comparison of patient controlled.pdf

8/13/2019 Comparison of patient controlled.pdf

1/6


2/6

Pang et al.: PCA WITH TRAMADOL 1031ARIOUS attempts have been made toimprove pain relief after major surgery. Themost commonly used drug for intravenousi v ) patient controlled analgesia (PCA) is

morphine, an opioid that has several adverse effects.Tramadol is a centrally acting analgesic with both

opioid and non-opioid modes of action. 1,2 It is effec-tive for the relief of acute and chronic pain. 3,4 Theadverse effect profile of tramadol, especially respirato-ry depression, is that of a weak opioid a t effective anal-gesic doses, s With low abuse and addic tion potential,6tramadol is not a controlled substance in many coun-tries. However, only one article was found in theEnglish literature in which the analgesic and sideeffect profiles of PCA tramadol were compared withthose of morphine. 7 They concluded that effectivepostopera tive analgesia can be achieved by either PCAmorphine or tramadol and the side effects, especiallynausea and vomiting were also comparable. 7 However,in that study only responders to loading doses (up to200 mg tramadol or 20 mg morphine) in 30 min wererecruited for further comparison and all the patientsreceived 2.5 mg droperidol and 10 mg metoclo-pramide during surgery. 7 We undertook the presentstudy without this exclusion or the use of intraopera-tive anti-emetics to re-evaluate the comparative clini-cal efficacy of tramadol PCA with that of morphinewith a less restricted protocol.MethodsFollowing approval of the hospital ResearchCommittee and informed consent, 80 adult patientswere enrolled in this prospective, randomized, doubleblind study. Patients who underwent either total hipor total knee arthroplasty were studied. All patientswere instructed in the use of the PCA device duringthe preoperative interview and again in the recoveryroom. Exclusion criteria included: (1) allergy to thestudy drugs, (2) inability to use PCA, (3) difficulty incommunication (4) history of hepatic, cardiopul-monary or renal disease (5) history of substanceabuse. Anesthesia was ind uced with 4 mg.kg 1thiopental and 1 mg.kg 1 succinylcholine i v and main-tained with nitrous oxide 60%/isoflurane 1-3%. Noopioids, local anesthetics, anti-emerics or non-steroidal anti-inflammatory drugs were administered24 hr before or during surgery. After surgery and assoon as the patient complained of pain in the recoveryroom, a baseline pain assessment was done with aVisual Analog Pain Score (VAS) with 0 being no painand 10 being the most excruciating pain. The patientwas then randomly assigned to receive incrementaldoses of either tramadol (Tramtor| Patron Chemical

& Pharmaceutical Co., Taiwan) or morphine(Ministry of Health, Taiwan) over 30 min until VAS4 was achieved as assessed by an anesthesiologistblinded to the identity of the drug. Similar syringes ofeither 30 mg.ml ~ tramadol or I mg-m1-1 morphine inequal volumes prepared by a pharmacist were used forthe loading dose. Then, the patient was connected toa PCA pump (Lifecare Infusor-4200 AbbottLaboratories, North Chicago, USA.) with the sameconcentration of either drug (30 mg.m1-1 tramadol or1 mg.m1-1 morphine). The PCA pump was set todeliver bolus doses of 1 ml with a lockout interval of10 min. No background infusion or four-hour maxi-mal limit was set. In either group, rescue analgesiawith titration of 25-50 mg meperidine i v was allowedif the patient could not obtain adequate pain relieffrom the above PCA regimen.

An anesthesia resident blinded to the iden tity of thedrug carried out the pain assessment every six hoursfor 48 hr. At interview, the patient was instructed toinform the investigator of the overall pain relief at restfor the past six hours using the visual analogue scale(VAS). Patients were also asked to express their saris-faction of their pain control in the recovery room andevery 24 hr with a Global Satisfaction Score which wasdivided into "very good," "go od ... fair," and "poo r".

