Intravenous patient-controlled analgesia after thoracotomy: a comparison of morphine with tramadol:

Patient-Controlled Intravenous Analgesia With Tramadol and Lornoxicam After Thoracotomy: A Comparison With Patient-Controlled Epidural Analgesia

Objective

To determine efficacy and safety of patient-controlled intravenous analgesia (PCIA) with tramadol and lornoxicam for postoperative analgesia, and its effects on surgical outcomes in patients after thoracotomy.

Summary of background data

Adequate pain relief after thoracic surgery is of particular importance, not only for keeping patients comfortable but also for reducing the incidence of postoperative complications. PCIA with tramadol and lornoxicam could be an acceptable alternative to patient-controlled epidural analgesia (PCEA) for pain management after thoracotomy.

Methods

The records of patients who underwent thoracotomy for lung resection between January 2014 and December 2014 at our institution were reviewed. The patients were divided into 2 groups according to postoperative pain treatment modalities. Patients of PCEA group (n = 63) received PCEA with 0.2% ropivacaine plus 0.5 μg/mL sufentanil, while patients in PCIA group (n = 48) received PCIA with 5 mg/mL tramadol and 0.4 mg/mL lornoxicam. Data were collected for quality of pain control, incidences of analgesia-related side effects and pulmonary complications, lengths of thoracic intensive care unit stay and postoperative hospital stay, and in-hospital mortality.

Results

Pain at rest was controlled well in both groups during a 4-day postoperative period. Patients in PCIA group reported significantly higher pain scores on coughing and during mobilization in the first 2 postoperative days. The incidences of side effects and pulmonary complications, in-hospital mortality, and other outcomes were similar between groups.

Conclusions

PCIA with tramadol and lornoxicam can be considered as a safe and effective alternative with respect to pain control and postoperative outcomes after thoracotomy.

Transversus Abdominis Plane Block Versus Local Wound Infiltration for Postoperative Pain After Laparoscopic Colorectal Cancer Resection: a Randomized, Double-Blinded Study

BACKGROUND

Despite the extensive administration of the enhanced recovery after surgery (ERAS) program, postoperative pain remains a major concern for patients. Transversus abdominis plane (TAP) block and local wound infiltration (LWI) are two techniques that have been widely applied in abdominal surgery. However, these two techniques have rarely been compared in terms of their analgesic effects on patients that undergo laparoscopic colorectal surgery with the ERAS program.

METHODS

A randomized, double-blinded study was conducted in this study. Briefly, 174 patients that underwent colorectal surgery with the ERAS program were randomly allocated to TAP block treatment (TAP group) or local wound infiltration (LWI group). All patients were assessed for their pain scores at rest and in motion at 6, 24, 48, and 72 h after surgery. The administration frequency of bolus for PCIA and the use amount of rescue analgesics (parecoxib) were recorded. Finally, the patients were monitored with follow-up surveys on their postoperative function recovery, complications, lengths of stay, treatment cost, and satisfaction.

RESULTS

In terms of the pain scores at rest and in motion, the two groups revealed no significant difference throughout the study sessions, and no difference was found in the administration frequency of bolus and the use amount of parecoxib. Moreover, the two groups demonstrated similar results in their postoperative recovery, and no significant differences were found in terms of postoperative complications.

CONCLUSIONS

Compared with local wound infiltration, transversus abdominis plane block is not significantly advantageous for postoperative pain control and recovery in patients undergoing laparoscopic colorectal surgery with the ERAS program. However, local wound infiltration might be preferred since it is available with less technical difficulties.

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.

Guidelines on enhanced recovery after pulmonary lobectomy

OBJECTIVE

To establish recommendations for optimisation of the management of patients undergoing pulmonary lobectomy, particularly Enhanced Recovery After Surgery (ERAS).

DESIGN

A consensus committee of 13 experts from the French Society of Anaesthesia and Intensive Care Medicine (Soci,t, franOaise d'anesth,sie et de r,animation, SFAR) and the French Society of Thoracic and Cardiovascular Surgery (Soci,t, franOaise de chirurgie thoracique et cardiovasculaire, SFCTCV) was convened. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence.

METHODS

Five domains were defined: 1) patient pathway and patient information; 2) preoperative management and rehabilitation; 3) anaesthesia and analgesia for lobectomy; 4) surgical strategy for lobectomy; and 5) enhanced recovery after surgery. For each domain, the objective of the recommendations was to address a number of questions formulated according to the PICO model (Population, Intervention, Comparison, Outcome). An extensive literature search on these questions was carried out and analysed using the GRADE® methodology. Recommendations were formulated according to the GRADE® methodology, and were then voted by all experts according to the GRADE grid method.

