1 Department of Anesthesiology and 2 Department of Urology, Düzce School of Medicine, Abant Izzet Baysal University, Duzce, Turkey
* Corresponding author: Osmaniye Mah. Prestij Konutlari, Kat. 3, Daire. 24, Akçakoca, Duzce, Turkey. E-mail: demiryvz{at}yahoo.com
Accepted for publication March 20, 2005.
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Abstract |
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Methods. Eighty children aged between 7 and 14 undergoing urological surgery were included in the study. After intubation, in the lateral decubitus position, a single dose of morphine 0.1 mg kg1 in isotonic saline 0.2 ml kg1 (morphine group) and tramadol 2 mg kg1 in isotonic saline 0.2 ml kg1 (tramadol group) was administered epidurally. During the 24-h postoperative period, heart rate, systolic blood pressure, respiration rate, pain score and sedation level of the patients were monitored. A modified objective pain score of 3 or lower was accepted as an indicator of inadequate analgesia and these patients were given 20 acetaminophen mg kg1 rectally or orally. Time to first analgesia was noted. Sedation level was evaluated with a four-point sedation scale.
Results. In the postoperative period, pain scores and the average time for analgesic requirement were similar in the two groups. However, the incidences of allergic rash, itching, sedation and respiratory depression and sedation score were greater in the morphine group than in the tramadol group.
Conclusion. Greater epidural use of tramadol may be preferred to morphine for postoperative analgesia under these circumstances.
Keywords: anaesthesia, paediatric ; analgesic techniques, epidural ; analgesics opioid, morphine
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Introduction |
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Tramadol, a synthetic 4-phenyl-piperidine analogue of codeine, has been available in the UK since 1994, although it is licensed only for use in children aged >12 yr. Tramadol is a racemic mixture of two enantiomers, (+)-tramadol and ()-tramadol. The (+)-enantiomer has moderate affinity for the opioid µ receptor, which is greater than that of the ()-enantiomer. In addition, the (+)-enantiomer inhibits serotonin uptake and the ()-enantiomer is a potent norepinephrine inhibitor. These complementary properties result in a synergistic antinociceptive interaction between the two enantiomers.8 The result is an opioid with a lack of respiratory depressant effects despite an analgesic potency that has been shown to be approximately equal to that of pethidine in some studies.911 Furthermore, animal work has suggested that tramadol may have a selective spinal action.12 13 Although not licensed for this indication, tramadol has been shown to provide effective, long-lasting analgesia after extradural administration in children.1416
The objective of this study was to compare the postoperative analgesic properties and side-effects of a single epidural dose of tramadol with those of morphine in children undergoing urological surgery.
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Methods |
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No premedication was used. After i.v. cannulation, anaesthesia was induced with thiopental 5 mg kg1 (Penthal Sodium® 500 mg; IE Ulagay, Istanbul, Turkey) and tracheal intubation was facilitated using atracurium 0.5 mg kg1 (Tracrium® 25 mg 2.5 ml1; Glaxo-Wellcome, Philadelphia, USA). Anaesthesia was maintained with sevoflurane 22.5% (Sevorane; Abbott, Chicago, USA) and nitrous oxide 50% in oxygen. After the induction of anaesthesia, patients were placed in the lateral decubitus position, and, after disinfecting the skin with an iodine-based solution and draping, an 18-gauge paediatric Tuohy needle (Epican Tuohy Needle® 18G; Braun, Melsungen, Germany) was introduced at the L3 to L4 interspace in the midline. The loss of resistance technique was used to locate the lumbar epidural space with a syringe containing preservative-free saline. After ensuring no cerebrospinal fluid (CSF) or blood backflow from the epidural Tuohy needle, a test dose containing epinephrine (1:200 000 or 5 µg ml1) was administered. The electrocardiogram was observed for 23 min for tachycardia or T wave changes. Morphine or tramadol was then given as a single dose. Patients were randomized into two groups prospectively. The morphine group (Group M) received morphine 0.1 mg kg1 diluted in saline 0.2 ml kg1 and the tramadol group (Group T) received tramadol 2 mg kg1 diluted in saline 0.2 ml kg1. No other peroperative analgesia was given.