Data on dosing patterns, demand, delivery andtotal accumulated dose (total loading dose was notincluded) were retrieved from the PCA computermemory. Vital signs (blood pressure, hea rt rate, respi-ratory rate), side effects and rescue medications wererecorded throu ghou t the 48-hr observation period.

All adverse events were recorded. Respiratorydepression was defined as a respiratory rate


3/6

1032R e s u l t sT h e r e w e r e n o d i f f e r e n c e s b e t w e e n t h e t w o g r o u p s i nt e r m s o f a g e, s e x, w e i g h t, h e i g h t , a n d t y p e o f s u r g e r y(Table I ) .

T h e o n s e t o f b o t h t r a m a d o l o r m o r p h i n e w a s a b o u tf ive minu tes , and VAS ~ 4 in the recov ery roo m wasa c h i e v e d i n 3 0 m i n i n b o t h g r o u p s . T h e p a i n s c o r e s i nt h e r e c o v e r y r o o m a n d a t 6, 12 18 24 30 36 4 2and 48 hr in t e rv iews were s imi la r (F igure ) . T he to t a ll o a d i n g d o s e s in t h e r e c o v e r y r o o m w e r e 2 8 4 . 9 1 5 6 . 6 m g f o r t r a m a d o l a n d 1 3 . 1 4 . 4 m g f o r m o r -p h i n e . A f t e r t h e p a t i e n t s w e r e b r o u g h t t o t h e w a r d ,t h e s u b s e q u e n t d o s e s w e r e 5 6 3 . 9 2 6 2 . 8 m g i n 2 4 h ra n d 8 6 8 . 3 4 1 2 . 2 m g i n 4 8 h r f o r t r a m a d o l , vs 2 8 . 0 1 4 . 2 m g i n 2 4 h r a n d 4 5 . 7 1 8 . 4 m g i n 4 8 h r f o rm o r p h i n e . O n e p a t i en t in th e t r a m a d o l g r o u pr e q u i r e d r e s c u e a n a l g e s i c d u r i n g t h e 4 8 h r . T h e m e a nf r e q u e n c y o f P C A d e l i v e ry w a s le ss in t h e t r a m a d o lg r o u p t h a n i n t h e m o r p h i n e g r o u p a t 2 4 h r ( 1 8 . 8 8 .7 vs 2 8 . 0 1 4 . 2 ) ( P < . 0 5 ) a n d a t 4 8 h r p e r i o d ( 2 8 . 9 13 .7 vs 4 2 . 7 1 8 . 4 ) ( P < . 0 5 ). T h e m e a n f r e q u e n -c y o f P C A d e m a n d s w a s 3 4 . 0 1 3 . 7 f o r t r a m a d o l , vs3 2 . 1 8 . 7 f o r m o r p h i n e i n 2 4 h r , a n d 4 3 1 4 . 7 f o rt r a m a d o l , vs 4 8 8 . 5 f o r m o r p h i n e i n 4 8 h r .

The ove ra l l s a t i s fac t ion s core in the recovery room,a t 2 4 a n d 4 8 h r a r e s u m m a r i z e d i n T a b l e II . V e r yg o o d s c or e s w e r e m o r e f re q u e n t i n t h e m o r p h i n eg r o u p t h a n i n t ra m a d o l g r o u p i n t h e r e c o v er y r o o m

TABLE I Demographic data and types of operation performedtramadol morphinen---40 n=40

Age 69 13 71 19Sex (male:female) 18:22 15:25Weight (kg) 56 4 55 a/6Height (cm) 164 7 163 5Total hip replacement 14 16Total knee replacement 26 24Data are mean standard deviation.

