Optimizing postoperative pain con-
trol is an important aspect in peri-
operative patient care. Wound infiltration
with lo...
of this study was to compare the therapeutic effects and
possible complications of intravenous versus local wound
infiltra...
Tramadol Wound Infiltration
The Annals of Pharmacotherapy I 2009 March, Volume 43 Iwww.theannals.com
Table 3. VAS, RSS, an...
during the study period are outlined in Table 3. RSS was
reported to be lower in the group that received subcuta-
neous ve...
tered. These findings were similar to the results of the
study conducted by Pang et al.6
In that study, they showed
that t...
8. Pang WW, Mok MS, Chang DP, Huang MH. Local anesthetic effects of
tramadol, metoclopramide and lidocaine following intra...
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tramadol

  1. 1. Optimizing postoperative pain con- trol is an important aspect in peri- operative patient care. Wound infiltration with local anesthetics has been the pre- ferred analgesic method since the early 20th century.1 Local anesthetic effects of opioids have been demonstrated in sev- eral studies; tramadol is an analgesic with different spectrums of activity.2 It causes the activation of both opioid and nonopioid (descending monoaminergic) systems, which are mainly involved in the inhibition of pain. The effect of the nonopioid component of tramadol is me- diated through α2 agonistic and seroton- ergic activities by inhibiting the reuptake of the norepinephrine and 5-hydroxy- tryptamine, and possibly by displacing stored 5-hydroxytryptamine from nerve endings.3,4 Moreover, as a weak opioid, tramadol is a centrally acting analgesic selective for µ-receptors, with local anes- thetic actions on peripheral nerves.5 The postoperative analgesic effects of subcutaneous wound infiltration with tramadol have not been extensively stud- ied and compared with those of intra- venous administration; therefore, the aim The Annals of Pharmacotherapy I 2009 March, Volume 43 I Subcutaneous Tramadol Infiltration at the Wound Site Versus Intravenous Administration after Pyelolithotomy Mohammad Reza Khajavi, Seyed Babak Mojaver Aghili, Reza Shariat Moharari, Atabak Najafi, Robab Mohtaram, Patricia Khashayar, and Mojtaba Mojtahedzade www.theannals.com Pain Management Author information provided at the end of the text. RESEARCH REPORTS BACKGROUND: Recently, the peripheral anesthetic effect of tramadol has been the theme of many studies. The postoperative analgesic effects of subcutaneous wound infiltration with tramadol have not been extensively studied and compared with those of intravenous administration. OBJECTIVE: To compare the therapeutic effects and complications of intravenous versus local wound infiltration of using tramadol following pyelolithotomy. METHODS: This double-blind study was carried out on 60 patients (age 18–60 y) of American Society of Anesthesiologists physical status I–II who were awaiting pyelolithotomy in Sina Hospital, Tehran, Iran, during 2006 and 2007. They were randomly assigned to receive intravenous or subcutaneous wound infiltration with tramadol. Vital signs, the intensity of pain (visual analog scale), and the level of consciousness (Ramsey Sedation Scale [RSS]), as well as the frequency of nausea and vomiting were recorded during 30 minutes to 1 hour after the patient entered the recovery room. Vital signs were also recorded every hour until 6 hours postoperatively and then on the day after the patient was transferred to the ward. RESULTS: The RSS was lower in patients who had received subcutaneous infiltration of tramadol (p < 0.001). A significant difference was noted in the severity of pain between the groups; it was higher in the group that received intravenous tramadol. The average time for the first meperidine requirement was 45.2 ± 8.4 min (mean ± SD) in the subcutaneous group and 21.6 ± 12.4 min in the intravenous group. Total meperidine consumption was lower in patients who had received subcutaneous wound infiltration with tramadol compared with those who had received intravenous tramadol (p < 0.001). Nausea and vomiting were more frequent during the first hour of recovery; the complication, however, was less frequent in the subcutaneous group. CONCLUSIONS: Subcutaneous wound infiltration with tramadol reduces post- operative opioid consumption and produces less nausea and vomiting than does intravenous administration. KEY WORDS: meperidine, postoperative analgesia, tramadol, wound infiltration. Ann Pharmacother 2009;43:xxxx. Published Online, 3 Mar 2009, www.theannals.com, DOI 10.1345/aph.1L494