During the recovery period, heart rate, arterial pressure, peripheral oxygen saturation, ventilatory frequency, pain and sedation scores were recorded before discharge to the surgical ward. A modified objective pain score (MOPS), amended to give a maximum score of 10, was used for postoperative pain evolution.17 Sedation score (0=eyes open spontaneously, 1=eyes open to speech, 2=eyes open when shaken, 3=unrousable) was also recorded after surgery.18 Assessments of postoperative pain and sedation scores were recorded 30 min after extubation and at 2, 4, 6 and 24 h. A pain score greater than 3/10 was taken as an indication for administering oral or rectal acetaminophen 20 mg kg1, as deemed appropriate. Episodes of nausea, vomiting, facial flushing or pruritus were recorded.
Patient characteristics were compared by using the unpaired Student's t-test. Repeated measures ANOVA was used to compare all the other variables within the same group. Differences within the group were assessed using the TukeyKramer test, and comparison of the groups was validated using the unpaired Student's t-test. A group size of 40 was derived based on 98% power to detect a maximum difference of 0.93 in MOP scores (=0.05, ß=0.2). A P-value <0.05 was considered statistically significant.
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Results |
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Discussion |
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In a doseresponse study using caudal epidural morphine 0.033, 0.067 and 0.1 mg kg1 in children aged 18 yr undergoing major surgical procedures below the diaphragm, Krane and colleagues23 showed that the mean duration of analgesia was significantly longer after 0.1 mg kg1. Also, Bozkurt and colleagues20 reported effective safe and prolonged analgesia by using epidural morphine 0.1 mg kg1 in 175 children. Efficacy, safety and longer duration of analgesia with 0.1 mg kg1 were the reasons for our preference in this study.
Naguib and colleagues24 administered tramadol 100 mg and morphine 10 mg intravenously 10 min before induction in two groups of patients undergoing laparoscopic cholecystectomy and found no significant difference between the groups when they compared peroperative haemodynamics (blood pressure, heart rate and ). Baraka and colleagues25 compared the peroperative haemodynamic status of two groups of patients undergoing major abdominal surgery who received morphine 4 mg and tramadol 100 mg epidurally and found no difference. Similar haemodynamic findings occurred in the present study.
Baraka and others25 reported effective analgesia lasting 24 h by using single-dose morphine and tramadol epidurally. On the other hand, Delikan and colleagues26 were able to obtain analgesia lasting 10 h by using tramadol 100 mg epidurally. Fu and colleagues27 reported 12 h of analgesia with tramadol 50 mg and 11.5 h of analgesia with tramadol 75 mg, and found lower visual pain scores in the 75 mg group. Grace and colleagues28 compared tramadol (50100 mg bolus, 10 mg h1 epidural infusion) and morphine (2 mg bolus and 0.2 mg h1 epidural infusion). Despite using higher equivalent analgesic dosages of tramadol than morphine, they obtained much better results with morphine. In this study supplementary analgesic was not needed for 16 h in the tramadol group and for 18 h in the morphine group. MOPS scores were observed to be similar in two groups.
Vickers and colleagues29 reported that the sedation potential of tramadol was less than that of morphine; the incidence of somnolence was 1.1% in the tramadol group and 1.2% in the morphine group. In our study, statistically higher sedation scores were observed in the morphine group compared with the tramadol group. One patient experienced a decrease in respiratory rate and somnolence in the postoperative recovery period (01 h).
The incidence of nausea and vomiting has been reported as 2080% when opioids are administered i.v. and epidurally.30 31 James and colleagues32 did not report any nausea and vomiting with tramadol i.v., whereas nausea and vomiting was evident in 20% of patients treated epidurally with morphine. On the other hand, Baraka and colleagues25 reported nausea and vomiting in 20% of patients with tramadol and 40% of patients with morphine epidurally. In another study,26 nausea and vomiting was observed in 50% of patients treated with tramadol epidurally; the incidence was less with smaller doses. In our study, nausea and vomiting rates were 25% in the tramadol and 20% in the morphine group.
James and colleagues32 observed i.v. tramadol and epidural morphine and reported that itching was not seen in any group. However, Baraka and colleagues25 found itching in 10% of tramadol-treated patients and in 20% of morphine-treated patients. In this study, itching was not observed in the tramadol group but observed in 40% (16 patients) of patients in the morphine group. Bozkurt and colleagues20 observed ventilatory depression in 1.12% of epidural morphine-treated patients. In our study, ventilatory depression was observed in two patients (4%).
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References |
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