Efficacy of local infiltration tramadol (transversus abdominis plane block technique) versus preemptive intravenous tramadol on postoperative pain after open appendectomy: a prospective randomized controlled trial
DOI:
https://doi.org/10.18203/2349-2902.isj20251163Keywords:
Tramadol, Transversus abdominal plane block, Open appendectomy, Postoperative painAbstract
Background: Acute postoperative pain, if mismanaged, leads to increased morbidity and mortality. Effective perioperative analgesia is crucial to prevent persistent pain. In abdominal surgeries, endogenous opioids are released, and tramadol, a weak synthetic opioid, has demonstrated effective analgesic properties. Recent studies suggest tramadol's mechanism involves blocking voltage-dependent sodium channels, which increases extracellular calcium and affects peripheral nerves. This suggests tramadol has both systemic and local anesthetic effects.
Methods: A prospective, randomized, double-blind study was conducted on 32 patients (ages 18–60) diagnosed with acute appendicitis who underwent open appendectomy under general anesthesia. Participants were randomly assigned to two groups: group 1 received normal saline with tramadol infiltration for transversus abdominis plane (TAP) block (n=16), and group 2 received preemptive intravenous tramadol with TAP normal saline infiltration (n=16). Pain was assessed using the visual analogue scale (VAS) at various postoperative intervals. Opioid consumption was monitored through patient-controlled analgesia (PCA), and intraoperative data, complications, and hospital stay were recorded.
Results: Demographic data were similar between groups. The primary outcome showed a significant reduction in postoperative pain (VAS score) at 0 hours (p=0.031) for the tramadol TAP group, with a 1-point reduction in pain over 24 hours compared to the intravenous group. Secondary outcomes indicated reduced opioid consumption, with no significant differences in complications (nausea/vomiting, infection, hospital stay).
Conclusions: Local tramadol combined with TAP block is an effective alternative for postoperative pain relief after open appendectomy, reducing opioid consumption without additional complications.
Metrics
References
Anderson JE, Bickler SW, Chang DC, Talamini MA. Examining a common disease with unknown etiology: trends in epidemiology and surgical management of appendicitis in California, 1995-2009. World J Surg. 2012;36(12):2787-94. DOI: https://doi.org/10.1007/s00268-012-1749-z
Körner H, Söndenaa K, Söreide JA, et al. Incidence of acute nonperforated and perforated appendicitis: age-specific and sex-specific analysis. World J Surg. 1997;21(3):313-7. DOI: https://doi.org/10.1007/s002689900235
Körner H, Söreide JA, Pedersen EJ, Bru T, Söndenaa K, Vatten L. Stability in incidence of acute appendicitis. A population-based longitudinal study. Dig Surg. 2001;18(1):61-6. DOI: https://doi.org/10.1159/000050099
Saleh O, Hosh M, Elgendy FI, Amer MA, Zalabia M, et al. Mortality of emergency abdominal surgery in high-, middle-and low-income countries. British J of Surg. 2017;104(5):632-5.
O'Leary DP, Walsh SM, Bolger J. A Randomized Clinical Trial Evaluating the Efficacy and Quality of Life of Antibiotic-only Treatment of Acute Uncomplicated Appendicitis: Results of the COMMA Trial. Ann Surg. 2021;274(2):240-7. DOI: https://doi.org/10.1097/SLA.0000000000004785
Salminen P, Tuominen R, Paajanen H. Five-year follow-up of antibiotic therapy for uncomplicated acute appendicitis in the APPAC randomized clinical trial. JAMA. 2018 Oct 23;320(16):1711. DOI: https://doi.org/10.1001/jama.2018.13201
Addiss DG, Shaffer N, Fowler BS, Tauxe RV. The epidemiology of appendicitis and appendectomy in the United States. Am J Epidemiol. 1990;132(5):910-25. DOI: https://doi.org/10.1093/oxfordjournals.aje.a115734
Kleif J, Vilandt J, Gögenur I. Recovery and convalescence after laparoscopic surgery for appendicitis: A longitudinal cohort study. J Surg Res. 2016;205(2):407-18. DOI: https://doi.org/10.1016/j.jss.2016.06.083
Zinner MJ, Ashley SW. Maingot's Abdominal Operations, 13e. McGraw-Hill Companies, Incorporated. 2019.
