1 Department of Anesthesiology and 2 Department of Plastic and Reconstructive Surgery, Zonguldak Karaelmas University, School of Medicine, Kozlu/Zonguldak, Turkey
Corresponding author: Ev-Ko Konutlari F-66 No. 8, 67600 Kozlu/Zonguldak, Turkey. E-mail: haltunkaya@hotmail.com
Accepted for publication: November 5, 2002
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Abstract |
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Methods. Sixty ASA I or II patients, undergoing excision of the cutaneous lesions under local anaesthesia, were included in the study. Patients were randomly assigned to receive either 1 ml of tramadol 5% (Group T, n=30) or 1 ml of prilocaine 2% (Group P, n=30) intradermally, in a double-blinded fashion. The degree of the burning sensation and pain at the injection site was documented. Sensory block was assessed 1 min after injection. The patient was asked to report the degree of sensation and to grade touch and pinprick sensation. Two minutes after drug administration, incision was performed and intensity of pain, felt by the patient was evaluated on a four-point scale (03). Any local adverse effects were recorded.
Results. There was no difference in the quality of block between the two groups. Side effects were noted in both groups with a significant increase in the incidence of local reaction (rash) in Group T (seven patients) when compared with Group P (one patient) (P<0.05). Seven patients in Group T vs four patients in Group P complained of burning at the injection site (P>0.05).
Conclusions. Intradermal tramadol 5% can provide a local anaesthesia similar to the prilocaine but the incidence of local adverse effects is higher.
Br J Anaesth 2003; 90: 3202
Keywords: anaesthetic techniques, subcutaneous; anaesthetics local, prilocaine; anaesthetics local, tranadol
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Introduction |
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The local anaesthetic effects of opioids have been demonstrated in both clinical and laboratory studies.4 Tramadol, which is a weak opioid and selective for the µ-receptors, was recently shown to have a local anaesthetic action on peripheral nerves.5 7
In this study, we aimed to compare the properties and side effects of local anaesthesia produced with either tramadol or prilocaine in surgery of the cutaneous lesions.
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Methods |
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Patients were randomly assigned to receive either 1 ml of tramadol 5% (Contramal, Abdi Ibrahim Ltd, Istanbul, TR) (Group T, n=30) or 1 ml of prilocaine 2% (Citanest 2%, AstraZenaca Ltd, Istanbul, TR) (Group P, n=30) in a double-blinded fashion. The drugs were prepared in an unlabelled syringe by an anaesthetist not involved in the patient care and data collection, and was given for injection to the surgeon who was unaware of the content of the syringe. The same surgeon performed all the injections with a 25-gauge needle mounted to the syringe.
Immediately after injection (considered as time zero) and at 60 s intervals, the sensory block was assessed by using 22-gauge, short-beveled needle. The patient was asked to score the sensation of pinprick and light touch by the anaesthetist who was unaware of the given medication. The grading system was 0=no pain, 1=mild pain, 2=moderate pain, 3=severe pain for pin prick, and 0=no light touch, 1=mild light touch, 2=moderate light touch, 3=severe light touch for light touch. Cold sensation was assessed by using a cube of ice. Surgical incision was performed 2 min after injection of local anaesthetic agent. The pain reported by the patient during incision was ranked from 0=no pain to 3=severe pain, incision impossible.
The patient was monitored by non-invasive arterial pressure measurement, heart rate, pulse oximetry, and ventilatory frequency. Local reactions (0=no reaction, 1=mild rash, 2=erythema, 3=urticaria) and injection pain (0=no pain, 1=mild pain, 2=moderate pain, 3=severe pain) were also recorded.
The data were analysed and compared using the Students t-test, 2 and Fishers exact
2 tests. A P-value <0.05 was considered statistically significant.
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Results |
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No difference in the quality of block was recorded between the groups. Onset of the sensory block in the two groups was similar. Pinprick, light touch, and cold sensations were lost within 1 min and no pain during surgery was recorded in both groups (Figs 1 and 2).
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Discussion |
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Nerve conduction effects of opioids have been demonstrated in both clinical and animal studies.4 79 Blockage of neural conduction in dorsal root axons may be the result of either specific opioid receptor-mediated mechanisms, or of non-specific membrane effects.4 The latter can be produced by a variety of chemical compounds, including peptides, alcohols, barbiturates, anticonvulsants, and narcotics.9
Tramadol, like codeine, has a methyl group substitution on the phenol moiety, which explains its weak affinity for opioid receptors.12 Unlike that of codeine, the analgesic effect of tramadol is also mediated via indirect modulation of the central monoaminergic inhibitory pain pathways. Clinically, it has been demonstrated that the local anaesthetic effect of opioids cannot be reversed by naloxone suggesting that this effect is more likely mediated by a non-opioid receptor dependent mechanism.8 9
Acalovschi and colleagues5 reported that, in differential sensory block during i.v. regional anaesthesia (IVRA), cold sensation decreased faster than the pinprick, and touch sensation was most resistant to block. In our study, no difference was seen between cold, pinprick, and light touch sensations with tramadol given intradermally.
A major disadvantage of the use of tramadol as a local anaesthetic is the increased frequency of side effect. Previous studies have demonstrated that using tramadol in IVRA was associated with a skin rash distal to the tourniquet, suggesting histamine release.5 Both tramadol and meperidine have a local irritating effect, which overrides the anaesthetic effect on the sensory nerves.13 In this study, we also determined that the incidence of pain or burning sensation at the injection site was significantly greater in the tramadol group compared with the prilocaine group.
In conclusion, tramadol 5% has a local anaesthetic effect similar to prilocaine 2% when used intradermally. However, prilocaine has significantly fewer local side-effects.
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References |
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