Analgesic effects of intrathecal tramadol in patients undergoing caesarean section: a randomised, double-blind study. Int J Obstet Anesth. 2013;22:316-321. [PMID: 23962470 DOI: 10.1016/j.ijoa.2013.05.009]

Efficacy and safety of intrathecal adjuvants for perioperative management of cesarean delivery: a systematic review and network meta-analysis of randomized controlled trials

BACKGROUND

Cesarean section (CS) rates have increased globally, necessitating effective anesthesia management. Single-shot spinal anesthesia has limitations due to its duration and the dose-limiting adverse effects of local anesthetics.

OBJECTIVES

To evaluate the effectiveness and safety of intrathecal adjuvants combined with local anesthetics in the perioperative management of CS pain.

DESIGN

Systematic review with network meta-analysis.

DATA SOURCES

PubMed, Cochrane Library for Clinical Trials, and Embase.

ELIGIBILITY CRITERIA

We included women undergoing CS under single-shot spinal anesthesia with any intrathecal drug or placebo added to a long-acting local anesthetic. We selected single- or double-blind, parallel-group, randomized controlled trials (RCTs) reported in English. We excluded crossover, non-randomized, up-and-down dose-finding studies and clinical trials comparing the same drugs in all study arms.

RESULTS

We included 166 RCTs with 14 925 patients assigned to 32 interventions. Buprenorphine and diamorphine were the highest-ranked treatments for reducing pain intensity at 24 hours, though not statistically significant. Morphine alone or in combination with meperidine, neostigmine, epinephrine, or nalbuphine significantly increased the duration of effective analgesia and reduced opioid consumption. Dexmedetomidine and morphine significantly prolonged the motor block duration. The safety profile of intrathecal adjuvants was generally adequate.

CONCLUSIONS

While the strength of evidence, overall, was very low to low, our study suggests that while none of the interventions significantly reduced pain intensity at 24 hours, several significantly prolonged effective analgesia and reduced postoperative opioid consumption. Dexmedetomidine and morphine prolonged the duration of motor block. None of the intrathecal adjuvants evaluated significantly increased the occurrence of severe adverse events. Future large-scale RCTs are essential to provide more robust evidence.

PROSPERO REGISTRATION NUMBER

CRD42024479424.

Intrathecally injected tramadol reduces articular incapacitation and edema in a rat model of lipopolysaccharide (LPS)-induced reactive arthritis

AIMS

Intrathecal injection of morphine presents analgesic and antiedematogenic effects in rats. However, it is unknown whether tramadol, which possess a mixed mechanism of action, can also produce analgesic and antiedematogenic effects similarly.

MAIN METHODS

Male Wistar rats received carrageenan and LPS in the right knee joint. Tramadol (10 μg) was injected intrathecally 20 min before articular LPS injection. Incapacitation and articular edema were measured 5 h after LPS stimulation. Synovial fluid was collected for leukocyte counting and western blot analysis. Whole joint and lumbar spinal cord were also collected for histology and immunohistochemistry, respectively. Intrathecal pretreatments groups were with the NKCC1 blocker bumetanide, TRPV₁ agonist resiniferatoxin, μ-opioid receptor antagonist CTOP and serotonergic neurotoxin 5,7-DHT, all previously to tramadol.

KEY FINDINGS

Tramadol treatment caused the reduction of incapacitation and edema. It also reduced c-Fos protein expression in the spinal cord dorsal horn and slightly reduced TNF-α levels in synovial fluid, but neither reduced cell migration nor tissue damage. Bumetanide and resiniferatoxin prevented the analgesic and antiedematogenic effects of tramadol. CTOP prevented the analgesic and the antiedematogenic effects, but 5,7-DHT prevented only tramadol-induced analgesia.

SIGNIFICANCE

Spinal NKCC1 cotransporter and peptidergic peripheral afferents seem to be important for the analgesic and antiedematogenic effects of tramadol, as well as μ-opioid receptor. However, the monoamine uptake inhibition effect of tramadol seems to be important only to the analgesic effect.

Comparison of meperidine, tramadol and fentanyl for post-spinal shivering prevention during cesarean delivery: A double-blind randomized controlled trial

AIM

To assess the effects of intravenously administered meperidine, fentanyl and tramadol in reducing the incidence, onset time and severity of the shivering response in parturients during cesarean delivery under spinal anesthesia. Secondary outcomes included patient satisfaction and sedation scores.