  2. 2. of this study was to compare the therapeutic effects and possible complications of intravenous versus local wound infiltration of tramadol following pyelolithotomy. Methods Following the approval of the institutional ethics com- mittee, a double-blind randomized clinical trial was carried out in the urology unit of Sina Hospital. Informed consent was obtained from the patients. All 18- to 60-year-old pa- tients of the American Society of Anesthesiologists physi- cal status I–II who underwent pyelolithotomy during 2006 and 2007 were enrolled in the study. A pyelolithotomy is an operation in which renal stones are extracted via a 15- cm incision in the flank. Patients with definite liver disease (eg, acute and chronic hepatitis, cirrhosis, hemochromato- sis); renal impairment (acute and chronic renal failure, glomerulonephritis); history of opium addiction and aller- gy to tramadol; history of seizure disorder; or administra- tion of monoamine oxidase inhibitors, naloxone, yohim- bine, cimetidine, carbamazepine, and ondansetron were excluded. Midazolam 0.04 mg/kg and fentanyl 2 µg/kg were used as premedication for all patients. Anesthesia induction was achieved using atracurium 0.5 mg/kg, thiopental sodium 5 mg/kg, and lidocaine 1.5 mg/kg. Isoflurane with 1 mini- mum alveolar concentration and O2/N2O 50% was main- tained during the anesthesia period. After acceptable anes- thesia was achieved, a Foley catheter was inserted. Patients were placed in a flank position during surgery. Bispectral index was maintained between 40 and 50. Until 30 minutes before the termination of the operation, fen- tanyl 0.7 µg/kg was injected in patients who experienced a 20% increase in blood pressure or heart rate (compared with baseline values measured in the ward). Patients who required higher doses of opioids were excluded from the study. Isoflurane was discontinued and N2O was increased to 70% at the end of the surgery and at the time of suturing. At this time, the patients were randomly assigned to 1 of 2 groups, using a computer random number generator: 1 group consisted of patients who received subcutaneous wound infiltration with tramadol, and intravenous tra- madol 2 mg/kg was prescribed for the other group. The content of a microset filled with tramadol 2 mg/kg (mini- mum dose 100 mg) plus NaCl 0.9% to a volume of 50 mL was infused slowly in the intravenous group within 20 minutes. Subcutaneous wound infiltration contained tra- madol 2 mg/kg titrated with NaCl 0.9% based on the pa- tient’s weight for a total of 20 mL. Intravenous administra- tion and subcutaneous wound infiltration with tramadol were performed by the anesthesiologist and the surgeon, respectively. Train of Four (TOF) was assessed with a nerve stimulator at the end of the operation by a resident unaware of the study objectives; N2O was discontinued and O2 100% was administered if TOF was documented to be 3 or 4. Muscular relaxation was reversed by neostig- mine 50 µg/kg and atropine 20 µg/kg. The patients’ vital signs, including blood pressure and heart rate, were moni- tored at the time of injection. Vital signs, the intensity of pain as measured by a 10- mm visual analog scale (VAS), the level of consciousness as measured by Ramsey Sedation Scale (RSS), and com- plications such as nausea and vomiting were recorded by a resident of anesthesiology, unaware of the type of drug ad- ministered to each patient, 30 and 60 minutes after the pa- tient had entered the recovery room. Patients were transferred to the ward if there were no signs of complication. Vital signs, pain, nausea, and vomit- ing were recorded every hour until 6 hours postoperatively and then on the day after they entered the ward. Meperi- dine 0.5 mg/kg was administered intravenously if pain in- tensity was greater than 4 and intravenous metoclopramide 10 mg/dose was prescribed if nausea and vomiting were present. STATISTICAL ANALYSIS Based on a pilot study, the difference between the mean VAS and the mean RSS of the 2 groups was calculated (2.7 ± 3.8 vs 3.2 ± 1.3) and, considering the findings, the required sample size for each group was calculated to be 30. For data analysis, we used independent sample t-tests, Fisher’s exact test, and repeated measures analysis of vari- ance with post hoc tests in SPSS software V. 15. Results The 60 patients enrolled in the study were divided into 2 groups. There were no significant differences in the demo- graphic data of the participants (Table 1). Hemodynamic changes (mean arterial pressure, heart rate) during the study period are listed in Table 2. The mean differences in RSS, VAS, and meperidine consumption in each group I The Annals of Pharmacotherapy I 2009 March, Volume 43 www.theannals.com MR Khajavi et al. Table 1. Patient Characteristicsa Characteristic Subcutaneous Intravenous p Value Age (y) 35 ± 2.4 33.8 ± 4.1 0.65b Male/female 17/13 13/17 0.439c MAP 122.44 ± 2.5 124.21 ± 1.9 0.170b HR 71.09 ± 3.27 68.66 ± 2.71 0.431b Operation time (min) 120 ± 15 110 ± 25 0.284b HR = heart rate; MAP = mean arterial pressure. a Mean ± SD. b Independent sample t-test. c Fisher’s exact test.
