Analgesic Efficacy and Safety of Local Infiltration of Tramadol in Pediatric Tonsillectomy Pain: A Systematic Review and Meta-Analysis

Efficacy of peritonsillar infiltration with dexmedetomidine versus tramadol in comparison to placebo for pain control and sedation after tonsillectomy in pediatric patients: A randomized clinical trial

Objective

This article aimed to assess the efficacy of peritonsillar infiltration with dexmedetomidine-ropivacaine versus tramadol-ropivacaine for pain control and sedation after tonsillectomy in pediatric patients.

Materials and Methods

This double-blind clinical trial recruited 99 eligible children (4-8 years old) undergoing tonsillectomy and assigned to three block-randomized groups, receiving dexmedetomidine-ropivacaine (group A), tramadol-ropivacaine (group B), or placebo-ropivacaine (group C). The vital signs included blood pressure, heart rate, and SaO2 before anesthesia induction, during surgery at regular intervals until 24 h after surgery. The duration of surgery and recovery, complications, and analgesic consumption were recorded and pain scores were measured by Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) and Oucher scales as well as sedation scores by the Wilson sedation scale. Data were analyzed within SPSS 20 at a significance level of 0.05.

Results

The lowest pain scores were measured by the CHEOPS scale in the dexmedetomidine-ropivacaine group (P < 0.05). Statistically significant difference was observed in the CHEOPS pain score between the first two groups at 30 min, 1 h, 2 h, and 4 h after surgery (P < 0.01). The differences were revealed in the Oucher pain assessments among all groups from the time of recovery to four postoperative hours (P < 0.05), with the lowest in the dexmedetomidine-ropivacaine group whose sedation score was greater during recovery and 5 min after surgery (P < 0.05). Subjects in tramadol group had six cases of dizziness and nausea, while no side effects were observed in two other groups (P < 0.05). Only seven participants receiving dexmedetomidine required acetaminophen, but 29 in the tramadol group and all in the placebo group demanded to receive acetaminophen (P = 0.001).

Conclusion

The authors concluded that dexmedetomidine as an adjuvant to ropivacaine has better performance in local infiltration for intra- and post-tonsillectomy analgesia and postoperative sedation, without any special side effects (like the placebo group), and that it hence is recommended to be used for local infiltration during tonsillectomy.

The analgesic Efficacy and Safety of Topically Applied Tramadol in Peritonsillar Space During Pediatric Adenotonsillectomy: A Meta-Analysis

OBJECTIVES

To evaluate the efficacy of topically applied tramadol in peritonsillar area for pain control and induction of perioperative morbidity in children undergoing adenotonsillectomy.

METHODS

Two authors independently searched the databases (MEDLINE, SCOPUS, and Cochrane databases) up to April 2022 for randomized controlled trials comparing the efficacy of an intraoperative peritonsillar administered tramadol with placebo or other agents only in pediatric patients. The outcomes were postoperative pain scores, time to take the first pain reducing drugs, and postoperative nausea/vomiting.

RESULTS

Our analysis was based on 17 trials. Peritonsillar administered tramadol significantly reduced postoperative pain at less than 20 minutes (SMD -1.5852, 95% CI [-2.3900; -0.7804]), 1 hour (SMD -1.5811, 95% CI [-2.3400; -0.8222]), 8 hours (SMD -1.0258, 95% CI [-1.8792; -0.1724]), 16 hours (SMD -0.8397, 95% CI [-1.4266; -0.2529]), and 1 day (SMD -1.0110, 95% CI [-1.5213; -0.5007]) and the time to take the first analgesic drug (SMD 1.6565, 95% CI [0.2838; 3.0293]) compared with the placebo. However, tramadol showed no significant difference on postoperative pain relief effects and the time to take the first analgesic drug compared to the other topical agents (bupivacaine, lidocaine, ketamine, and dexamethasone). Tramadol did not cause significant postoperative nausea and vomiting.

CONCLUSIONS

This study demonstrated that intraoperatively applied topical tramadol could control postoperative pain and reduce the analgesic uptake compared with a control. However, the efficacy of tramadol in pain control was similar to other agents in pediatric adenotonsillectomy.

The efficacy and safety of peri-tonsillar administrated agents on pain treatment after pediatric tonsillectomy: A network meta-analysis

OBJECTIVES

We assessed the pain control efficacies and associated morbidities of drugs administered locally (around the tonsils) in pediatric patients undergoing a tonsillectomy.

METHODS

Randomized controlled trials up to April 2022 were retrieved from six databases. The treatment networks featured six interventions (ropivacaine, bupivacaine, levobupivacaine, ketamine, tramadol, and dexamethasone) and a control (placebo). The outcomes were the postoperative pain scores, the time to use of the first analgesic drugs, and postoperative nausea/vomiting. Both pairwise and network meta-analyses were performed.

