An Evaluation of Analgesic Efficacy and Clinical Acceptability of Intravenous Tramadol: DISCUSSION

In: Anesthesia

28 Oct 2009

Sedation combined with local anesthesia is a safe alternative to general anesthesia because spontaneous reflexes and patient cooperation are retained while fear and apprehension (common reasons to delay dental care) are reduced. Local anesthetic techniques are often complemented by the balanced use of low doses of analgesic and sedative/hypnotic drugs to provide analgesia, anxiolysis, and sedation. Recovery is then more rapid and patients are more clear-headed, making this technique invaluable for outpatient medical and surgical procedures. Mepivacaine 2% (with 1/20,000 levonor-defrin) has been successfully used intraosseously to supplement inferior alveolar dental blocks for molar extraction. Newer dental local anaesthetics (such as arti-caine) and especially more longer-acting local anaesthetics (such as levobupivicaine) have the capacity for better postoperative pain control and for longer periods.

Postoperatively, intravenous and intramuscular tramadol has been used with good efficacy. Orally, in postsurgical pain, tramadol 50, 100, and 150 mg had numbers needed to treat for >50% maximal total pain relief of 7.1 (95% confidence intervals, 4.6-18), 4.8 (3.4-8.2), and 2.4 (2.0-3.1), comparable with aspirin 650 mg plus codeine 60 mg (numbers needed to treat 3.6 [2.5-6.31) and paracetamol 650 mg plus propoxyphene 100 mg (numbers needed to treat 4.0 [3.0-5.7J).
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Tramadol has recently been evaluated as a postoperative analgesic in dento-alveolar pain. It shows a dose-response for analgesia in patients undergoing dental surgery. In this study of dento-alveolar pain, the average pain value of the tramadol group was significantly lower than that of the placebo group. The 2 groups differed significantly at each individual time period (P = .0001). At each time period, the level of pain was lower in the tramadol group (Figure 1). In both groups, the degree of pain experienced peaked between 3 and 4 hours.

The prevention of postoperative pain is based on 2 phenomena: (a) that the effective blockade of noxious stimuli generated during surgery and during the initial postoperative period (inflammatory phases) reduces subsequent postoperative pain (phenomenon of pre-emptive analgesia in the broad sense), and (b) that an antinociceptive treatment started before surgery is more effective in the reduction of postoperative pain than the treatment given on recovery from general anesthesia (phenomenon of pre-emptive analgesia in the narrow sense). It was found that both phenomena can be induced by neural blockade with local anesthetics and by systemic or epidural opioids. Clinically impressive results are observed when the blockade of noxious stimuli is complete and extended into the initial postoperative period (a combination of both phenomena). Opioid premedication has been found to reduce the sustained hy-perexcitability of the central nervous system to intraoperative stimuli, prolonging the pain-free period immediately postoperatively and decreasing the frequency of analgesic demands. cheap viagra professional

For third molar extractions, both patient-controlled and operator-controlled sedation with propofol have been used successfully with minimal changes in respiratory function and with the return of psychomotor functions to normal by 60 minutes.

A weakness of the pilot study that will be corrected in future studies was that no direct assessment of the difficulty of surgical removal was performed. Differently impacted third molars may cause varying degrees of pain.

Although predominantly mild in nature, data from short-term multiple-dose studies show tramadol most commonly to cause nausea, tiredness, vomiting, sweating, drowsiness, and postural hypotension. These were significantly higher after dental surgery due possibly to the acute dosing in awake patients and rapid mobilization. Despite tramadol being an opioid, there was a low incidence of nausea and vomiting in the early postoperative period in the tramadol group in this study. This is probably due to the antiemetic effect of the propofol as there is strong evidence for its antiemetic efficacy in the postanesthesia care unit.

Overall, in this study, postoperative pain was much better controlled in the group receiving tramadol 1.5 mgAg intravenously despite there being no significant difference in the dose of propofol administered in both groups. Intravenous tramadol, when given with propofol, did not affect the cardiovascular, respiratory, and sedative effects of propofol. With tramadol, despite being an opioid, no nausea and vomiting were reported in the early postoperative period, indicating the value of using tramadol with propofol. cheap levitra professional

Dental health-care professionals have used a variety of drugs to control pain after oral surgery. Strong opioids are still being used, but fears concerning the risk of opioid dependence—adverse effects such as respiratory depression, excess sedation, and postoperative nausea and vomiting—still result in some reluctance to prescribe them. Many patients cannot tolerate nonsteroidal anti-inflammatory drugs due to a history of allergy, peptic ulceration, or bleeding disorders. Tramadol would therefore appear to lend itself particularly to use in the day-case surgical environment. When combined with propofol for third molar surgery, tramadol provided safe monitored-anesthetic care with good postoperative analgesia and minimal postoperative nausea and vomiting. In this pilot study, its potential use with propofol in the day-case dento-alveolar surgery has been demonstrated.

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Blog invites submissions of review articles, reports on clinical techniques, case reports, conference summaries, and articles of opinion pertinent to the control of pain and anxiety in dentistry.