TABLE II Overall satisfaction rateSatisfaction rate

Time Dru g verygood good fa ir poor totalrecovery room tram ado l 23 43 30 5 40after loading dos e mor phin e 43* 40 15 0 40postoperative tram ado l 20 40 30 10 40day 1 morphine 40* 48 13 0 40postoperative tram ado l 83 13 5 0 40day 2 morphine 80 15 5 0 40* very good satisfaction rate is statistically more w ith morphinethan tramadol in the recovery room and at 24 hr interviews(Chi-squared test).

CANADIAN JOURNAL OF ANESTHESIA

FIG UR E The overall pain relief by VAS at each assessment. RR= recovery room (after the loading dose).

and a t 24 h r in te rv iew. O the rw ise th e re was no d i f fe r -e n c e b e t w e e n t h e g r o u p s .

N a u s e a a n d v o m i t i n g w a s m o r e f r e q u e n t w i t h t r a -m a d o l t h a n w i t h m o r p h i n e i n t h e r e c o v e r y r o o m a f t e rthe load in g dose an d in the f i r st pos to pe ra t i ve day ,m o s t o f w h ic h , h o w e v e r , w e r e t r a n s i e n t i n d u r a t i o n(Table I I I ) . F ive , 12 .5%, pa t i en t s ( fou r in the reco veryr o o m , o n e o n w a r d ) w e r e t r e a t e d w i t h m e t o c l o -p r a m i d e . M o r p h i n e s h o w e d m o r e s e d a t i o n t h a n t r a -m a d o l i n b o t h t h e r e c o v e r y r o o m a n d o n t h e f ir stp o s t o p e r a t i v e d ay . N o n e o f t h e p a t i e n t s h a d a s ed a t i o ns c o r e o f 3 ( u n r o u s a b l e s l ee p ) . N o n e o f t h e a d v e r s ee f fec ts war ra n ted t e rm ina t in g PC A use . V i ta l s ignsw e r e s t a b le in b o t h g r o u p s . N o r e s p i r a t o r y d e p re s s i o no c c u r r e d i n e i t h e r g r o u p . D i z z i n e s s a n d d r y m o u t ho c c u r r e d m o r e i n t h e t r a m a d o l g r o u p b u t t h e d i f f e r -ence was s ta t is t ical ly ins ignif icant .iscussion

T h i s s t u d y d e m o n s t r a t e d t h a t , w i t h t h e s a m e P C A s e tu p a s m o r p h i n e , t r a m a d o l a t h i g h d o s e p r o v i d e d e f f e c-t ive ana lges ia s imi l a r t o tha t o f morp hin e bu t w i th ah i g h e r i n c i d en c e o f n a u s ea a n d v o m i t i n g . T r a m a d o lh a s a w e a k / a - a g o n i s t a c t iv i ty a n d a n o n - o p i o i d m o d eo f a c ti o n p r e s u m a b l y b y b l o c k i n g t h e r e - u p t a k e o fs e r o t o n i n a n d n o r e p i n e p h r i n e i n t h e c e n t r a l n e r v o u ssys t em. 3 Be ing a m uch weak er ~a -agoni st t han mo r-p h i n e t r a m a d o l d o e s n o t p o s s e s s t h e e u p h o r i c a n daddic t ive l i ab i l it y tha t i s a s soc ia t ed wi th mo rphi ne , s Ina s t u d y o n t h e e f fi c ac y a n d s a f e t y o f p o s t o p e r a t i v ea n a l g e s i a H o u m e s e t a l . 9 found l e s s re sp i ra tory depres -s i o n a s s o c i a t e d w i t h t r a m a d o l t h a n w i t h m o r p h i n e .


4/6

P ang et aL: PCA W ITH TRAMADOLTABLE I II Side effectsobserved during loading dose and PCA

1033

Drug time nau sea vomiting di zz in es s sleepines s som nol enc e pruritus dry mouthTramadol RR 48 28 35 23 5 0 18% 24hr 28* 15 10 15 8 0 10n=40 48hr 13 5 3 0 0 0 5Morphine RR 28 5 23 45* 10 3 8% 24hr 12 3 3 35* 12 3 3n=40 48hr 3 0 0 5 5 0 0PCA = patient-controlledanalgesia. RR = recovery oom.N = total number o f patients in each groupSedation scale 1 = drowsiness Sedation scale 2 = som nolenceNausea, *P < 0.05 compared with morphine in recovery oom and 1st postoperativeday (C hi-squared test).Sleepiness, *P < 0.05 comp ared with tram adol in reco very oom and 1st postoperative day (Chi-squared test).

