Comparison of single-dose nalbuphine versus tramadol for postoperative pain management in children: a randomized, controlled trial

The Effectiveness of Tramadol in Pain Relief in Chronic Diseases: A Review Based on Clinical Trials

Tramadol is a synthetic opioid with a central effect from the aminocyclohexanol group, which has two main mechanisms of action, including as a weak agonist of opioid receptors and as a norepinephrine and serotonin reuptake inhibitor. The present study presents a review based on clinical trials designed in 2023. In July 2023, six international databases, including Medline/PubMed, ProQuest, Scopus, EMBASE, Google Scholar, and ISI (Web of Science), were searched and 58 articles were included in the study. The results of most studies showed that tramadol can be used as an analgesic drug, although in some studies it was shown that tramadol is not therapeutically superior in reducing pain compared to other treatments. Also, complications related to this treatment have been reported in some studies. Physicians should consider these factors to prevent drug toxicity, poor pain relief, use disorder in patients, and unpredictable complications. It should be noted that there is not enough evidence to support the long-term effectiveness of tramadol, but this argument also extends to nonopioid and other types of opioid analgesics, and the lack of long-term trials is due to regulatory and ethical issues. Although opioids can cause addiction when used for a long time, tramadol has a reasonable safety profile. According to the patient's condition and the clinical judgment of the medical professional, tramadol can be prescribed for patients, but the consequences of its use must be considered and a personalized treatment algorithm should be selected if the benefits outweigh the risks of the drug.

Effects of prophylactic nalbuphine on emergence agitation and postoperative pain in pediatric patients undergoing ENT surgery with sevoflurane anesthesia

Background

Emergence agitation (EA) is a common complication in the pediatric population. This study aimed to investigate the effect of the prophylactic nalbuphine on EA in pediatric patients receiving sevoflurane anesthesia.

Methods

The children undergoing ear, nose, and throat (ENT) surgery were administered 0.2 mg/kg nalbuphine (the nalbuphine group) or the same volume of normal saline (the control group) 5 min before the end of the surgery. The extubating time, time to eye-opening and duration of the post-anesthesia care unit (PACU) were recorded. Heart rate and blood pressure were monitored before and 5 min after nalbuphine administration. Pain was assessed using Face Legs Activity Cry and Consolability (FLACC) scales, and the drug-related postoperative complications (e.g., EA, delayed awakening, nausea and vomiting, and respiratory depression) were recorded.

Results

One-hundred and thirty pediatric patients were randomly divided into nalbuphine and control groups (n = 65). The nalbuphine group showed a significantly lower incidence of EA than the control group (20% vs. 46.2%, P = 0.002). No significant differences between the two groups were observed in heart rate and blood pressure 5 min after nalbuphine administration (P > 0.05). No significant differences were observed between the two groups regarding extubating time, time to eye-opening, and duration of PACU. The FLACC scales demonstrated lower values in the nalbuphine group than in the control group during the initial 4 h after the surgery. However, the FLACC scales showed similar values between 5 and 12 h after the surgery.

Conclusions

In summary, the results of this study demonstrated that prophylactic natbuphine could minimize the incidence of EA in pediatric patients following ENT surgery without increasing the extubating time and PACU duration.

Clinical Trial Registration

http://www.chictr.org.cn, identifier [ChiCTR2300070046].

Nalbuphine in Pediatric Emergence Agitation Following Cochlear Implantation: A Randomized Trial

Background

To investigate the effects of nalbuphine on emergency agitation (EA), which affects up to 80% of the children following otolaryngology procedures, in children undergoing cochlear implantation.

Methods

A prospective double-blinded randomized controlled clinical trial was conducted between November 2020 and October 2022. Eligible children, aged 6 months to 3 years old, were randomly assigned to either 0.1 mg/kg, 0.15 mg/kg, 0.2 mg/kg nalbuphine or 0.9% saline groups. EA was defined by the Pediatric Anesthesia Emergence Delirium (PAED) score ≥10. Extubation time, post-anesthesia care unit (PACU) length of stay, severe EA (PAED ≥ 15), peak PAED score, the Faces, Legs, Activity, Cry, and Consolability (FLACC) scale, Ramsay sedation score, and adverse events were also recorded.

Results

A total of 104 children were enrolled, with 26 children in each group. Nalbuphine significantly reduced the EA occurrence from 73.1% in the saline group to 38.5%, 30.8%, and 26.9% in the 0.1 mg/kg, 0.15 mg/kg, and 0.2 mg/kg nalbuphine groups, respectively (P < 0.001), without affecting the extubation time and PACU length of stay. More children (34.6%) in the 0.9% saline group experienced severe EA. Higher dose nalbuphine (0.15 mg/kg, 0.2 mg/kg) showed lower peak PAED score, better analgesia and sedation effect compared with 0.1 mg/kg nalbuphine and saline groups. However, 0.2mg/kg nalbuphine caused undesired over-sedation in two (7.7%) children. No other adverse events were reported.

Conclusion

Young children undergoing cochlear implantation surgery were at a high risk of EA and postoperative pain, while 0.2 mg/kg nalbuphine might be an ideal candidate for EA and pain prevention when used under close monitoring.

Trial Registration

ChiCTR2000040407.

Impact of intravenous administration of nalbuphine at different time points for postoperative analgesia and sedation in adenotonsillectomized children: a prospective, randomized controlled trial

Objective

To compare the efficacy of intravenous administration of nalbuphine at different time points for postoperative analgesia and sedation in adenotonsillectomized children.

