/-3.9 h) and group B (6.04+/-3.7 h) (P<0.05).

CONCLUSIONS

Wound infiltration with tramadol may be a good choice for postoperative analgesia in children having inguinal herniotomy.

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.

Plasma concentrations of meperidine and normeperidine following continuous intrathecal meperidine in patients with neuropathic cancer pain

BACKGROUND

Intrathecal administration of meperidine, an opioid with local anesthetic activity, can induce analgesia in patients with intractable cancer pain. However, continuous intrathecal administration may result in the accumulation of normeperidine, responsible for central nervous system toxicity.

METHODS

Ten patients with neuropathic cancer pain, not responding to conventional opioid therapy, were treated with continuous intrathecal administration of meperidine. In all patients, plasma concentrations of meperidine and normeperidine were measured the first days after the start of treatment. Visual analog scale scores were recorded to evaluate pain relief. Quality of life was assessed before and 3 weeks following the start of intrathecal treatment.

RESULTS

In three patients the plasma concentrations of meperidine and normeperidine increased rapidly. In one patient the plasma normeperidine concentration was higher than the meperidine concentration. One patient demonstrated transient symptoms suggestive for central nervous system excitation. Three weeks following the start of treatment, seven patients were available for evaluation of their quality of life. Pain relief and overall quality of life improved during the intrathecal treatment.

CONCLUSION

We conclude that continuous intrathecal administration of meperidine alone, or in combination with clonidine, can provide significant pain relief in patients with poor pain control despite pharmacological treatment. However, accumulation of meperidine and normeperidine resulting in central nervous system toxicity may occur during this treatment.

Analgesic, hemodynamic, and respiratory effects induced by caudal epidural administration of meperidine hydrochloride in mares

OBJECTIVE

To determine the analgesic, hemodynamic, and respiratory effects induced by caudal epidural administration of meperidine hydrochloride in mares.

ANIMALS

7 healthy mares.

PROCEDURE

Each mare received meperidine (5%; 0.8 mg/kg of body weight) or saline (0.9% NaCl) solution via caudal epidural injection on 2 occasions. At least 2 weeks elapsed between treatments. Degree of analgesia in response to noxious electrical, thermal, and skin and muscle prick stimuli was determined before and for 5 hours after treatment. In addition, cardiovascular and respiratory variables were measured and degree of sedation (head position) and ataxia (pelvic limb position) evaluated.

RESULTS

Caudal epidural administration of meperidine induced bilateral analgesia extending from the. coccygeal to S1 dermatomes in standing mares; degree of sedation and ataxia was minimal. Mean (+/- SD) onset of analgesia was 12 +/- 4 minutes after meperidine administration, and duration of analgesia ranged from 240 minutes to the entire 300-minute testing period. Heart and respiratory rates, rectal temperature, arterial blood pressures, Hct, PaO2, PaCO2, pHa, total solids and bicarbonate concentrations, and base excess were not significantly different from baseline values after caudal epidural administration of either meperidine or saline solution.

CONCLUSIONS AND CLINICAL RELEVANCE

Caudal epidural administration of meperidine induced prolonged perineal analgesia in healthy mares. Degree of sedation and ataxia was minimal, and adverse cardiorespiratory effects were not detected. Meperidine may be a useful agent for induction of caudal epidural analgesia in mares undergoing prolonged diagnostic, obstetric, or surgical procedures in the anal and perineal regions.