T a r r a d e l l et a l3 ~ i n a s i ng l e d o s e s t u d y c o m p a r i n g 1 0 0m g t r a m a d o l w i t h 1 0 0 m g m e p e r i d i n e f o r p o st o p e r a -t iv e a n al g es i a r e p o r t e d t h a t m e p e r i d i n e i n d u c e d s e d a-t i o n a n d r e s p i r a t o r y d e p r e s s i o n w h i le t r a m a d o l d i dn o t . T h i s s a f e t y f e a t u r e m a k e s t r a m a d o l a v e r y s u it a b lea n a lg e s ic t o b e u s e d o n t h e w a r d w h e r e i n t e n s i v e n u rs -i n g m o n i t o r i n g i s n o t t h e r o u t i n e . I n s p i t e o f t h e f a c tt h a t t r a m a d o l h a s b e e n a v a i l a b l e f o r c l i n i c a l u s e f o rn e a r l y t w o d e c a d e s i t s u s e is m a r r e d s o m e w h a t b y t h ec o n t r o v e r s i e s s u r r o u n d i n g i t s a n a l g e s i c e f f i c a c y , n-14O u r s t u d y a i m e d t o a n s w e r t h e s e t w o q u e s t i o n s : ( 1 )C a n P C A t r a m a d o l p r o v i d e s a ti s f a c t o r y a n a l g e si a f o l -l o w i n g m a j o r o r t h o p e d i c s u r g e ry ? ( 2 ) W h a t i s t h e t r u ei n c i d e n c e o f a d v e r s e e f f e c t s , es p e ci a ll y n a u s e a / v o m i t -i n g , w h e n l a rg e d o s e s o f t r a m a d o l a r e g i v en w i t h o u ta n t i - e m e t i c p r o p h y l a x i s ?

T o m e e t t h e s e o b j e c t i v e s , w e s e l e c t e d p a t i e n t su n d e r g o i n g m a j o r o r t h o p e d i c s u r g e r y , n a m e l y t o t a lh i p a n d t o t a l k n e e a r t h r o p la s t ie s f o r h o m o g e n e i t y ,b o t h o f w h i c h a r e r e c o g n i z e d t o c a u s e c o n s i d e r a b lep o s t o p e r a t i v e p a i n . W e c h o o s e P C A a s a m e a n s o fd r u g a d m i n i s t r a t io n b y w h i c h t h e p a t i e n t w o u l d d e t e r -m i n e h i s / h e r o w n m e d i c a t i o n n e e d w h i l e p a ti e n t s af e-t y a n d a v o i d a n c e o f b ia s f r o m t h e h e a l t h c a rep e r s o n n e l w e r e a l so a c h i e v e d . W e a l l o w e d t h e p a t i e n t su n r e s t r ic t e d l o a d i n g d o s e s o f e i th e r t r a m a d o l o r m o r -p h i n e i n t h e r e c o v e r y r o o m u n d e r i n t e n s iv e s u rv e i l-l a n c e u n t i l t h e p a t i e n t o b t a i n e d a d e q u a t e p a i n r e l i e fw i t h a V A S s c o r e o f _< 4 . N o p r e m e d i c a t i o n , o p i o i d o ra n t i - e m e t i cs w e r e a l l o w e d d u r i n g s u r g e r y i n o r d e r t or e m o v e t h e a b o v e i m p o r t a n t i n f l u e n c i n g f a c t o r s o nt h e i n c i d e n c e o f n a u s e a / v o m i t i n g a s s o ci a te d w i t h t ra -m a d o l i n t h e p o s t o p e r a t i v e p e r i o d . A n a l g e s i c w a sg i v e n i m m e d i a t e l y , a s s o o n a s t h e p a t i e n t c o m p l a i n e do f p a i n i n t h e r e c o v e r y r o o m . S i n c e th e p a t i e n t is t h eu l t i m a t e j u d g e o f h o w g o o d a d r u g i s, g l o b a l sa ti sf a c-t i o n a s s e s s m e n t s w e r e m a d e f r o m t h e p a t i e n t a t e a c h

