Comparison of patient-controlled analgesia versus continuous infusion of tramadol in post-cesarean section pain management

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.

Transversus abdominis plane block versus wound infiltration for post-cesarean section analgesia: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Transversus abdominis plane (TAP) block and wound infiltration (WI) with local anesthetics are used for postoperative analgesia after cesarean section (CS), reducing the need for administration of opioids.

OBJECTIVE

To compare the analgesic effect of TAP block related to WI.

SEARCH STRATEGY

MEDLINE, Scopus, ClinicalTrials.gov, EMBASE, Cochrane Library, and CINAHL were searched from inception until April 2020.

SELECTION CRITERIA

Randomized controlled trials (RCTs) about women who underwent TAP block or WI after CS.

DATA COLLECTION AND ANALYSIS

Relevant data were extracted and tabulated. Review Manager 5.3 was used for data analysis. Primary outcome was cumulative opioid consumption (COC) 24 and 48 h after CS.

MAIN RESULTS

Five RCTs, enrolling 268 women, were included. There were no significant differences between the interventions regarding COC at 24 (mean difference [MD] -1.68, 95% confidence interval [CI] -6.29 to 2.93) and 48 hours (MD 1.28, 95% CI -10.44 to 13.00). Adverse effects (relative risk [RR] 0.93, 95% CI 0.75-1.16), gastrointestinal reactions (RR 1.30, 95% CI 0.46-3.68), or mild-moderate sedation (RR 1.12, 95% CI 0.72-1.74), pain scores, satisfaction of women, and withdrawals were similar between groups.

CONCLUSIONS

There might be no significant advantages selecting TAP block over WI for post-CS analgesia.

Combination of Dexmedetomidine and Tramadol in Patient-Controlled Intravenous Analgesia Strengthens Sedative Effect in Pregnancy-Induced Hypertension

Objective: The aim of the present study is to explore the combination of dexmedetomidine (DXM) and tramadol (TMD) on sedative effect in patients with pregnancy-induced hypertension (PIH). Methods: A total of 356 patients with pregnancy-induced hypertension (PIH) were randomly divided into three groups: DXM, TMD and DXM + TMD groups. These patients were treated with different doses of DXM, TMD or combination of DXM and TMD by a patient-controlled intravenous injection device. The scores of static pain and dynamic pain, sedation degree, and adverse reaction were recorded. The plasma levels of inflammatory mediators IL-10 and C-reactive protein (CRP), and the serum level of p-p38-MAPK were evaluated. Results: It was found that administration with DXM 1.0 µg/kg/h + TMD 700 mg and DXM 2.0 µg/kg/h + TMD 600 mg result in stronger sedative effect than single administration with DXM or TMD. The mean arterial pressure (MAP) and heart rate (HR) of patients with PIH were decreased with the combinational treatment of DXM and TMD. Interestingly, the PIH patients injected with DXM 1.0 µg/kg/h + TMD 700 mg and DXM 2.0 µg/kg/h + TMD 600 mg showed stronger sedative effect. In addition, the plasma level of level of IL-10 was increased and CRP decreased. The serum level of p-p38/MAPK was decreased. Conclusion: Taken together, our study indicates that combination of DXM and TMD effectively lowers blood pressure and reduces inflammation through increasing the level of IL-10, reducing CRP and inhibiting p-p38/MAPK in patients with PIH. This study suggests that the combination of DXM and TMD could be an anesthetic choice in the management of PIH.

Patient-controlled intravenous tramadol versus patient-controlled intravenous hydromorphone for analgesia after secondary cesarean delivery: a randomized controlled trial to compare analgesic, anti-anxiety and anti-depression effects

Introduction

This study aimed to compare the postoperative analgesic effects of tramadol and hydromorphone for secondary cesarean delivery (CD) as well as their anti-anxiety and anti-depression properties.

Methods

A total of 106 patients receiving secondary CD under spinal anesthesia were randomly allocated to the tramadol group (n=53) and the hydromorphone group (n=53). Each group received patient-controlled intravenous analgesia using flurbiprofen 4 mg/kg combined with tramadol (4 mg/kg) or hydromorphone (0.04 mg/kg) immediately after the surgery. Postoperative pain numerical rating scale (NRS) for incision and visceral pain, hospital anxiety and depression scale (HADS), early walking time and length of hospital stay were assessed.

Results

Patients in the tramadol and hydromorphone groups exhibited equivalent incision pain NRS at different time points (P>0.05). Visceral pain in the tramadol group was higher than that in the hydromorphone group at postoperative 4 hours (2.9 [1.2] vs 2.3 [1.4], P=0.011) and 8 hours (2.4 [1.1] vs 1.8 [1.1], P=0.028). One week after the surgery, the patients in the tramadol group, as compared to the hydromorphone group, had lower anxiety scores (1.9 [3.5] vs 3.6 [4.1], P=0.033) and depression scores (0.8 [1.3] vs 2.7 [4.1], P=0.023). In addition, early walking time (25.3 [7.0] hours vs 29.3 [9.6] hours, P=0.016) and length of hospital stay (2.9 [0.8] days vs 3.3 [0.8] days, P= 0.008) after the surgery in the tramadol group were less than those in the hydromorphone group.