RESULTS

The SFAR/SFCTCV guideline panel provided 32 recommendations on the management of patients undergoing pulmonary lobectomy. After two voting rounds and several amendments, a strong consensus was reached for 31 of the 32 recommendations and a moderate consensus was reached for the last recommendation. Seven of these recommendations present a high level of evidence (GRADE 1+), 23 have a moderate level of evidence (18 GRADE 2+ and 5 GRADE 2-), and 2 correspond to expert opinions. Finally, no recommendation was provided for 2 of the questions.

CONCLUSIONS

A strong consensus was expressed by the experts to provide recommendations to optimise the whole perioperative management of patients undergoing pulmonary lobectomy.

Tramadol non-medical use in Four European countries: A comparative analysis

BACKGROUND

Understanding prescription medication misuse is challenging due to lack of consistent measures of misuse behaviors and prevalence between countries. Tramadol is an atypical opioid with a dual mechanism, and has low drug liking compared to conventional opioids. We evaluate tramadol misuse compared to conventional opioids utilizing a harmonized validated national survey across four countries: Germany, Italy, Spain, and the United Kingdom (UK).

METHODS

Data from the Survey of Non-Medical Use of Prescription Drugs (NMURx) Program online cross-sectional general population national surveys are analyzed from 2018 from four countries, with 45,000 total responses. Misuse and abuse of tramadol, codeine, morphine, and oxycodone are compared, and national prevalence estimates calculated via calibration weighting. Rates are calculated per population and per drug availability. Supplemental data are included from patients entering treatment centres and poison centre exposures.

RESULTS

In 2018, distribution, misuse, and abuse of four prescription opioids show similar patterns across four countries. In all countries, codeine is misused by the largest number of adults (estimated 861,181 in Italy to 4,676,680 in Spain in past 12 months). When adjusted for availability, tramadol is misused uncommonly with lowest or second lowest rates in all countries. Most abuse occurs by the oral route for all opioids, including tramadol with only 7.27 (Germany) to 54.92 (UK) cases per 100,000 units sold.

CONCLUSIONS

In four countries, tramadol misuse and abuse are infrequent both in absolute number of cases and in comparison to conventional opioids. Even with availability of intravenous tramadol formulations, misuse by injection is rare.

Patient-controlled intravenous analgesia with tramadol and lornoxicam after thoracotomy: A comparison with patient-controlled epidural analgesia

To determine efficacy and safety of patient-controlled intravenous analgesia (PCIA) with tramadol and lornoxicam for postoperative analgesia, and its effects on surgical outcomes in patients following thoracotomy.The records of patients who underwent thoracotomy for lung resection between January 2014 and December 2014 at our institution were reviewed. The patients were divided into 2 groups according to postoperative pain treatment modalities. Patients of the patient-controlled epidural analgesia (PCEA) group (n = 63), received PCEA with 0.2% ropivacaine plus 0.5 μg/mL sufentanil, while patients in the PCIA group (n = 48), received PCIA with 5 mg/mL tramadol and 0.4 mg/mL lornoxicam. Data were collected for the quality of pain control, incidences of analgesia related side effects and pulmonary complications, lengths of thoracic intensive care unit stay and postoperative hospital stay, and in-hospital mortality.Pain at rest was always controlled well in both groups during the 4-day postoperative period. Patients in the PCIA group reported significantly higher pain scores on coughing and during mobilization in the first 2 postoperative days. The incidences of side effects and pulmonary complications, in-hospital mortality and other outcomes were similar between groups.PCIA with tramadol and lornoxicam can be considered as a safe and effective alternative with respect to pain control and postoperative outcomes for patients underwent thoracotomy.

Compatibility and stability of binary mixtures of ketorolac tromethamine and tramadol hydrochloride injection concentrate and diluted infusion solution

OBJECTIVE

Ketorolac added to tramadol as an injection mixture convenient for clinical use has been shown to be an effective balanced analgesic regimen in alleviating moderate-to-severe pain. However, analytical confirmation of the compatibility and stability of this combination is not available. This study examined the compatibility and stability of this combination.

METHODS

Two different mixtures containing ketorolac tromethamine and tramadol hydrochloride were examined: ketorolac (10 mg/mL) and tramadol (33.3 mg/mL) prepared as injection concentrate in ampoule mingled together in the ratio of one ampoule to one ampoule; diluted ketorolac (2 mg/mL) and tramadol (20 mg/mL) prepared in saline infusion solution, with or without pH adjustment. The mixtures were visually inspected for precipitation and color change. Quantitative chemical analysis was performed on days 0, 1, 3 and 7 by high-performance liquid chromatography.