d e s i g n a te d o b s e r v a t i o n p o in t . L e h m a n n et al i n a no p e n s t u d y u s i n g P C A t r a m a d o l i n 4 0 p a t i e n t s w i t hp o s t o p e r a t i v e p a i n a f t e r g y n e c o l o g i c a n d o r t h o p e d i cs u r g e r y , r e p o r t e d s a t i s f a c t o r y a n a l g e si a i n a ll b u t t w op a t i e n t s w i t h l o a d i n g d o s e o f 9 7 . 5 4 2 . 3 m g ( m e a n +S D ) a n d a c c u m u l a t e d d o se o f 2 5 7 + 1 0 2 . 8 m g i n 2 4h r . I s I n t h e i r m u l t i - c e n t r e s t u d y , i n w h i c h d a t a f r o m5 2 3 p a t i e n t s w e r e p o o l e d f r o m 2 6 h o s p i t a l s , V i c k e r sa n d P a r a v i ci n i r e p o r t e d t h a t w i t h a lo a d i n g d o s e o f u ptO 2 5 0 m g t r a m a d o l iv i n 9 0 m i n , 7 3 % o f t h e p a t i e n t sh a d n o o r s l i g h t p a i n , a n d t h e r e m a i n i n g 2 7 % h a dt o b e e x c l u d e d f r o m t h e s t ud y . 16 S t a m e r a n d c o w o r k -e r s i n a d o u b l e - b l i n d , r a n d o m i z e d , a n d p l a c e b o - c o n -t r o l l e d s t u d y u s i n g s e l f - a d m i n i s t e r e d P C A w i t h al o ad i n g do s e o f t r a m a d o l u p t o 2 0 0 m g iv o v e r 3 0 r a i nf o u n d t h a t o n l y 67 % h a d a V AS ~ 2 i n t h e t r a m a d o lg r o u p . 7 I n a p r e l i m i n a r y p i l o t s t u d y w e f o u n d t h a t ,w i t h a l o c k o u t in t e r v a l o f 1 0 m i n . a n d a n e q u i v a l e n td o s e o f 1 1 :1 m g ( t ra m a d o l : m o r p h i n e ) a s s u g g e s t e db y V i c k e r s4 , t r a m a d o l w a s i n e f f e c t i v e i n a c h i e v i n g s a t -i s f a c to r y an a l ge s ia i n m a n y p a t i e n t s . H e n c e , w e a d o p t -e d t h e r a t io o f 3 0 :1 m g f o r tr a m a d o l : m o r p h i n e i n t h ep r e s e n t s t u d y a n d , b y a l lo w i n g a n u n r e s t r i c t e d l o a d i n gd o s e o f t r a m a d o l , w e w e r e a b l e t o a c h i e v e s a t is f a c to r ya n a l g e s i a ( V A S < 4 ) i n a l l t h e p a t i e n t s i n t h e t r a m a d o lg r o u p . I n o u r s t u d y , i n o r d e r t o a c h i e v e a n e f f e c t i v ei n i ti a l a n al g e s ia t h e r a t i o o f t h e l o a d i n g d o s e f o r t r a-m a d o l : m o r p h i n e t u r n e d o u t t o b e 2 2 : 1 w h i c h w a sm u c h h i g h e r t h a n t h o s e r e p o r t e d b y o t h e r s . 7,16 T h i sm i g h t e x p l ai n th e h i g h i n c i d e n c e o f n o n - r e s p o n d e r sr e p o r t e d b y t h e o t h e r i n v e s t i g a t o r s 6 ,1 6 a n d a h i g h i n c i -d e n c e o f n a u s e a / v o m i t i n g o b s e r v e d in t h e t ra m a d o lg r o u p i n o u r s t u d y .