METHODS

After Ethics board approval and informed written consent, 350 parturients (ASA physical status I or II), between 20 and 40 years of age, undergoing emergency or elective cesarean delivery under spinal anesthesia were recruited. Parturients were then randomly allocated to seven study groups: normal saline (control), low-dose meperidine (0.5 mg/kg), high-dose meperidine (0.75 mg/kg), low-dose fentanyl (0.5 mcg/kg), high-dose fentanyl (0.75 mcg/kg), low-dose tramadol (0.5 mg/kg) and high-dose tramadol (0.75 mg/kg). The incidence, onset time and severity of shivering, along with patient satisfaction and sedation scores were measured.

RESULTS

All study drugs showed significant reduction in incidence, onset time and severity of shivering and greater satisfaction scores compared to the control group (P < 0.01). Within each drug class, no significant differences in shivering were found between the high-dose and low-dose groups. Among study drugs, low-dose tramadol was superior due to shivering prevention and significantly reduced sedation.

CONCLUSION

Intravenously administered meperidine, fentanyl and tramadol reduce shivering incidence, onset time and severity in parturients undergoing cesarean delivery following spinal anesthesia. Importantly, low-dose intravenous tramadol (0.5 mg/kg) allowed shivering prevention and low sedation scores, thereby offering greater parturient satisfaction and better maternal-newborn bonding.

Neuraxial adjuvants for prevention of perioperative shivering during cesarean section: A network meta-analysis following the PRISMA guidelines

BACKGROUND

Perioperative shivering is clinically common during cesarean sections under neuraxial anesthesia, and several neuraxial adjuvants are reported to have preventive effects on it. However, the results of current studies are controversial and the effects of these neuraxial adjuvants remain unclear.

AIM

To evaluate the effects of neuraxial adjuvants on perioperative shivering during cesarean sections, thus providing an optimal choice for clinical application.

METHODS

A systematic review and network meta-analysis were conducted following the PRISMA (Preferred Reported Items for Systematic Review and Meta-analysis) guidelines. Analyses were performed using Review Manager 5.3 and Stata 14.0. We searched PubMed, EMBASE, Web of Science, and Cochrane Central databases for eligible clinical trials assessing the effects of neuraxial adjuvants on perioperative shivering and other adverse events during cesarean sections. Perioperative shivering was defined as the primary endpoint, and nausea, vomiting, pruritus, hypotension, and bradycardia were the secondary outcomes.

RESULTS

Twenty-six studies using 9 neuraxial adjuvants for obstetric anesthesia during caesarean sections were included. The results showed that, compared with placebo, pethidine, fentanyl, dexmedetomidine, and sufentanil significantly reduced the incidence of perioperative shivering. Among the four neuraxial adjuvants, pethidine was the most effective one for shivering prevention (OR = 0.15, 95%CI: 0.07-0.35, surface under the cumulative ranking curve 83.9), but with a high incidence of nausea (OR = 3.15, 95%CI: 1.04-9.57) and vomiting (OR = 3.71, 95%CI: 1.81-7.58). The efficacy of fentanyl for shivering prevention was slightly inferior to pethidine (OR = 0.20, 95%CI: 0.09-0.43), however, it significantly decreased the incidence of nausea (OR = 0.34, 95%CI: 0.15-0.79) and vomiting (OR = 0.25, 95%CI: 0.11-0.56). In addition, compared with sufentanil, fentanyl showed no impact on haemodynamic stability and the incidence of pruritus.

CONCLUSION

Pethidine, fentanyl, dexmedetomidine, and sufentanil appear to be effective for preventing perioperative shivering in puerperae undergoing cesarean sections. Considering the risk-benefit profiles of the included neuraxial adjuvants, fentanyl is probably the optimal choice.

Evaluation of Anesthetic and Analgesic Effects of Intrathecal Administration of Tramadol vs Fentanyl

Objectives:

The aim of this study was to examine the anesthetic and analgesic effects of intrathecal tramadol compared with intrathecal fentanyl added to bupivacaine and that of a placebo added to bupivacaine in patients undergoing elective transurethral procedures.

Methods:

The anesthetic and analgesic efficacy of intrathecal tramadol hydrochloride (HCL) was assessed against a local anesthetic in this prospective, double-blind, randomized study of 146 American Society of Anesthesiologists classification I-III patients who underwent an elective transurethral procedure. A lumbar intrathecal block was performed using bupivacaine heavy 0.5 % combined with either tramadol HCL, fentanyl, or saline for surgery. Each group received 12.5 mg bupivacaine with 50 μg (1 mL) fentanyl, 12.5 mg bupivacaine with 10 mg (1 mL) tramadol, or 12.5 mg bupivacaine with 1 mL preservative-free saline.

Results:

The saline group experienced more pain than patients in the tramadol HCL and fentanyl groups (p<0.05). The mean time to regression of the sensory block to the S1-2 segment was significantly longer in the fentanyl group compared with the tramadol and saline groups (p<0.05). The incidence of complications was similar.