RESULTS

All treatments controlled pain at 1 h and 1 day postoperatively. Although all agents tended to delay the time to the first analgesic drug, only bupivacaine, dexamethasone, ketamine, and tramadol significantly reduced the need for analgesics. No agent caused significant postoperative nausea or vomiting. The ranking hierarchy revealed that tramadol was superior in terms of pain control 1 h postoperatively, the time to the first analgesic drug, and the number of analgesic doses required; however, it ranked third in terms of operative time.

CONCLUSION

All drugs reduced postoperative pain. Tramadol was optimal in pain control, and dexamethasone also afforded good pain control with low incidences of nausea and vomiting.

Local Tramadol Improves the Anesthetic Success in Patients with Symptomatic Irreversible Pulpitis: A Meta-Analysis

Symptomatic irreversible pulpitis is a painful clinical condition with a broad inflammatory component. Dental anesthesia in these patients is affected by the inflammatory process, reporting a high incidence of anesthesia failure. The aim of this systematic review and meta-analytical evaluation was to determine the effect of pre-treatment with tramadol in patients with symptomatic irreversible pulpitis, as well as for pain control and adverse effects. This study was registered in PROSPERO (ID: CRD42021279262). PubMed was consulted to identify clinical investigations comparing tramadol and placebo/local anesthetics in patients with symptomatic irreversible pulpitis. Data about the anesthesia, pain control, and adverse effects were extracted. Both the anesthetic success index and the adverse effects of local tramadol and placebo were compared with the Mantel−Haenszel test and odds ratio. Data analysis showed that the local administration of tramadol increased the anesthetic success rate when compared to placebo in patients with symptomatic irreversible pulpitis (n = 228; I2 = 0; OR = 2.2; 95% CIs: 1.30 to 3.79; p < 0.004). However, local administration of tramadol increased the risk of adverse effects when compared to placebo/local anesthetics (n = 288; I2 = 0; OR = 7.72; 95% CIs: 1.37 to 43.46; p < 0.02). In conclusion, this study shows that the local administration of tramadol increases the anesthetic success index when compared to placebo in patients with symptomatic irreversible pulpitis.

Tramadol Use in Perioperative Care and Current Controversies

PURPOSE OF REVIEW

The aim of this review is to discuss the use of tramadol in the perioperative period. There is no doubt that tramadol has revolutionized pain treatment, making it important to understand the pharmacokinetics and pharmacodynamics in order to provide patients with the safest and most effective analgesia.

RECENT FINDINGS

Tramadol is a centrally acting synthetic analgesic with a multimode of action used to help treat moderate to severe pain. Pharmacologically, the unique opioid acts as a serotonin-norepinephrine reuptake inhibitor, while its metabolite, O-desmethyltramadol, acts on the μ-opioid receptor. The analgesic strength of tramadol is about one-tenth that of morphine, making it a relatively safe analgesic. Potential side effects of tramadol include nausea, vomiting, constipation, pruritus, and respiratory depression; however, the severity of these symptoms is minimal compared to traditional opioids. Although some of the perioperative uses of tramadol may be rare, it is a pain management option to consider when alternatives have proved ineffective.

Analgesic Efficacy and Safety of Local Infiltration Following Lumbar Decompression Surgery: A Systematic Review of Randomized Controlled Trials

This systematic review aims to appraise available clinical evidence on the efficacy and safety of wound infiltration with adjuvants to local anesthetics (LAs) for pain control after lumbar spine surgery. A database search was conducted to identify randomized controlled trials (RCTs) pertinent to wound infiltration with analgesics or miscellaneous drugs adjunctive to LAs compared with sole LAs or placebo. The outcomes of interest were postoperative rescue analgesic consumption, pain intensity, time to first analgesic request, and the occurrence of adverse events. Twelve double-blind RCTs enrolling 925 patients were selected for qualitative analysis. Most studies were of moderate-to-good methodological quality. Dexmedetomidine reduced analgesic requirements and pain intensity within 24 h postoperatively, while prolonged pain relief was reported by one RCT involving adjunctive clonidine. Data on local magnesium seem promising yet difficult to interpret. No clear analgesic superiority could be attributed to steroids. Τramadol co-infiltration was equally effective as sole tramadol but superior to LAs. No serious adverse events were reported. Due to methodological inconsistencies and lack of robust data, no definite conclusions could be drawn on the analgesic effect of local infiltrates in patients undergoing lumbar surgery. The probable positive analgesic efficacy of adjunctive dexmedetomidine and magnesium needs further evaluation.