Almeida OD, Val-Gallas JM, Rizk B. Appendectomy under local anaesthesia following conscious pain mapping with microlaparoscopy. Hum Reprod. 1998;13(3):588-90. DOI: https://doi.org/10.1093/humrep/13.3.588
Fletcher D, Stamer UM, Pogatzki-Zahn E, et al. Chronic postsurgical pain in Europe: An observational study. Eur J Anaesthesiol. 2015;32(10):725-34. DOI: https://doi.org/10.1097/EJA.0000000000000319
Bagshaw KR, Hanenbaum CL, Carbone EJ, et al. Pain management via local anesthetics and responsive hydrogels. Ther Deliv. 2015;6(2):165-76. DOI: https://doi.org/10.4155/tde.14.95
Schwartz DR, Kaufman B. Local Anesthetics In: Hoffman RS, editor, Howland MA, editor, Lewin NA, editor, Nelson LS, editor, Goldfrank LR, editor. (eds). Goldfrank’s toxicologic emergencies, 10th edn New York: McGraw-Hill Education. 2015.
Rafi AN. Abdominal field block: a new approach via the lumbar triangle. Anaesthesia. 2001;56(10):1024-6. DOI: https://doi.org/10.1046/j.1365-2044.2001.02279-40.x
Hebbard P, Fujiwara Y, Shibata Y, Royse C. Ultrasound-guided transversus abdominis plane (TAP) block. Anaesth Intensive Care. 2007;35(4):616-7.
Gray H. Anatomy of human the body. 12th edition. New York. 2000: 211-12
Molina PE. Stress-specific opioid modulation of haemodynamic counter-regulation. Clin Exp Pharmacol Physiol. 2002;29(3):248-53. DOI: https://doi.org/10.1046/j.1440-1681.2002.03638.x
Troullos E, Hargreaves KM, Dionne RA. Ibuprofen elevates immunoreactive beta-endorphin levels in humans during surgical stress. Clin Pharmacol Ther. 1997;62(1):74-81. DOI: https://doi.org/10.1016/S0009-9236(97)90153-3
Kho HG, Kloppenborg PW, van Egmond J. Effects of acupuncture and transcutaneous stimulation analgesia on plasma hormone levels during and after major abdominal surgery. Eur J Anaesthesiol. 1993;10(3):197-208.
Ozarda Ilçöl Y, Ozyurt G, Kilicturgay S, Uncu G, Ulus IH. The decline in serum choline concentration in humans during and after surgery is associated with the elevation of cortisol, adrenocorticotropic hormone, prolactin and beta-endorphin concentrations. Neurosci Lett. 2002;324(1):41-4. DOI: https://doi.org/10.1016/S0304-3940(02)00171-4
Sprouse-Blum AS, Smith G, Sugai D, Parsa FD. Understanding endorphins and their importance in pain management. Hawaii Med J. 2010;69(3):70-1.
Cheever KH. Pain, analgesic use, and morbidity in appendectomy patients. Clin Nurs Res. 1999;8(3):267-82. DOI: https://doi.org/10.1177/10547739922158296
Radbruch L, Grond S, Lehmann KA. A risk-benefit assessment of tramadol in the management of pain. Drug Saf. 1996;15(1):8-29. DOI: https://doi.org/10.2165/00002018-199615010-00002
Sousa AM, Ashmawi HA. Local analgesic effect of tramadol is not mediated by opioid receptors in early postoperative pain in rats. Braz J Anesthesiol. 2015;65(3):186-90. DOI: https://doi.org/10.1016/j.bjane.2014.06.006
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(1-3):77-81.
Pang WW, Mok MS, Chang DP, Huang MH. Local anesthetic effect of tramadol, metoclopramide, and lidocaine following intradermal injection. Reg Anesth Pain Med. 1998;23(6):580-3. DOI: https://doi.org/10.1097/00115550-199823060-00012
Al-Haideri YA. 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(12):2035-8. DOI: https://doi.org/10.1016/j.joms.2013.08.009
Food US. Drug Administration FDA Drug Safety Communication: FDA updates warnings for oral and injectable fluoroquinolone antibiotics due to disabling side effects. 2017.
