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To evaluate the clinical benefits and disadvantages of adding metoclopramide to tramadol for patient-controlled analgesia (PCA).Forty adult patients, undergoing elective arthroplasties, were recruited into this prospective, randomized, double-blind study. During general anesthesia all patients received 2.5 mg x kg(-1) of tramadol as a loading dose at the beginning of wound closure. In the postanesthesia care unit (PACU) patients were randomly allocated to receive PCA containing either 20 mg tramadol + 1 mg metoclopramide per millilitre (n = 20, Group T+M) or tramadol 20 mg per millilitre (n = 20, Group T). The PCA setup was 1 mL/bolus with a lockout interval of five minutes. A blinded investigator assessed the vital signs, visual analogue scale, and severity of postoperative nausea and/or vomiting in the PACU. The PCA demand and delivery, overall satisfaction rate and adverse effects were recorded in the PACU and on postoperative days one and two.Nausea/vomiting scores were more severe (1.7 +/- 1.0 vs 0.2 +/- 0.5, 2.3 +/- 1.2 vs 0.6 +/- 0.6, 1.9 +/- 0.9 vs 0.2 +/- 0.5, at 12 hr, 18 hr, 24 hr, respectively, P0.05) and more frequent (7/20 vs 1/20, 5/20 vs 0/20 for nausea and vomiting respectively, P0.05) on postoperative day one in Group T compared to Group T+M. However, the incidence of sedation was higher in Group T+M (7/20 vs 1/20, P0.05).The incidence and severity of nausea/vomiting decreased if metoclopramide was added to tramadol for PCA. An increased incidence of sedation was noticed with this drug combination.

To evaluate the adverse effect profile of tramadol by patient-controlled analgesia (PCA) with administration of the loading dose either intraoperatively or postoperatively.Sixty adult patients scheduled for elective abdominal surgery were enrolled into this prospective, randomized, double blind study. The patients were anesthetized in a similar manner. At the beginning of wound closure, the patients were randomly allocated to receive 5 mg x kg(-1) tramadol (Group 1) or normal saline (Group 2). In the post-anesthesia care unit (PACU), when patients in either group complained of pain, 30 mg x ml(-1) tramadol i.v. were given every three minutes until visual analogue scale (VAS) 3, followed by tramadol PCA with bolus dose of 30 mg and five minute lockout interval. Pain control and adverse effect assessments were done in the PACU and every six hours for 48 hr post drug by an independent observer.The loading dose was 290 +/- 45 mg in Group 1 and 315 +/- 148 mg in Group 2. In PACU, more nausea/vomiting both in terms of incidence (13/30, 43% vs 2/30, 6.6%, P0.05) and severity (nausea/vomiting score 2.5 +/- 2.0 vs 0.2 +/- 0.6, P0.05) was observed in patients with postoperative loading than in those with intraoperative loading of tramadol.Administering the loading dose of tramadol during surgery decreases the nausea/vomiting associated with high dose of tramadol and improves the quality of tramadol PCA in the relief of postoperative pain.

To compared the clinical efficacy of tramadol and morphine using a patient-controlled analgesia (PCA) delivery system.In a prospective, randomized, double blind study, we evaluated 80 adult patients scheduled for elective hip or knee arthroplasty with general inhalational anesthesia. When patients complained of pain in the recovery room, patients were randomized to receive either tramadol or morphine by titration in 30 min to achieve analgesia (VASor =4). Equivalent volumes containing either 30 mg x ml(-1) tramadol or 1 mg x ml(-1) morphine were used for PCA with a lockout interval of 10 min. The patients were followed six-hourly for 48 hr for VAS, satisfaction rate, analgesic dose, and side effects.Patients obtained adequate analgesia with either drug. More patients had very good satisfaction scores in the morphine group in the recovery room (43% vs. 23%, P0.05) and at 24 hr (40% vs. 20%, P0.05) than those in the tramadol group. More nausea was evident in the tramadol group (48% vs. 11% in recovery room and 28% vs. 12% in 24 hr, P0.05) than in the morphine group. Vomiting was also more (28% vs. 5% in recovery room, 15% vs. 3% in 24 hr, P0.05). Morphine produced more sleepiness (45% vs. 23% in recovery room, P0.05 and 35% vs. 15% in 24 hr, P0.05).Tramadol PCA can provide effective analgesia following major orthopedic surgery provided sufficiently high doses are given for loading and by patient demand. However, the incidence of nausea/vomiting is also higher causing decreased satisfaction.