  3. 3. Tramadol Wound Infiltration The Annals of Pharmacotherapy I 2009 March, Volume 43 Iwww.theannals.com Table 3. VAS, RSS, and Meperidine Use p Value Mean 95% CI of (repeated Subcutaneous Intravenous Difference Mean measures Parameter (mean ± SD) (mean ± SD) p Valuea ± SD Difference ANOVA) VAS 30 min 2.2 ± 0.9 2.4 ± 1.7 0.702 0.1 ± 0.3 –0.6 to 0.8 1 h 2.4 ± 1.7 3.1 ± 1.7 0.117 0.7 ± 0.4 –1.6 to 0.2 2 h 1.7 ± 0.9 3.6 ± 2.3 <0.001 1.9 ± 0.4 –2.8 to –0.9 3 h 2.3 ± 1.2 4.1 ± 2.2 <0.001 1.8 ± 0.5 –2.7 to –0.8 <0.001b 4 h 2.7 ± 1.3 3.7 ± 2.1 0.028 1.0 ± 0.5 –1.9 to –0.1 5 h 2.8 ± 1.3 3.5 ± 2.3 0.137 0.7 ± 0.5 –1.7 to 0.2 6 h 2.9 ± 1.6 3.6 ± 1.9 0.119 0.7 ± 0.5 –1.7 to 0.2 24 h 2.4 ± 0.8 2.7 ± 0.8 0.080 0.3 ± 0.2 –0.8 to 0.1 RSS 30 min 2.7 ± 0.8 3.9 ± 1.1 <0.001 1.2 ± 0.2 –1.7 to –0.7 <0.001c 60 min 1.9 ± 0.6 1.9 ± 0.8 0.848 0.3 ± 0.2 –0.4 to 0.3 Meperidine use 1 h 8.3 ± 14.3 13.6 ± 17.4 0.198 5.4 ± 4.1 –13.6 to 2.9 2 h 1.2 ± 6.4 13.6 ± 18.6 0.001 12.5 ± 3.6 –19.6 to –5.2 3 h 5.3 ± 14.2 19.0 ± 18.8 0.002 13.7 ± 4.3 –22.3 to –5.0 <0.001d 4 h 5.2 ± 11.9 15.9 ± 18.9 0.011 10.7 ± 4.1 –18.9 to –2.5 5 h 10.2 ± 17.6 13.3 ± 17.1 0.491 3.1 ± 4.5 –12.0 to 5.8 6 h 6.4 ± 11.9 13.5 ± 18.4 0.081 7.1 ± 4.0 –15.1 to 0.9 24 h 0 6.6 ± 15.2 0.024 6.6 ± 2.8 –12.3 to –0.9 ANOVA = analysis of variance; RSS = Ramsey Sedation Scale; VAS = visual analog scale. a Independent sample t-test. b Comparison of the changes in the VAS scores during the study period using repeated measure. c Comparison of the changes in the RSS scores during the study period using repeated measure. d Comparison of the changes in the amount of meperidine consumption during the study period using repeated measure. Table 2. MAP and HR During the Study p Value Mean 95% CI of (repeated Subcutaneous Intravenous Difference Mean measures Parameter (mean ± SD) (mean ± SD) p Valuea ± SD Difference ANOVA) MAP 30 min 129.3 ± 15.3 127.3 ± 12.6 0.571 2.1 ± 3.6 –9.3 to 5.2 1 h 123.9 ± 10.3 124.4 ± 9.4 0.845 0.5 ± 2.5 –4.6 to 5.6 2 h 125.0 ± 14.3 122.0 ± 9.2 0.338 3.0 ± 3.1 –9.2 to 3.2 3 h 124.7 ± 13.5 122.8 ± 9.7 0.535 1.9 ± 3.0 –7.9 to 4.2 0.027b 4 h 122.5 ± 13.7 122.2 ± 9.1 0.929 0.3 ± 3.0 –6.3 to 5.7 5 h 122.6 ± 13.7 121.4 ± 10.1 0.510 2.4 ± 3.6 –9.5 to 4.8 6 h 125.8 ± 14.0 122.1 ± 10.0 0.237 3.8 ± 3.1 –10.1 to 2.5 24 h 125.1 ± 9.5 123.3 ± 8.1 0.416 1.9 ± 2.3 –6.4 to 2.7 HR 30 min 83.5 ± 15.2 77.4 ± 11.7 0.087 6.1 ± 3.5 –13.1 to 0.9 1 h 81.1 ± 8.4 76.0 ± 8.7 0.026 4.6 ± 2.9 –10.5 to 1.2 2 h 78.2 ± 10.6 72.0 ± 8.8 0.017 6.2 ± 2.5 –11.2 to –1.2 3 h 81.9 ± 13.1 75.7 ± 9.0 0.036 6.2 ± 2.9 –12.0 to –0.4 0.017c 4 h 78.4 ± 11.9 75.8 ± 10.6 0.364 2.7 ± 2.9 –8.5 to 3.2 5 h 78.8 ± 10.5 74.7 ± 10.6 0.146 4.0 ± 2.7 –9.5 to 1.4 6 h 79.0 ± 12.1 77.5 ± 10.4 0.6 1.5 ± 2.9 –7.4 to 4.3 24 h 77.4 ± 8.2 75.1 ± 8.1 0.285 2.3 ± 2.1 –6.5 to –1.9 ANOVA = analysis of variance; HR = heart rate; MAP = mean arterial pressure. a Independent sample t-test. b Comparison of the changes in the MAP values during the study period using repeated measure. c Comparison of the changes in the HR values during the study period using repeated measure.