Methods

Patients with obstructive sleep apnea syndrome scheduled for adenotonsillectomy were randomly divided into group A (patients received intravenous nalbuphine 0.2 mg/kg before anesthesia induction), group B (patients received intravenous nalbuphine 0.2 mg/kg 10 min before the end of surgery), and group C (patients did not receive nalbuphine injection). The time points for measuring outcomes were before anesthesia induction (T0), extubation (T1), and 0, 15, 30, or 45 min in the postanesthesia care unit (PACU) (T2-T5, respectively).

Results

There were 40 patients in group A, 41 patients in group B and 39 patients in group C. Patients in group B had significantly lower FLACC (Face, Legs, Activity, Cry, Consolability) pain scores at T2-T5 than those in group C (all p<0.05). Patients in group B had higher Ramsay Sedation Score at T2-T4 than those in group C (all p<0.05). The proportion of patients who received remedial analgesia in the PACU in group A (17.5%, p=0.008) and group B (9.8%, p<0.001) was significantly lower than that in group C (46.2%).

Conclusion

Intravenous administration of nalbuphine 10 min before the end of adenotonsillectomy in children could decrease pain intensity and increase sedation levels during the recovery period with the reduction of remedial analgesia in the PACU.Trial registration number ChiCTR2200060118.

Effects of modified multimodal analgesia on postoperative pain, sedation, and prognosis of gynecological patients

Patient-controlled intravenous analgesia is one of the most common pain relief methods in  the postoperative period, but its adverse reactions remain high. This study aimed to explore the role of improved combined analgesia methods in pain, sedation, postoperative nausea, and vomiting (PONV) in patients undergoing gynecological surgeries. This study was a prospective, randomized, double-blind controlled study. A study population of 72 patients undergoing gynecological surgery were randomly assigned to either the TAPB + S group or the TAPB + N group. All patients in both groups underwent a transversus abdominis plane block (TAPB) after induction of anesthesia. The TAPB + S group received a continuous intravenous infusion (2 ml/h) of sufentanil (1 μg/kg) plus metoclopramide (30 mg) through 100 ml elastomeric pumps postoperatively. The TAPB + N group received a continuous intravenous infusion (2 ml/h) of nalbuphine hydrochloride (1 mg/kg) plus metoclopramide (30 mg) postoperatively. The main outcome measures were as follows: postoperative pain intensity, Ramsay sedation score (RSS) after surgery, PONV occurrence rate, and rescue analgesics. The RSS of the TAPB + S group was significantly higher than that of the TAPB + N group at 2, 4, and 6 h after the operation. However, the visual analog scale score of the TAPB + S group was much higher than that of the TAPB + N group. No significant differences were found between the two groups in terms of consumption of opioids and other narcotic drugs at 2, 4, 6, 24, and 48 h after the operation. No statistically significant differences were found with respect to PONV and other adverse events in both groups. Taken together, our data indicate that the TAPB + N program can provide better postoperative analgesia and also reduce the use of strong opioids. The more optimized scheme of perioperative analgesia still needs to be researched further.

Neurotoxic effect of nalufin on the histology, ultrastructure, cell cycle and apoptosis of the developing chick embryo and its amelioration by selenium

The use of opioids during pregnancy has recently dramatically increased presenting major health problems, especially on the developing neonatal nervous system development. Nalufin is considered one of the most used opioid analgesics for treatment of moderate to severe pain, especially during pregnancy. The aim of the present study was firstly to assess the possible neurotoxic effects of nalufin injection during the organogenesis period of chick embryos, and second to investigate the ameliorative effects of selenium as a supplement. Fertilized chicken eggs were in ovo injected with 0.2ml of either nalufin (20 mg/kg egg) or selenium (0.1 mg/kg egg) or both. Nalufin injection resulted in cerebral cortical layer disruption, increase of Caspase-3 immunoexpression and chromatolytic nuclei, degenerated organelles, rarefied cytoplasm and hemorrhage. On the molecular levels, nalufin induced DNA fragmentation, cell cycle arrest and increased the percentage of apoptosis of the neuronal cells. Selenium combined treatment restored the three-layered structure of the cerebral cortex, decreased caspase-3 immuno-expression, improved ultrastructure and recovered cell cycle arrest, decreased apoptosis, and DNA degradation. In conclusion, nalufin treatment during pregnancy imposes great concerns and should not be used during embryonic development, on the other hands, selenium appears to be a promising neuroprotective agent against nalufin-induced neurotoxicity.

When the Safe Alternative Is Not That Safe: Tramadol Prescribing in Children

Children represent a vulnerable population in which management of nociceptive pain is complex. Drug responses in children differ from adults due to age-related differences. Moreover, therapeutic choices are limited by the lack of indication for a number of analgesic drugs due to the challenge of conducting clinical trials in children. Furthermore the assessment of efficacy as well as tolerance may be complicated by children's inability to communicate properly. According to the World Health Organization, weak opioids such as tramadol and codeine, may be used in addition to paracetamol and ibuprofen for moderate nociceptive pain in both children and adults. However, codeine prescription has been restricted for the last 5 years in children because of the risk of fatal overdoses linked to the variable activity of cytochrome P450 (CYP) 2D6 which bioactivates codeine. Even though tramadol has been considered a safe alternative to codeine, it is well established that tramadol pharmacodynamic opioid effects, efficacy and safety, are also largely influenced by CYP2D6 activity. For this reason, the US Food and Drug Administration recently released a boxed warning regarding the use of tramadol in children. To provide safe and effective tramadol prescription in children, a personalized approach, with dose adaptation according to CYP2D6 activity, would certainly be the safest method. We therefore recommend this approach in children requiring chronic or recurrent nociceptive pain treatment with tramadol. In case of acute inpatients nociceptive pain management, prescribing tramadol at the minimal effective dose, in a child appropriate dosage form and after clear instructions are given to the parents, remains reasonable based on current data. In all other situations, morphine should be preferred for moderate to severe nociceptive pain conditions.