Bass KD, Heiss KF, Kelley-Quon LI, Raval MV. Opioid use in children's surgery: awareness, current state, and advocacy. J of Ped Surg. 2020;55(11):2448-53. DOI: https://doi.org/10.1016/j.jpedsurg.2020.02.015
Farcaş A, Măhălean A, Bulik NB, Leucuta D, Mogoșan C. New safety signals assessed by the Pharmacovigilance Risk Assessment Committee at EU level in 2014–2017. Expert Rev of Clin Pharmacol. 2018;11(10):1045-51. DOI: https://doi.org/10.1080/17512433.2018.1526676
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(1-3):77-81. DOI: https://doi.org/10.1016/S0014-2999(02)01368-7
Grond S, Sablotzki A. Clinical pharmacology of tramadol. Clin Pharmacokinet. 2004;43(13):879-923. DOI: https://doi.org/10.2165/00003088-200443130-00004
Dayer P, Collart L, Desmeules J. The pharmacology of tramadol. Drugs. 1994;47(1):3-7. DOI: https://doi.org/10.2165/00003495-199400471-00003
Gharagozlou P, Hashemi E, DeLorey TM, Clark JD, Lameh J. Pharmacological profiles of opioid ligands at kappa opioid receptors. BMC Pharmacol. 2006;6:3. DOI: https://doi.org/10.1186/1471-2210-6-3
Gilly H, Kramer R, Zahorovsky I. "Lokalanaesthetische" Effekte von Morphin und Naloxon. Local anesthetic effects of morphine and naloxone. Anaesthesist. 1985;34(11):619-26.
Erciyes N, Aktürk G, Solak M, Dohman D. Morphine/prilocaine combination for intravenous regional anesthesia. Acta Anaesthesiol Scand. 1995;39(6):845-6. DOI: https://doi.org/10.1111/j.1399-6576.1995.tb04182.x
Pang WW, Mok MS, Huang S, Hwang MH. The analgesic effect of fentanyl, morphine, meperidine, and lidocaine in the peripheral veins: a comparative study. Anesth Analg. 1998;86(2):382-6. DOI: https://doi.org/10.1213/00000539-199802000-00031
Werner MU, Kongsgaard UE. I. Defining persistent post-surgical pain: is an update required. Br J Anaesth. 2014;113(1):1-4. DOI: https://doi.org/10.1093/bja/aeu012
Vahabi S, Heidari M, Ahmadinejad M, Akhlaghi J, Birjandi M. Comparison of local anesthetic effects of tramadol and lidocaine used subcutaneously in minor surgeries with local anesthesia. Middle East J Anaesthesiol. 2011;21(1):9-14. DOI: https://doi.org/10.1016/S1754-3207(11)70280-2
Sahmeddini MA, Azemati S, Motlagh EM. Local Infiltration of Tramadol versus Bupivacaine for post cesarean section pain control: a double-blind randomized study. Iran J Med Sci. 2017;42(3):235-41.
Biondi A, Di Stefano C, Ferrara F, Bellia A, Vacante M, Piazza L. Laparoscopic versus open appendectomy: a retrospective cohort study assessing outcomes and cost-effectiveness. World J Emerg Surg. 2016;11(1):44. DOI: https://doi.org/10.1186/s13017-016-0102-5
Katkhouda N, Mason RJ, Towfigh S, Gevorgyan A, Essani R. Laparoscopic versus open appendectomy: a prospective randomized double-blind study. Ann Surg. 2005;242(3):439-50. DOI: https://doi.org/10.1097/01.sla.0000179648.75373.2f
Alireza K Arbabi F. The Effect of Local Tramadol Injection in Post Appendectomy Pain. Zahedan J Res in Med Sci. 2015;17(4):973 DOI: https://doi.org/10.5812/zjrms.17(4)2015.973
Lowenstein L, Zimmer EZ, Deutsch M, Paz Y, Yaniv D, Jakobi P. Preoperative analgesia with local lidocaine infiltration for abdominal hysterectomy pain management. Eur J Obstet Gynecol Reprod Biol. 2008;136(2):239-42. DOI: https://doi.org/10.1016/j.ejogrb.2006.11.008
Khajavi MR, Aghili SB, Moharari RS, et al. Subcutaneous tramadol infiltration at the wound site versus intravenous administration after pyelolithotomy. Ann Pharmacother. 2009;43(3):430-5. DOI: https://doi.org/10.1345/aph.1L494
Santos TO, Estrela TG, Azevedo VL, Oliveira OE, Oliveira G, Figueiredo S. Intravenous and subcutaneous tramadol for inguinal herniorrhaphy: comparative study. Rev Bras Anestesiol. 2010;60(5):522-7. DOI: https://doi.org/10.1590/S0034-70942010000500008
Downloads
Published
How to Cite
Issue
Section