Conclusion:

Fentanyl added to a local anesthetic provided longer postoperative analgesia compared with tramadol added to a local anesthetic.

Addition of Neostigmine and Tramadol to 1.5 % Lidocaine for paracervical block to reduce post-operative pain in colporrhaphy

Pain is a complex and multi-faceted human perception and several factors could dampen the pain. Therefore, we aimed to comparison of addition of neostigmine and tramadol to 1.5 % lidocaine with paracervical block in reduce of post-operative pain in colporrhaphy. This study was a randomized and double-blind clinical trial for 108 patients’ as candidate for colporrhaphy. Patients were randomly divided in three groups (Neostigmine, tramadol and control).We recorded pain in 2 and 6 and 12 hours after surgery, duration of analgesia and mean of use narcotic drug in 24 hours after surgery for all patients. Mean of narcotic drug used in 24 hours after surgery in neostigmine group was more than tramadol group(p=0/01).Pain in 2 and 6 and 12 hours after surgery in neostigmine group was more than tramadol group (p=0/01). Duration of analgesia in tramadol group was over neostigmine group and also, it was in neostigmine group was more than placebo (p=0/01).Taken together, tramadol could reduce pain in 2 and 6 and 12 hours after surgery and mean of narcotic drug used in 24 hours after surgery and increase duration of analgesia.

Adjuvants to local anesthetics: Current understanding and future trends

Although beneficial in acute and chronic pain management, the use of local anaesthetics is limited by its duration of action and the dose dependent adverse effects on the cardiac and central nervous system. Adjuvants or additives are often used with local anaesthetics for its synergistic effect by prolonging the duration of sensory-motor block and limiting the cumulative dose requirement of local anaesthetics. The armamentarium of local anesthetic adjuvants have evolved over time from classical opioids to a wide array of drugs spanning several groups and varying mechanisms of action. A large array of opioids ranging from morphine, fentanyl and sufentanyl to hydromorphone, buprenorphine and tramadol has been used with varying success. However, their use has been limited by their adverse effect like respiratory depression, nausea, vomiting and pruritus, especially with its neuraxial use. Epinephrine potentiates the local anesthetics by its antinociceptive properties mediated by alpha-2 adrenoreceptor activation along with its vasoconstrictive properties limiting the systemic absorption of local anesthetics. Alpha 2 adrenoreceptor antagonists like clonidine and dexmedetomidine are one of the most widely used class of local anesthetic adjuvants. Other drugs like steroids (dexamethasone), anti-inflammatory agents (parecoxib and lornoxicam), midazolam, ketamine, magnesium sulfate and neostigmine have also been used with mixed success. The concern regarding the safety profile of these adjuvants is due to its potential neurotoxicity and neurological complications which necessitate further research in this direction. Current research is directed towards a search for agents and techniques which would prolong local anaesthetic action without its deleterious effects. This includes novel approaches like use of charged molecules to produce local anaesthetic action (tonicaine and n butyl tetracaine), new age delivery mechanisms for prolonged bioavailability (liposomal, microspheres and cyclodextrin systems) and further studies with other drugs (adenosine, neuromuscular blockers, dextrans).

Intrathecal ropivacaine with or without tramadol for lower limb orthopedic surgeries

BACKGROUND AND AIM

Preservative free tramadol has been used as an adjuvant to intrathecal bupivacaine. However, the effect of the addition of tramadol on intrathecal isobaric ropivacaine has never been studied.

MATERIAL AND METHODS

This prospective, randomized, double-blind study was conducted in 50 adult male American Society of Anesthesiologists grade I or II patients, aged 18-60 years, being operated for unilateral femur fractures. An epidural catheter was inserted in L2-L3 interspace and subarachnoid block was given in L3-L4 space. The patients were randomized to receive 0.5 mL normal saline (group R) or 0.5 mL (25 mg) preservative free tramadol (group RT) with 2.5 mL of 0.75% intrathecal ropivacaine. Hemodynamic parameters, sensory level, motor block, sedation and side-effects were recorded. Statistical analysis was done using Student's t-test, Chi-square test, Fischer's exact test and repeated measures ANOVA.

RESULTS

The time of sensory block onset was 9.2 ± 4.9 min and 8.6 ± 5.3 min (P = 0.714) in group R and group RT, respectively. The motor block onset was also comparable in both the groups (P = 0.112). The duration of sensory block was 147.2 ± 37.4 min in group R and 160.4 ± 40.9 min in group RT (P = 0.252). The median maximum block height achieved in both the groups was T6 and the time to achieve the maximum block was also comparable statistically (P = 0.301).

CONCLUSION

The addition of intrathecal tramadol 25 mg to the isobaric ropivacaine does not alter the block characteristics produced by intrathecal ropivacaine alone.