  4. 4. during the study period are outlined in Table 3. RSS was reported to be lower in the group that received subcuta- neous versus intravenous wound infiltration with tramadol (2.7 ± 0.8 vs 3.9 ± 1.1, respectively); a significant differ- ence was found between the 2 groups within the first 30 minutes (p = 0.006). The VAS score in the first 30 minutes following the op- eration was 2.2 ± 0.9 in the subcutaneous group and 2.4 ± 1.7 in the intravenous group. The VAS score was reported to be higher in the group that received intravenous tra- madol throughout the study (Figure 1). These scores were found to be significant at 2 (p < 0.001), 3 (p < 0001), and 4 (p = 0.028) hours. The average time for the first meperidine requirement was 45.2 ± 8.4 minutes in the subcutaneous group and 21.6 ± 12.4 minutes in the intravenous group (p < 0.001). Total meperidine consumption was lower in the group that re- ceived subcutaneous wound infiltration with tramadol. This difference was statistically significant in the fourth hour and a day following the operation (4 h 5.2 ± 11.9 mg [subcutaneous] vs 15.9 ± 18.9 mg [intravenous]; 24 h [sub- cutaneous] vs 6.6 ± 15.2 mg [intravenous]). Considering both groups, nausea and vomiting were fre- quently reported during the first hours of recovery (31.7%); the complication, however, was less frequent 6 hours after the operation (Table 4). Nausea and vomiting occurred less frequently in the subcutaneous group throughout the study period. None of the subjects com- plained about peri-incisional allodynia or hyperalgesia dur- ing the study period. Discussion Opioids have long been the mainstay for postoperative pain relief; however, the high rates of adverse effects pro- vide an impetus to investigate alternatives. Recent studies have shown that localized use of these drugs can overcome the associated problems.6-8 Many studies have shown that the peripheral local anes- thetic effects of tramadol are related to those of codeine.2,9,10 According to these studies, the suggested sites of action for this drug are the nerve endings as well as a possible associat- ed central effect. In this study, we demonstrated that subcu- taneous wound infiltration with tramadol following pyelolithotomy is associated with a lower incidence of nausea and vomiting, reduced need for meperidine, de- crease in VAS scores, and lower RSS level. There was no significant difference between the final mean arterial pressure and heart rate of the 2 groups; this could be due to complete absorption of tramadol after it is infiltrated into the wound, along with good pain control in the 2 groups. However, a significant change in mean arteri- al pressure was reported over time in each group; this was not related to the method by which tramadol was adminis- I The Annals of Pharmacotherapy I 2009 March, Volume 43 www.theannals.com MR Khajavi et al. Figure 1. Mean pain severity (VAS) in each group (repeated measures analysis with comparing factor, p < 0.001). IV = intravenous administration; SC = subcutaneous wound infiltration; VAS = visual analog scale.