W e d i d n o t s e t a P C A l i m it o n t h e d o s e o f t ra m a d o lo r m o r p h i n e b u t r e l ie d o n t h e l o c k o u t i n t er v a l as w e lla s t h e i n h e r e n t s a f e ty o f t h e P C A a s a s a f e g u a r d ( e . g . t h ep a t i e n t w a s i n s t r u c t e d n o t t o p r e s s t h e b u t t o n i f t h e r e


5/6

1034 CANADIAN JOUR NAL OF ANESTHESIAwas no pain). As expected, our pat ients used a relat ive-l y h i g h e r d o s e o f t ra m a d o l w i t h a t o ta l o f 8 6 8 .3 m g vsmorph ine 45 .7 mg over the 48 h r . Th is g ives a po tencyra t io fo r t ramado l : morph ine a t 19 :1 wh ich i s h ighert h a n t h e r a t io o f 1 1 :1 r e p o r t e d b y V i c k e rs a n dParavicini 17 and 11.8:1 rep orte d by Stam er et a l . 7 A tth is h igher dose , how ever , a ll o f the pa t i en t s com ple tedthe s tudy . More pa t i en t s in the morph ine g roup werefoun d to have s leepiness than in the t ramado l g roup (P< 0 .05 ) , b u t no resp i ra to ry depress ion was found in anyof the pa t i en t s in e i ther g roup . M ore pa t i en t s in the t ra -m a d o l g ro u p h a d n a u s e a / v o m i t i n g ( P < 0 .0 5 ) .

Us in g such a h igh load ing dose in 30 ra in resu l ted inan inc idence o fna nse a (48 ) and vom i t ing (28 ) in ther e c o v e ry ro o m p h a s e w h i c h w a s h ig h e r t h a n t h a tr e p o r t e d b y S ta m e r et a l . 7 and Vickers e t a l l 6 H o w e v e r ,t h e i n c id e n c e o f n a u s e a / v o m i t i n g i n t h e a b o v e t w os tud ies was mod i f ied by the co ncurren t u se o f op io idso r an t i -emet ics : anes thes ia induct ion inc luded 2 .5 mgd ro p e r i d o l iv a n d 1 0 m g m e t o c l o p ra m i d e iv was g ivena t 30 min befo re t e rmina t ion o f the su rgery in the s tud yb y S t a m e r et a l . 7 Th e o b s e rv e d h i g h i n c i d en c e o f na u -sea /v om i t ing in ou r s tudy migh t be dose and ra te relat -ed wi th the h ighes t inc idence occurr ing dur ing thel o a d i ng p h a s e w h e n a la rge a m o u n t o f tr a m a d o l w a sg iven in a shor t per iod o f time. I t s eem s tha t a suddeni n cre a se o f b l o o d t r a m a d o l c o n c e n t r a ti o n w o u l d c a u s en a u s e a / v o m i t i n g t h a t w a s o b s e rv e d t o b e t r a n s i e n t i nna tu re in m any o f the pa t i en ts . T he inc idence o f nauseaand vom i t ing dec l ined to 12 .5 and 5 respect ively a t48 h r. T o m i t iga te th is adverse e f fec t, a num ber o f p re-v e n t i v e m e a s u re s c o u l d b e a d o p t e d . D e W i t t e et a l .repo r ted ad min is te r ing h igh doses o f t ramado l (3m g .k g 1 iv ) a t t h e e n d o f s u rg e ry w i t h o u t c a u si n g a n yadverse e f fec t du r ing the recovery per iod and shiver ing ,n a u s e a / v o m i t i n g w e re e f f ec t iv e ly p r e v e n t e d Y N g et a l .repor ted tha t a t ramado l and d roper ido l mix tu re wassuper io r to t ramado l a lone wi th l es s nausea /vomi t inga n d w i t h o u t i n c r e a s e d s ed a t i o n . T P r o p h y l a c t i c a d m i n i s -t r a t i o n o f 1 0 m g m e t o c l o p ra m i d e i v b e fo re t r a m a d o lw a s a l s o r e p o r t e d t o b e e f f e c t iv e i n r e d u c i n gn a u s e a / v o m i t in g b y L e h m a n n J 9