Background and Objectives. Tramadol and metoclopramide have a local anesthetic effect similar to lidocaine following intradermal injection. When metoclopramide was retained in the venous system for 1 minute, it was found to be as effective as lidocaine in reducing propofol injection pain. Using this metoclopramide model, the effects of tramadol in reducing pain on propofol injection was investigated. Methods. One hundred five patients were randomly allocated to receive 50 mg tramadol (group T), 60 mg lidocaine (group L), or normal saline (group NS) as pretreatment to reduce pain on propofol injection. Following venous occlusion with a tourniquet (70 mm Hg), one of the drugs was intravenously administered. Venous retention of the drug was maintained for 1 minute. Immediately after the tourniquet release, intravenous injection of 100 mg propofol (10 mL) at a rate of 0.5 mL/s followed. Pain assessment was made after each injection. Results. Transient minor injection pain and local skin reactions were significantly greater with tramadol than with lidocaine (P Conclusions. Using 1-minute retention in veins, both tramadol and lidocaine significantly reduced propofol injection pain. A local anesthetic activity is postulated.

We observed clinically that tramadol and metoclopramide appear to have local anesthetic action. Tramadol is a central-acting analgesic. Metoclopramide is a commonly used antiemetic. The local anesthetic effect of tramadol in reducing propofol injection pain has never been mentioned, although it was speculated with metoclopramide.We conducted a double-blind, placebo-controlled study by injecting tramadol or metoclopramide intradermally in 10 healthy volunteers (5 men, 5 women; age 25-56 years). Each subject received 0.5 mL of four solutions in random order on the volar side of the forearm. These solutions were 25 mg tramadol, 5 mg metoclopramide, 5 mg lidocaine, and 0.5 mL normal saline. Pain on injections and the degree of local anesthesia (tested by pinprick, light touch, and cold) at each site was reported on a 0-3 scale at designed time intervals.Like 1% lidocaine, tramadol and metoclopramide demonstrated loss of sensation for pinprick, light touch, and cold for 15 minutes after intradermal injection (P.01 ).Intradermal tramadol or metoclopramide can produce local anesthetic effect.

Background and ObjectivesMeperidine is frequently used in general anesthesia and perioperative analgesia. In addition to its opioid action, meperidine possesses some local anesthetic properties. A preliminary study using the tourniquet venous retention technique found meperidine to be more effective in reducing propofol injection pain than fentanyl or morphine, both of which were slightly better than placebo. This study was undertaken to evaluate whether this peripheral analgesic effect of meperidine is affected by naloxone.MethodsIn a randomized, double-blind manner, after venous occlusion with a tourniquet, meperidine 40 mg was given intravenously to patients in group A (n = 31), meperidine 40 mg followed by naloxone 0.04 mg to group B (n = 32), meperidine 40 mg followed by naloxone 0.2 mg to group C (n = 30), and normal saline placebo to group D (n = 30). The venous retention of drug(s) was maintained for 1 minute, followed by tourniquet release and intravenous administration of propofol 100 mg. Pain assessment was made immediately after the propofol injection.ResultsAll three groups given meperidine had significantly less propofol injection pain (P < .01) than the group given saline placebo, and there was no difference among groups A, B, and C.ConclusionThe peripheral analgesic effect of meperidine in reducing propofol injection pain is not mediated by its opioid activity.