  5. 5. tered. These findings were similar to the results of the study conducted by Pang et al.6 In that study, they showed that there was no significant difference in arterial blood pressure, heart rate, and respiratory depression following intramuscular and intravenous injection of the analgesic. Several studies have noted that use of analgesic agents such as tramadol during surgery lowers a patient’s postop- erative need for morphine. Unlugenc et al.11 found a con- siderable decrease in morphine consumption following tra- madol administration after major abdominal surgery. Al- tunkaya et al.12 showed that the duration of postoperative analgesia provided by subcutaneous wound infiltration with tramadol was significantly longer compared with the length achieved with lidocaine. Similarly, in our study, there was a significant decrease in the postoperative de- mand for analgesia in the group that received subcuta- neous wound infiltration with tramadol. This fact demon- strates the higher effectiveness of subcutaneous wound in- filtration with tramadol, possibly due to its concurrent local and systemic effects. Immer et al.13 could not identify any significant differ- ences in VAS, morphine consumption, or antiemetic re- quirement following tramadol administration; this was contrary to the findings of our study. Nausea and vomiting are the major adverse effects of tramadol.14,15 The rate of titration of the tramadol dose, rather than the target dose, is the major determinant of a patient’s tolerability; therefore, our patients experienced less nausea and vomiting when receiving tramadol via subcutaneous wound infiltration.16 Yet, there is no report of such complications following subcutaneous wound infiltration with tramadol.6 Another study demonstrated skin rash due to histamine release after tramadol injection17 ; however, such a complication was ab- sent in our study. Similar to other studies, our study concluded that intra- venous administration of tramadol is accompanied by more complications, as well as a longer recovery time (higher RSS), compared with localized subcutaneous infil- tration.18 We did not evaluate the link between tramadol’s blood concentrations and the resulting analgesic effects. We rec- ommend that the serum concentration of tramadol and the key pharmacokinetic parameters be determined to estab- lish a dose–response relationship and the reliability for this method of drug administration. In conclusion, following subcutaneous wound infiltra- tion with tramadol, postoperative analgesia was prolonged and the need for more opioid was reduced considerably. However, administration of tramadol at the operation site requires further studies. Mohammad Reza Khajavi MD, Associate Professor of Anesthe- siology, Tehran University of Medical Sciences, Sina Hospital, Tehran, Iran Seyed Babak