RESULTS

When stored at room temperature under ambient light, the ketorolac (10 mg/mL)-tramadol (33.3 mg/mL) injection concentrate and ketorolac (2 mg/mL)-tramadol (20 mg/mL) solution, without pH adjustment and adjusted to pH 5-8, were physico-chemically stable, and neither visible precipitation nor loss of concentration was found. With the ketorolac (2 mg/mL)-tramadol (20 mg/mL) solution adjusted to pH 9, however, precipitation occurred immediately, resulting in a significant loss of tramadol.

CONCLUSION

This study suggests that a ready-to-use ketorolac-tramadol mixture, either undiluted or diluted in physiological saline solution, can be prepared, with a shelf life of at least 7 days when stored at room temperature under ambient light.

Nausea and vomiting after surgery under general anesthesia: an evidence-based review concerning risk assessment, prevention, and treatment

BACKGROUND

The German-language recommendations for the management of postoperative nausea and vomiting (PONV) have been revised by an expert committee. Major aspects of this revision are presented here in the form of an evidence-based review article.

METHODS

The literature was systematically reviewed with the goal of revising the existing recommendations. New evidence-based recommendations for the management of PONV were developed, approved by consensus, and graded according to the scheme of the Scottish Intercollegiate Guidelines Network (SIGN).

RESULTS

The relevant risk factors for PONV include female sex, nonsmoker status, prior history of PONV, motion sickness, use of opioids during and after surgery, use of inhalational anesthetics and nitrous oxide, and the duration of anesthesia. PONV scoring systems provide a rough assessment of risk that can serve as the basis for a risk-adapted approach. Risk-adapted prophylaxis, however, has not been shown to provide any greater benefit than fixed (combination) prophylaxis, and PONV risk scores have inherent limitations; thus, fixed prophylaxis may be advantageous. Whichever of these two approaches to manage PONV is chosen, high-risk patients must be given multimodal prophylaxis, involving both the avoidance of known risk factors and the application of multiple validated and effective antiemetic interventions. PONV should be treated as soon as it arises, to minimize patient discomfort, the risk of medical complications, and the costs involved.

CONCLUSION

PONV lowers patient satisfaction but is treatable. The effective, evidence-based measures of preventing and treating it should be implemented in routine practice.

Patient-controlled analgesia in the management of postoperative pain

Patient-controlled analgesia (PCA) is a delivery system with which patients self-administer predetermined doses of analgesic medication to relieve their pain. Since its introduction in the early 1980s, the daily management of postoperative pain has been extensively optimised. The use of PCA in hospitals has been increasing because of its proven advantages over conventional intramuscular injections. These include improved pain relief, greater patient satisfaction, less sedation and fewer postoperative complications. All PCA modes contain the following variables: initial loading dose, demand dose, lockout interval, background infusion rate and 1-hour or 4-hour limits. Morphine is the most studied and most commonly used intravenous drug for PCA. In spite of the fact that it is the 'first choice' for PCA, other opioids have been successfully used for this option. The most observed adverse effects of opioid-based PCA are nausea and vomiting, pruritus, respiratory depression, sedation, confusion and urinary retention. Although intravenous PCA is the most studied route of PCA, alternative routes have extensively been described in the literature. PCA by means of peridural catheters and peripheral nerve catheters are the most studied. Recently, transdermal PCA has been described. The use of peripheral or neuraxial nerve blocks is recommended to avoid the so called opioid tolerance observed with the intravenous administration of opioids. Numerous studies have shown the superiority of epidural PCA to intravenous PCA. The beneficial postoperative effects of epidural analgesia are more apparent for high-risk patients or those undergoing higher risk procedures. PCA with peripheral nerve catheters results in increased postoperative analgesia and satisfaction for surgery on upper and lower extremities. Serious complications occur rarely with these catheters. With the introduction of an Acute Pain Service, management of postoperative pain can be improved. This will also help to minimise adverse effects related to PCA and to avoid lethal mishaps.

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.

Patient-controlled analgesia

One of the most common methods for providing postoperative analgesia is via patient-controlled analgesia (PCA). Although the typical approach is to administer opioids via a programmable infusion pump, other drugs and other modes of administration are available. This article reviews the history and practice of many aspects of PCA and provides extensive guidelines for the practice of PCA-administered opioids. In addition, potential adverse effects and recommendations for their monitoring and treatment are reviewed.