We previously established that a 5 mg x kg(-1) intraoperative dose can reduce the nausea/vomiting associated with tramadol patient-controlled analgesia (PCA). This study was conducted to identify the most appropriate initial dose to improve the quality of tramadol PCA.During general anesthesia, 60 patients undergoing knee arthroplasty were randomly allocated to receive 1.25 mg x kg(-1) (Group I), 2.5 mg x kg(-1) (Group II), 3.75 mg x kg(-1) (Group III), or 5 mg x kg(-1) (Group IV) tramadol. The emergence condition was recorded. The titration of additional tramadol 20 mg + metoclopramide 1 mg doses by PCA every five minutes was performed in the postanesthesia care unit (PACU) until the visual analogue scale (VAS) score wasor = 3. An investigator blinded to study group recorded the VAS and side effects every ten minutes.In the PACU, significantly more tramadol (8.4 +/- 3.1 vs 4.3 +/- 2.1, 2.5 +/- 1.8, and 0.4 +/- 0.3, P0.05), and a higher incidence (15/15 vs 5/15, 3/15, and 2/15, P0.05) of PCA use was observed in Group I compared to Groups II-IV. VAS was significantly higher in Group I than in Groups II-IV at zero and ten minutes (P0.05). Unexpected delayed emergence anesthesia (30 min) was observed in Group III (n = 1) and in Group IV (n = 2). Sedation was more important in Groups III and IV than in Groups I and II (P0.05).When considering efficacy and side-effect profile, 2.5 mg x kg(-1) of tramadol is the optimal intraoperative dose of this drug to provide effective postoperative analgesia with minimal sedation.

Neostigmine has been found to cause peripheral analgesia. We used venous retention technique to evaluate whether neostigmine displayed peripheral analgesic effect in reducing propofol injection pain.In a double blind fashion, 105 patients were randomly allocated to receive either 1 ml 0.5 mg neostigmine (Group N, n = 35), 1 ml 2% lidocaine (Group L, n = 35), or 1 ml normal saline (Group C, n = 35) as pretreatment to reduce pain on propofol injection. A pediatric T-connector linking with the i.v. catheter port was used for injection. Venous occlusion was made possible with a tourniquet before the intravenous administration of one of the three drugs. The tested drug was allowed to retain for one minute and then the tourniquet was released for propofol injection. Pain and side effect assessments were made after propofol injection.The incidence of propofol injection pain was 85% in normal saline group, 46% in neostigmine group and 6% in lidocaine group (P0.05 among groups). The tested drugs arrayed in order of increasing magnitude of intensity of pain upon propofol injection were lidocaine (mean rank 34.20), neostigmine (mean rank 50.42) and normal saline (mean rank 76.81) in sequence (P0.05 among groups).With one-minute venous retention, 0.5 mg neostigmine (1 ml) could produce peripheral analgesia to some degree in reducing propofol injection pain. However, its analgesic effect was inferior to 1 ml of 2% lidocaine.

UNLABELLED By using a patient-controlled analgesia (PCA) delivery system, we compared the clinical advantages and disadvantages of PCA with tramadol and PCA with a mixture of tramadol plus lysine acetyl salicylate (a soluble aspirin). Fifty adult patients who had undergone major orthopedic surgeries were enrolled into a prospective, randomized, and double-blinded study. The general anesthesia was performed in a standard manner. At the beginning of wound closure, an equal volume dose of either tramadol 2.5 mg/kg (Group 1) or tramadol 1.25 mg/kg + lysine acetyl salicylate 12.5 mg/kg mixture (Group 2) was administered slowly IV. These solutions were continued postoperatively for IV PCA. Pain control, patient satisfaction, vital signs, and adverse effects were assessed for 48 h. Visual Analog Scale