Mojaver Aghili MD, Resident of Anesthesiology, Tehran University of Medical Sciences, Sina Hospital Reza Shariat Moharari MD, Assistant Professor of Anesthesiology, Tehran University of Medical Sciences, Sina Hospital Atabak Najafi MD, Associate Professor of Anesthesiology, Tehran University of Medical Sciences, Sina Hospital Robab Mohtaram MD, Assistant Professor of Anesthesiology, Tehran University of Medical Sciences, Farabi Hospital, Tehran, Sina Hospital Patricia Khashayar MD, General Practitioner, Research and De- velopment Center, Tehran University of Medical Sciences, Sina Hos- pital Mojtaba Mojtahedzade PharmD, Professor of Pharmacotherapy, Tehran University of Medical Sciences, Sina Hospital Reprints: Dr. Reza Shariat Moharari, Tehran University of Medical Sciences, Sina Hospital, Hassan Abad Square, Tehran, Iran, fax 98- 2188276654, moharari@sina.tums.ac.ir, naeem.moharari@ gmail.com We are indebted to the Research and Development Center of Sina Hospital for their support. We acknowledge Gazelle Shariat Moharari, biology student, for her review and helpful comments on this article. We also thank Mohsen Rezaii MD for his sup- port and comments regarding the statistics of the study. References 1. Brower MC, Johnson ME. Adverse effects of local anesthetic infiltration on wound healing. Reg Anaesth Pain Med 2003;28:233-40. 2. Altunkaya H, Ozer Y, Kargi E, Babuccu O. Comparison of local anaes- thetic effects of tramadol with prilocaine for minor surgical procedures. Br J Anaesth 2003;90:320-2. 3. Desmeules JA, Piguet V, Collart L, Dayer P. Contribution of monoamin- ergic modulation to the analgesic effect of tramadol. Br J Clin Pharmacol 1996;41:7-12. 4. Mert T, Gunes Y, Guven M, Gunay I, Ozcengiz D. Comparison of nerve conduction blocks by an opioid and a local anesthetic. Eur J Pharmacol 2002;439:77-81. 5. Altunkaya H, Ozer Y, Kargi E, Babuccu O. Comparison of local anaes- thetic effects of tramadol with prilocaine for minor surgical procedures. Br J Anaesth 2003;90:320-2. 6. Pang WW, Huang PY, Chang DP, Huang MH. The peripheral analgesic effect of tramadol in reducing propofol injection pain: a comparison with lidocaine. Reg Anaesth Pain Med 1999;24:246-9. 7. Raffa RB, Friderich E, Reimann W, Shank RP, Codd EE, Vaught JL. Opioid and non opioid components independently contribute to the mechanism of action of tramadol, an atypical opioid analgesic. J Phar- macol Exp Ther 1992;260:257-85. Tramadol Wound Infiltration The Annals of Pharmacotherapy I 2009 March, Volume 43 Iwww.theannals.com Table 4. Frequency of Nausea and Vomiting in Each Group During the Study Subcutaneous Intravenous Time (%) (%) p Valuea p Valueb 30 min 1 (3.3) 10 (33.3) 0.006 1 h 3 (10) 16 (53.3) <0.001 2 h 0 13 (43.3) <0.001 3 h 2 (6.7) 12 (40) 0.002 <0.001c 4 h 1 (3.3) 9 (30) <0.001 5 h 0 8 (26.7) 0.002 6 h 2 (6.7) 6 (20) 0.254 a Fisher’s exact test b Repeated measure analysis of variance. c Comparison of the incidence of nausea and vomiting during the study period using repeated measure.
