A single dose of tramadol in continuous wound analgesia with levobupivacaine does not reduce post-sternotomy pain: a randomized controlled trial

Floriane Bethenod, Omar Ellouze, Vivien Berthoud, Anis Missaoui, Amélie Cransac, Serge Aho, Olivier Bouchot, Claude Girard, Pierre Grégoire Guinot, Belaid Bouhemad, Floriane Bethenod, Omar Ellouze, Vivien Berthoud, Anis Missaoui, Amélie Cransac, Serge Aho, Olivier Bouchot, Claude Girard, Pierre Grégoire Guinot, Belaid Bouhemad

Abstract

Background: Medial sternotomy is commonly used in cardiac surgery, although it results in intense post-operative pain. The placement of a sternal wound catheter for the administration of local anesthetic represents an effective technique. An initial bolus of tramadol in the sternal wound catheter could potentiate the effect of the local anesthetic and decrease both the post-operative pain and the morphine consumption.

Patients and methods: We conducted a prospective, randomized, double-blind study at the University Hospital Center, Dijon, France. Patients requiring scheduled or non-extreme emergency surgery for valve disease, aorta disease, atrial myxoma, or coronary artery bypass graft via sternotomy were included. A sternal wound catheter was inserted at the end of the surgery. The patients were randomized to receive either a 2 mg/kg bolus of tramadol (n=80) or a placebo (n=80) in the wound catheter. The bolus administration was followed by a continuous infusion of 1.25% levobupivacaine for the first 48 hrs following surgery. The patients' morphine consumption during the first 48 hrs after extubation was recorded. The other investigated variables were the patients' rescue analgesia, arterial blood gasses, and length of stay in the intensive care unit and in hospital, as well as the incidence of chronic pain at the four-month follow-up point.

Results: The morphine consumption was found to be comparable in the two groups (38 mg vs 32 mg, p=0.102). No effect was found in terms of the arterial blood gasses, lengths of stay, or incidence of chronic pain.

Conclusion: The addition of tramadol to the local anesthetic delivered via a wound catheter following sternotomy did not reduce the patients' post-operative morphine consumption.

Trial registration: Clinicaltrials.gov identifier: NCT02851394.

Keywords: cardiac surgery; post-operative pain; sternotomy; tramadol.

Conflict of interest statement

Dr Floriane Bethenod reports non-financial support from Gamida during the conduct of the study. The authors report no other conflicts of interest in this work.

© 2019 Bethenod et al.

Figures

Figure 1
Figure 1
Flow chart.
Figure 2
Figure 2
Evolution of the morphine consumption during the first 48 hrs post-surgery.
Figure 3
Figure 3
Results concerning the blood gasses during the first 48 hrs post-surgery.
Figure 4
Figure 4
Ramsay scores during the first 48 hrs post-surgery.