UNLABELLED Using a patient-controlled analgesia (PCA) delivery system, we evaluated the clinical advantages and disadvantages of morphine PCA compared with morphine plus lysine acetyl salicylate (LAS), a soluble aspirin. After major orthopedic surgery, 50 adult patients were enrolled in a prospective, randomized, and double-blinded study. When a patient in the recovery room complained of pain, an initial dose of morphine or the morphine/LAS mixture was titrated to achieve analgesia of visual analog score < or = 3 in 30 min. An equivalent volume PCA dose of either morphine 1 mg/mL or morphine 0.5 mg + LAS 90 mg/mL was used with a lockout interval of 10 min. Pain score, patient satisfaction, vital signs, and adverse effects were observed for 48 h. Adequate analgesia (visual analog scale score < or = 3) was achieved with either drug. Morphine consumption in the morphine/LAS group was significantly less than in morphine group (13.9 vs 18.4 mg in 24 h and 24.3 vs 32.4 mg in 48 h). Significantly more sedation was evident with the morphine group (P < 0.05). We conclude that injectable LAS can be used as an effective and safe adjuvant to morphine for PCA. This combination reduces dose requirements of morphine and hence some of its adverse effects. IMPLICATIONS Injectable aspirin could be used as an effective and safe adjuvant to morphine for patient-controlled analgesia. This combination reduces the dose requirement of morphine and therefore some of the morphine-related untoward effects.

Negative pressure pulmonary oedema (NPPE) is a well-recognized but rare complication secondary to upper airway obstruction such as laryngeal spasm during emergence from general anaesthesia. Cauterization of the second and third thoracic sympathetic ganglia is a treatment for hyperhidrosis of the hands. We report a case of NPPE induced by direct suctioning of the endotracheal tube adapter during thoracic sympathetic ganglionectomy without recognized upper airway obstruction.A 19-yr-old otherwise healthy, non-smoking man was scheduled for elective bilateral chest endoscopic ablation of the second and third thoracic sympathetic ganglion for hyperhidrosis of the hands under general anaesthesia. To view and cauterize the ganglion with the endoscope, the surgeon requested cessation of positive pressure ventilation. As the surgeon could not satisfactorily visualize the target ganglia, he requested brief application of wall suction via the ETT tube adapter. A pressure of -100 mmHg was generated which lasted for three to four seconds. The goal was to reduce further the lung volume by increasing the pneumothorax produced by the endoscope. The patient developed negative pressure pulmonary oedema without upper airway obstruction.This case demonstrated that intrathoracic negative pressure generated by direct ETT adapter suctioning may produce pulmonary oedema similar to that induced by laryngeal spasm during the emergence of general anaesthesia.

Sixty adult patients scheduled for elective abdominal surgery were enrolled into this prospective, randomized, double-blinded study. The patients were anesthetized in a similar manner. At the beginning of wound closure, the patients were randomly allocated to receive tramadol (Group 1) or normal saline (Group 2). Pain control and adverse effect assessments were done in the PACU and every 6 h for 48 h post drug by an independent observer. The loading dose was 290 ± 45 mg in Group 1 and 315 ± 148 mg in Group 2. In PACU, more nausea and vomiting both in terms of incidence and severity were observed in patients with postoperative loading than in those with intraoperative loading of tramadol. Conclude that administering the loading dose of tramadol during surgery decreases the nausea and vomiting associated with a high dose of tramadol and improves the quality of tramadol PCA in the relief of postoperative pain. Comment by Lian-Kah Ti, M.D. The clinical application and conclusions of this study have to be questioned. It was not surprising that a loading dose of tramadol could effectively be given intraoperatively. What was surprising was that the authors chose not to give any analgesics either preoperatively or intraoperatively for relatively major surgery in an older population, potentially risking morbidity. Indeed, analgesics were withheld in the control group until the patients were extubated, awake, responsive, and complained of pain. Another source of concern was the large loading dose used. Based on their own experience, the authors gave doses of 300 mg of tramadol, which far exceeded the maximum recommended single dose of 100 mg as stated in the manufacturer's instruction for use. The authors did not report any intraoperative hemodynamic consequences from the loading dose, although they noted that the amount of isoflurane required was decreased. The authors concluded that the decreased nausea and vomiting seen in the patients receiving tramadol intraoperatively resulted from the patients being anesthetized at the point when peak plasma levels were achieved. An alternative explanation could be that the patients in the control group had greater postoperative pain (initial VAS of 5.9), and that pain itself resulted in the increased nausea and vomiting. Therefore, the value of this study is doubtful.