Conclusion

Postoperative intravenous analgesia with tramadol or hydromorphone for secondary CD provides comparable analgesic effects on incision pain. Tramadol is less effective in controlling visceral pain compared to hydromorphone. However, tramadol can help to alleviate anxiety and depression in the early postpartum period, improve patients’ early mobilization and shorten their hospital stay.

Clinical trial number and registry URL

No: ChiCTR-IIR-17011043; URL: www.chictr.org.cn.

Comparison of different sufentanil-tramadol combinations for pain relief within the first 24 hours after cesarean section: a retrospective study

Introduction

Postcesarean section pain management is important for both the mother and the newborn. This study compared the analgesic effects and incidence of adverse events associated with intravenous patient-controlled analgesia (iv-PCA), using different sufentanil–tramadol combinations for postoperative pain control.

Methods

Parturients (n=5,794) who had been scheduled for cesarean section under neuraxial anesthesia and had received iv-PCA between September 2013 and March 2017 were retrospectively analyzed. These patients were assigned to three groups, based on different sufentanil–tramadol combinations: ST1 (n=1,347), ST2 (n=2,401), and ST3 (n=2,046). The analgesic efficacy, total drug consumption, and incidence of adverse effects within 24 hours after surgery were compared among the three groups.

Results

The ST3 group had lower visual analog scale pain scores at rest and with movement at all time points during the first 24 hours postoperatively than the other two groups (P<0.01, Bonferroni corrected). The sufentanil dosage administered to the ST3 group was lower, and the tramadol dosage was higher than those administered to the other groups within 24 hours after surgery (P<0.01, Bonferroni corrected). Moreover, all parturients scored 2 points on the Ramsay sedation scale. Adverse reactions such as pruritus and respiratory depression were not observed in any group. No significant differences were noted in the incidence of nausea/vomiting, abdominal distension, and dizziness among the three groups (P>0.05).

Conclusion

The visual analog scale scores for postoperative pain decreased as the concentrations of sufentanil and tramadol administered in iv-PCA moderately increased over 24 hours after surgery. This analgesic strategy resulted in a significant reduction in the total sufentanil requirement without increasing the incidence of adverse effects.

Protocol for a randomised, double-blind, placebo-controlled trial to explore the effect of tramadol in the prevention of postpartum depression (ETPPD)

INTRODUCTION

Postpartum depression is one of the most commonly experienced psychological disorders for women patients undergoing caesarean section, which accounts for about one-third of puerpera worldwide. Tramadol, a commonly used analgesic with an inhibitory effect on the reuptake of norepinephrine and serotonin, is an effective and well-tolerated agent for analgesia after caesarean section. Based on the role of changes in the postpartum levels of serotonin and norepinephrine in postpartum depression, we speculated that postoperative intravenous analgesia using tramadol may decrease the incidence of postpartum depression for caesarean patients. Therefore, this trial aimed to explore the effect of tramadol in the prevention of postpartum depression.

METHODS AND ANALYSIS

A randomised double-blind placebo-controlled trial will be performed and 1230 singleton parturients will be randomised to receive patient-controlled intravenous analgesia with tramadol or hydromorphone, or patient-controlled epidural analgesia with ropivacaine. The primary outcome of this trial will be the incidence of postpartum depression at 4 weeks after the caesarean section, together with the collection of the relevant data during hospitalisation and at 3 months after the caesarean section. Subgroup data according to the preoperative depression score will be analysed. Demographic characteristics, postoperative analgesic effects and postoperative recovery score will also be summarised and presented.

ETHICS AND DISSEMINATION

The current trial protocol was approved by the Institutional Ethics Committee of Xinqiao Hospital (ID: 2017-026), Third Military Medical University, Chongqing, China. The results of this trial will be disseminated at scientific meetings and in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT03309163; Pre-results.

Comparison of patient-controlled intravenous analgesia with sufentanil versus tramadol in post-cesarean section pain management and lactation after general anesthesia - a prospective, randomized, double-blind, controlled study

Introduction

Acute pain is a common complication following cesarean section under general anesthesia. Post–cesarean section pain management is important for both the mother and the newborn. This study compared the effects of patient-controlled intravenous analgesia (PCIA) using sufentanil or tramadol on postoperative pain control and initiation time of lactation in patients who underwent cesarean section under general anesthesia.

Methods

Primiparas (n=146) scheduled for cesarean section under general anesthesia were randomized to receive PCIA with sufentanil or tramadol. Movement-evoked and rest-pain intensity were assessed by the Numerical Rating Scale (NRS) postoperatively. The number of PCIA attempts, amount of drug consumed, initiation time of lactation, and Quality of Recovery Score 40 (QoR-40) were recorded at 4, 8, 12, and 24 h postoperatively. Pre- and postoperative serum prolactin levels were recorded.

Results

No between-group difference existed in the NRS at rest at any time point postoperatively. Patients on sufentanil had more movement-evoked pain and a higher sedation score at 4, 8, and 12 h postoperatively, as compared with the tramadol group. At 24 h, the QoR-40 was higher in the tramadol group compared with the sufentanil group. No significant between-group differences were present in patient satisfaction and nausea/vomiting scores. Postpartum prolactin levels were significantly higher in the tramadol group versus the sufentanil group, corresponding with a significant delay in initiation of lactation in the latter.

Conclusion

PCIA with tramadol may be preferred due to lower movement-evoked pain, higher quality of recovery, and earlier lactation in patients following cesarean section under general anesthesia.