  6. 6. 8. Pang WW, Mok MS, Chang DP, Huang MH. Local anesthetic effects of tramadol, metoclopramide and lidocaine following intradermal injection. Reg Anesth Pain Med 1998;23:580-3. 9. Tsai YC, Chang PJ, Jou IM. Direct tramadol application on sciatic nerve inhibits spinal somatosensory evoked potentials in rats. Anesth Analg 2001;92:1547-51. 10. Kapral S, Gollmann G, Waltl B, et al. Tramadol added to mepivacaine prolongs the duration of an axillary brachial plexus blockade. Anesth Analg 1999;88:853-6. 11. Unlugenc H, Ozalevli M, Gunes Y. Pre-emptive analgesic efficacy of tra- madol compared with morphine after major abdominal surgery. Br J Anaesth 2003;91:209-13. 12. Altunkaya H, Ozer Y, Kargi E, et al. The postoperative analgesic effect of tramadol when used as subcutaneous local anesthetic. Anesth Analg 2004;99:1461-4. 13. Immer FF, Immer Bansi AS, Trachsel N, et al. Pain treatment with a COX-2 inhibitor after coronary artery bypass. Ann Thoracic Surg 2003; 75:490-5. 14. Demiraran Y, Ilce Z, Kocaman B, Bozkurt P. Does tramadol wound in- filtration offer an advantage over bupivacaine for postoperative analgesia in children following herniotomy? Pediatr Anesth 2006;16:1047-50. 15. Shipton EA. Tramadol: present and future. Anesth Intensive Care 2000; 28:363-74. 16. Petrone D, Kamin M, Olson W. Slowing the titration rate of tramadol HCl reduces the incidence of discontinuation due to nausea and/or vom- iting: a double-blind randomized trial. J Clin Pharm Ther 1999;24:115-23. 17. Acalovschi I, Cristea T, Margarit S, Gavrus R. Tramadol added to lido- caine for intravenous regional anesthesia. Anesth Analg 2001;92:209-14. 18. But AK, Erdil F, Yucel A, Gedik E, Durmus M, Ersoy MO. The effect of single dose tramadol on post operative pain and morphine requirements after coronary artery bypass. Acta Anaesthesiol Scand 2007;51:601-6. La Infiltración Subcutánea de Tramadol en el Lugar de la Herida en Comparación con la Administración Intravenosa Después de una Pielolitotomía MR Khajavi, SBM Aghili, RS Moharari, A Najafi, R Mohtaram, P Khashayar, y M Mojtahedzade Ann Pharmacother 2009;43:xxxx. EXTRACTO TRASFONDO: Recientemente, el efecto anestésico periférico del tramadol ha sido el tema de muchos estudios. Los efectos analgésicos postoperatori- os de la infiltración subcutánea del tramadol en la herida no han sido ampliamente estudiados ni comparados con los de la administración intravenosa. OBJETIVOS: El propósito de este estudio fue comparar los efectos terapéuti- cos y las complicaciones de la administración intravenosa en comparación con la infiltración local en la herida al usar el tramadol después de una pielolitotomía. MÉTODOS: Este estudio doble ciego fue llevado a cabo en 60 pacientes, con un estado físico I-II según la ASA en un grupo de edad de 18 a 60 años en espera de una pielolitotomía en el Hospital de Sina durante 2006 y 2007. Los pacientes fueron asignados al azar a recibir tramadol intravenoso o mediante infiltración subcutánea en la herida. Se registraron los signos vitales, la intensidad del dolor (VAS) y el nivel de consciencia (Escala de Sedación de Ramsey [RSS]) al igual que la frecuencia de las náuseas y los vómitos durante 30 minutos a una hora después de que el paciente entrara a la sala de recuperación. También, se registraron cada hora durante 6 horas y luego el día después de entrar a la habitación. RESULTADOS: La RSS fue menor en los que habían recibido la infiltración subcutánea de tramadol (p < 0.001). Se observó una diferencia significativa en cuanto a la severidad del dolor entre los grupos. Ésta fue mayor en el grupo que recibió el tramadol intravenoso. El tiempo promedio para requerir la primera dosis de la meperidina fue 45.2 ± 8.4 minutos en el grupo SC y 21.6 ± 12.4 minutos en el grupo IV. El uso total de la meperidina fue menor en el grupo que había recibido la infiltración subcutánea de tramadol en la herida en comparación con los que habían recibido el tramadol intravenoso (p < 0.001). La náusea y el vómito fueron más frecuentes durante la primera hora de la recuperación; sin embargo, la complicación fue menos frecuente en el grupo SC. CONCLUSIONES: La infiltración subcutánea de tramadol en la herida reduce el uso postoperatorio de opiodes y se produce menos náusea y vómito que con el uso IV. Traducido por Rafaela Mena I The Annals of Pharmacotherapy I 2009 March, Volume 43 www.theannals.com MR Khajavi et al.

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