References

    1. Lahtinen P, Kokki H, Hynynen M. Pain after cardiac surgery: a prospective cohort study of 1-year incidence and intensity. Anesthesiology. 2006;105:794–800. doi:10.1097/00000542-200610000-00026
    1. Schwann NM, Chaney MA. No pain, much gain? J Thorac Cardiovasc Surg. 2003;126:1261–1264. doi:10.1016/S0022-5223(03)01327-8
    1. Recommandations formalisées d’experts 2008. Prise en charge de la douleur postopératoire chez l’adulte et l’enfant. Ann Fr Anesth Réanimation. 2008;27:1035–1041.
    1. Fletcher D, Aubrun F. Les textes longs de la recommandation formalisée d’experts sur la prise en charge de la douleur postopératoire. Ann Fr Anesth Réanimation. 2009;28:1–2. doi:10.1016/j.annfar.2008.12.001
    1. White PF, Rawal S, Latham P, et al. Use of a continuous local anesthetic infusion for pain management after median sternotomy. Anesthesiology. 2003;99:918–923. doi:10.1097/00000542-200310000-00026
    1. McDonald SB, Jacobsohn E, Kopacz DJ, et al. Parasternal block and local anesthetic infiltration with levobupivacaine after cardiac surgery with desflurane: the effect on postoperative pain, pulmonary function, and tracheal extubation times. Anesth Analg. 2005;100:25–32. doi:10.1213/
    1. Kocabas S, Yedicocuklu D, Yuksel E, et al. Infiltration of the sternotomy wound and the mediastinal tube sites with 0.25% levobupivacaine as adjunctive treatment for postoperative pain after cardiac surgery. Eur J Anaesthesiol. 2008;25:842–849. doi:10.1017/S0265021508004614
    1. Koukis I, Argiriou M, Dimakopoulou A, et al. Use of continuous subcutaneous anesthetic infusion in cardiac surgical patients after median sternotomy. J Cardiothorac Surg. 2008;3:2. doi:10.1186/1749-8090-3-2
    1. Dowling R, Thielmeier K, Ghaly A, Barber D, Boice T, Dine A. Improved pain control after cardiac surgery: results of a randomized, double-blind, clinical trial. J Thorac Cardiovasc Surg. 2003;126:1271–1278. doi:10.1016/S0022-5223(03)00585-3
    1. Kaabachi O, Ouezini R, Koubaa W, et al. Tramadol as an adjuvant to lidocaine for axillary brachial plexus block. Anesth Analg. 2009;108:367–370. doi:10.1213/ane.0b013e31818e0c6b
    1. Kapral S, Gollmann G, Waltl B, et al. Tramadol added to mepivacaine prolongs the duration of an axillary brachial plexus blockade. Anesth Analg. 1999;88:853–856. doi:10.1213/00000539-199904000-00032
    1. Tsai YC, Chang PJ, Jou IM. Direct tramadol application on sciatic nerve inhibits spinal somatosensory evoked potentials in rats. Anesth Analg. 2001;92:1547–1551. doi:10.1097/00000539-200106000-00040
    1. Haeseler G, Foadi N, Ahrens J, et al. Tramadol, fentanyl and sufentanil but not morphine block voltage-operated sodium channels. Pain. 2006;126:234–244. doi:10.1016/j.pain.2006.07.003
    1. Gentili M-E, Estèbe J-P. Utilisation clinique du Tramadol [Clinical use of Tramadol] In: Communications MAPAR. Paris: MAPAR Editions; 1998:233–241. French.
    1. Altunkaya H, Ozer Y, Kargi E, et al. Comparison of local anaesthetic effects of tramadol with prilocaine for minor surgical procedures. Br J Anaesth. 2003;90:320–322. doi:10.1093/bja/aeg079
    1. Jabalameli M, Hazegh P, Talakoub R. Preemptive subcutaneous tramadol for post-operative pain in lower abdomen surgeries: a randomized double blinded placebo-control study. Adv Biomed Res. 2013;2:68. doi:10.4103/2277-9175.115816
    1. Demiraran Y, Ilce Z, Kocaman B, et al. Does tramadol wound infiltration offer an advantage over bupivacaine for postoperative analgesia in children following herniotomy? Paediatr Anaesth. 2006;16:1047–1050. doi:10.1111/j.1460-9592.2006.01910.x
    1. Demiraran Y, Albayrak M, Yorulmaz IS, et al. Tramadol and levobupivacaine wound infiltration at cesarean delivery for postoperative analgesia. J Anesth. 2013;27:175–179. doi:10.1007/s00540-012-1510-7
    1. Cruccu G, Sommer C, Anand P, et al. EFNS guidelines on neuropathic pain assessment: revised 2009. Eur J Neurol. 2010;17:1010–1018. doi:10.1111/j.1468-1331.2010.02969.x
    1. Mazzeffi M, Khelemsky Y. Poststernotomy pain: a clinical review. J Cardiothorac Vasc Anesth. 2011;25:1163–1178. doi:10.1053/j.jvca.2011.08.001
    1. Eljezi V, Dualé C, Azarnoush K, et al. The analgesic effects of a bilateral sternal infusion of ropivacaine after cardiac surgery. Reg Anesth Pain Med. 2012;37:166–174. doi:10.1097/AAP.0b013e318240957f
    1. Wang JT, Chung CC, Whitehead RA, et al. Effects of local tramadol administration on peripheral glutamate-induced nociceptive behaviour in mice. Can J Anesth. 2010;57:659–663. doi:10.1007/s12630-010-9301-9
    1. Al-Haideri YAA. Comparison of local anesthetic efficacy of tramadol hydrochloride (with adrenaline) versus plain tramadol hydrochloride in the extraction of upper molar teeth. J Oral Maxillofac Surg. 2013;71:2035–2038. doi:10.1016/j.joms.2013.08.009
    1. Koputan MH, Apan A, Oz G, et al. The effects of tramadol and levobupivacaine infiltration on postoperative analgesia in functional endoscopic sinus surgery and septorhinoplasty. Balk Med J. 2012;29:391–394. doi:10.5152/balkanmedj.2012.027
    1. Alemanno F, Ghisi D, Fanelli A, et al. Tramadol and 0.5% levobupivacaine for single-shot interscalene block: effects on postoperative analgesia in patients undergoing shoulder arthroplasty. Minerva Anestesiol. 2012;78:291–296.
    1. Yildiz TS, Ozdamar D, Bagus F, et al. Levobupivacaine-tramadol combination for caudal block in children: a randomized, double-blinded, prospective study. Paediatr Anaesth. 2010;20:524–529. doi:10.1111/j.1460-9592.2010.03296.x
    1. Cekic B, Geze S, Erturk E, Akdogan A, Eroglu A. A comparison of levobupivacaine and levobupivacaine-tramadol combination in bilateral infraorbital nerve block for postoperative analgesia after nasal surgery. Ann Plast Surg. 2013;70:131–134. doi:10.1097/SAP.0b013e318236baa8
    1. Ekmekçi P, Çağlar GS, Yılmaz H, et al. Effects of different doses of tramadol added to levobupivacaine in continuous wound infusion for postoperative pain treatment following cesarean section. J Matern-Fetal Neonatal Med. 2017;30:343–346. doi:10.3109/14767058.2016.1172567
    1. Ozyilmaz K, Ayoglu H, Okyay RD, et al. Postoperative analgesic effects of wound infiltration with tramadol and levobupivacaine in lumbar disk surgeries. J Neurosurg Anesthesiol. 2012;24:331–335. doi:10.1097/ANA.0b013e3182611a1d
    1. Robaux S, Blunt C, Viel E, et al. Tramadol added to 1.5% mepivacaine for axillary brachial plexus block improves postoperative analgesia dose-dependently. Anesth Analg. 2004;98:1172–1177. doi:10.1213/01.ane.0000103265.48380.89

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