Postoperative pain is a major postoperative problem. The use of intraperitoneal local anesthetic agents has been shown to reduce postoperative pain . In contrast, other investigators have found that intraperitoneal administration of either bupivacaine or morphine was not effective in reducing postoperative pain . Tramadol has a dual mechanism of action where it blocks the reuptake of norepinephrine and 5-hydroxytryptamine at the α2 adrenergic receptor level . The aim of this study was to examine the intraperitoneal application of saline, bupivacaine and bupivacaine with tramadol and compare it with intravenous (i.v.) tramadol on postoperative pain following total abdominal hysterectomy.
Following Ethics Committee approval and written informed consent, 100 patients were randomly divided into four groups. The first three received 20 mL saline (Group S), bupivacaine 0.5% 20 mL (Group B) or bupivacaine 0.5% 20 mL with tramadol 100 mg (Group BT) administered into the peritoneal cavity. The fourth group received 100 mg tramadol i.v. (Group T). Postoperative pain was evaluated using a visual anolog scale (VAS) at 30 min and at 2, 4, 6, 12, 18 and 24 h after extubation. Mean arterial pressure (MAP), heart rate (HR) and peripheral oxygen saturation (SpO2) were also noted. When pain scores were between 3 and 6, 0.5 mg kg−1 pethidine (meperidine) was given intramuscularly (i.m.) as a rescue analgesic. If the pain score was >6, 1 mg kg−1 meperidine was given. The rescue analgesic dose, time and side-effects were noted.
No significant differences were found in demographic criteria and SpO2. When Groups S and B were compared with Groups BT and T at 30 min, 2 and 4 h, MAP and HR were found to be significantly greater (P < 0.001). Pain scores in Groups S and B were significantly higher when compared with Groups BT and T at 30 min (P < 0.001), 2 (P < 0.001) and 4 h (P < 0.05). When Groups BT and T were compared, no significant differences were found (Table 1).
Meperidine usage was as follows: 74.1 ± 8.9 mg in Group S, 72.2 ± 7.8 mg in Group B, 61.4 ± 11 mg in Group BT and 58.3 ± 17 mg in Group T. When Groups S and B were compared with groups BT and T no significant differences were found. The time to first analgesic requirement was 34.2 ± 4.8 min in Group S, 39 ± 5.8 min in Group B, 107.8 ± 23.4 min in Group BT and 118.8 ± 25 min in Group T. When Groups B and S were compared with Groups BT and T significant differences were found (P < 0.001). We did not observe any side-effects.
Pang and colleagues  in a study in which they injected 25 mg tramadol i.m. and examined its local anaesthetic effect, demonstrated that tramadol has local anaesthetic activity. This mechanism accounts for strengthening of the local anaesthetic block achieved by perineural administration of the drug. Systemic absorption may have played a role but it has been demonstrated that local intraperitoneal bupivacaine and intraperitoneal meperidine were better than the combination of intraperitoneal bupivacaine and i.m. meperidine for postoperative analgesia in patients undergoing laparoscopic tubal ligation demonstrating a local effect . In our study, we found that tramadol when added to intraperitoneal bupivacaine was as effective in the early postoperative period as i.v. tramadol.
Department of Anaesthesiology, Trakya University Medical Faculty, Edirne, Turkey
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