In t o d a y ' s c o s t c o n s c i o u s he a l t h c a r e e n v i ro n m e n t ,c o s t - b e n e f i t a s s e s s m e n t o f a d r u g n e e d s t o b eaddressed to a l low c l in ic ians to dec ide on the bes tana lgesia a t the low es t cos t . In Ta iwan , a t equa l po ten td o s e , t r a m a d o l c o s t s s u b s t a n t i a l l y m o re t h a n m o r -p h i n e . I n a d d i t io n , t h e u s e o f a nt i -e m e t i c s w o u l den ta i l added cos t to the t ramado l therapy . Th is h ighc o s t w i t h t h e u s e o f tr a m a d o l w o u l d n e e d t o b e b a l -anced aga ins t the po ten t ia l be nef i t o f less resp i ra to ryd e p re s s i o n t h a n m o rp h i n e , w h i c h o c c u r s q u i t e i n f r e -q u e n t l y , w h e n d e l i v e re d b y P C A . Th e re fo re , t h e c l in i-

ca] advan tage o f t ramado l in th i s se t t ing i s mo re th eo -ret ical than pract ical .

I n c o n c l u s io n , t h e p r e s e n t s t u d y c o n f i rm e d t h a t P C Aadmin is t ra tion o f t ra ma do l cou ld p rov ide e f fec tive anal -gesia fo l lowing majo r o r thope d ic su rgery p rov ided su f-f ic ien tly h igh doses were g ivcn fo r load ing a nd dema nd .How ever , the inc idcnce o f nausea and vo mi t ing assoc i-a ted wi th the increased dose o f t ramado l i s very h ighand resul ts in decre ase o f pat ie nt satisfact ion.cknowledgments

The au thors wou ld l ike to express thanks to RainyCh ih -C heng Lin msc fo r s t a ti s ti ca l consu l ta t ion and a llof the nurses for their ass is tance.References

1 Ra f fa R B, Nayak RK , L iao S , Minn FL. T h e m e c h a -nism s) of action and pharmacokinetics o f tramodolhydrochloride. Rev Con tem p Pharmacother 1995; 6:485-97 .

2 Co l l a r t L , Lu t h y 2 , Day e r P. Partial inhibition of tra-madol antinociceptive effect by naloxone in m an. Br JClin Pharmacol 1992; 35: 73P.

3 K a t z W A . Pharmacology and clinical experience withtramadol in osteoarthritis. Drugs 1996; 52(Supp13):39-47.

4 Vickers M D. The efficacy of tramadol hydrochloride inthe treatment o f postoperative pain. Rev Con tem pPharmacother 1995; 6: 499-506.

5 VickersM D, O Flaherty 19, Szekely SM, R ead M,YoshizumiJ. T ramadol : pa i n r e l i e f by an op i o i d w i t ho u tdepres s ion o f re sp i ra t i on . Anaes thes i a 1992 ; 47 : 291 -6 .

6 Preston KL , Jasinski D R, Testa M. Abuse po t en t i a l andpharmacological comparison of tramadol and mor-phine. Dru g Alcohol Depend 1991; 27: 7-17.

7 S t am e r UM , Ma i e r C , Gr ond t S , Ve h - Sc hmi d t B ,K l a se h ik E , L e h m a n n K A . Tramadol in the manage-men t of post-operative pain: a doub le blind, placebo-and act ive drug-cont rol led s tudy. Eur J Anesthesiol1997 ; 14 : 646-54 .

8 Stoelting RK . Opi o i d agon i s ts and an t agon i s ts . In:S t oe t ti ng RK. P h a rmaco l ogy and P hys i o l ogy i nAn esthe tic Practice. Philadelphia: JB Lip pin co ttC o m p a n y , 1 9 8 7 : 6 9 - 1 0 1 .

9 Houmes R-J M, VoetsMA , Verkaaik ,4 , Erdm ann W,L a c h m a n n B . Efficacy and safety of tramadol versusmorphine for moderate and severe postoperative painwith special regard to respiratory depression. AnesthAnalg 1992; 74: 510-4.

10 Tar r ade l l R , Po l O , Farr ~ 3 f , Bar r e r a E , Pu i g M M .Respiratory and analgesic effects of meperidine and tra-madol in patients undergoing orthopedic surgery.Meth Find Exp Clin Pharmacol 1996, 18: 211-8.


6/6

P a n g et al .: PCA W ITH TRAMADOL 1 0 3 511 Stubhaug A Grimstad J Breivik H. Lack of analgesic

e f f ec t o f 5 0 an d 1 0 0 m g o ra l t r am ad o l a f t ero r t h o p aed i c su rgery : a r an d o m ized , d o u b l e -b l in d ,p lacebo and s tandard act ive drug compar ison . Pain1 9 9 5 ; 6 2 : 1 1 1 -8 .

12 A m in E Tawfik O Elborolossy K. Tram ad o l h y d ro ch lo -r ide in postoperat ive analgesia . A do uble b l ind com par-ison against bu torphanol tar t rate and nalbuphinehydrochlor ide. Pain 1990; 186( 5) : 55-8 .

1.3 Kupers R Callebaut V D ebois V et al . Efficacy andsafety o f o ra l t r am ad o l an d p en t azo c in e fo r p o s to p era -tive pain following prolapsed intervertebral disc repair.Acta Anesthesio l Belg 1995; 46 : 31-7 .

14 Chrubasik J B uzina M Schulte-M6nting J Atan asso ff PAlon E. In t r av en o u s t r am ad o l fo r p o s t -o p era ti v e p a in -co m p ar i so n o f i n t e rm i t t en t d o se r eg im en s wi th an dwithout main tenance in fusion . Eur J Anesthesio l 1992;9 : 2 3 -8 .

15 Lehmann K A Kratzenberg U Schroeder-Bark BHorrichs-Haermeyer G. Postoperat ive pat ien t -cont ro lledanalgesia with tramadol: analgesic efficacy and minimumeffective concentration. Clin J Pain 1990; 6: 212-20.

16 VickersMD Paravicini D. Co m p ar i so n o f t r am ad o l wi thmorp hine for post -operat ive pain fol lowing abdo minalsurgery. Eur J Anesthesiol 1995; 12: 265-71.

17 De W it te J Rietm an GW Vandenbroucke G Deloof T.Post -operat ive effects o f t ramadol adminis tered atwound closure. Eur J Anesthesio l 1998; 15 : 190-5 .

18 Ng K_FJ Tsui SI~ Yang JCS Ho ET F. C o m p a r i s o n o ft r am ad o l an d t r am ad o l /d ro p er id o l m ix tu re fo r p a t i ent -cont ro l led analgesia . Can J Anaesth 1997; 44 : 810-5 .

19 Lehmann KA .Tram adol in acu te pain . (French) Drug s .1 9 9 7 ; 5 3 ( 2 ) : 2 5 -3 3 .

comparison of patient controlled.pdf

Documents