Role of ketamine and tramadol as adjuncts to bupivacaine 0.5% in paravertebral block for breast surgery: A randomized double-blind study

Omar, Ahmed M.; Mansour, M. A.; Abdelwahab, Hisham; Aboushanab, Ossama H.

doi:10.1016/j.egja.2011.04.002

Cited by 12 publications

(12 citation statements)

References 33 publications

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“…The time required to perform a single‐injection paravertebral block was shorter compared with the multiple‐injection group (5 min vs. 10 min; median difference 4 min; 95%CI ‐6 to ‐3 min; p < 0.001) . Ultrasound guidance was used to perform paravertebral injections or catheter positioning in eight studies , whereas 16 other studies did not use ultrasound . The results were not different depending on the use of ultrasound guidance or not.…”

Section: Resultsmentioning

confidence: 94%

“…The efficacy of paravertebral blocks in breast cancer surgery has been reported in four meta‐analyses including 32 studies . Our literature search identified 21 studies over our search period, nine of which were included in those meta‐analyses . The use of thoracic paravertebral blocks resulted in lower postoperative pain scores (p < 0.001) , lower opioid consumption compared with general anaesthesia (relative risk (RR) 0.23; 95%CI 0.15–0.37) and a lower incidence of postoperative nausea and vomiting (RR 0.27; 95%CI 0.12–0.61) compared with a control group receiving systemic analgesia alone.…”

Section: Resultsmentioning

confidence: 99%

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PROSPECT guideline for oncological breast surgery: a systematic review and procedure‐specific postoperative pain management recommendations

et al. 2020

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Summary Analgesic protocols used to treat pain after breast surgery vary significantly. The aim of this systematic review was to evaluate the available literature on this topic and develop recommendations for optimal pain management after oncological breast surgery. A systematic review using preferred reporting items for systematic reviews and meta‐analysis guidance with procedure‐specific postoperative pain management (PROSPECT) methodology was undertaken. Randomised controlled trials assessing postoperative pain using analgesic, anaesthetic or surgical interventions were identified. Seven hundred and forty‐nine studies were found, of which 53 randomised controlled trials and nine meta‐analyses met the inclusion criteria and were included in this review. Quantitative analysis suggests that dexamethasone and gabapentin reduced postoperative pain. The use of paravertebral blocks also reduced postoperative pain scores, analgesia consumption and the incidence of postoperative nausea and vomiting. Intra‐operative opioid requirements were documented to be lower when a pectoral nerves block was performed, which also reduced postoperative pain scores and opioid consumption. We recommend basic analgesics (i.e. paracetamol and non‐steroidal anti‐inflammatory drugs) administered pre‐operatively or intra‐operatively and continued postoperatively. In addition, pre‐operative gabapentin and dexamethasone are also recommended. In major breast surgery, a regional anaesthetic technique such as paravertebral block or pectoral nerves block and/or local anaesthetic wound infiltration may be considered for additional pain relief. Paravertebral block may be continued postoperatively using catheter techniques. Opioids should be reserved as rescue analgesics in the postoperative period. Research is needed to evaluate the role of novel regional analgesic techniques such as erector spinae plane or retrolaminar plane blocks combined with basic analgesics in an enhanced recovery setting.

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Section: Resultsmentioning

confidence: 94%

Section: Resultsmentioning

confidence: 99%

PROSPECT guideline for oncological breast surgery: a systematic review and procedure‐specific postoperative pain management recommendations

et al. 2020

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“…A study of high-dose tramadol added to lidocaine plus epinephrine showed an increase in sensory block duration of approximately two hours and time to first analgesic by approximately five hours [ 90 ]. In contrast, multiple publications have shown limited benefit of tramadol added to levobupivacaine plus lidocaine [ 91 ], levobupivacaine alone [ 92 ], and mepivacaine [ 93 , 94 ], and no effect when added to ropivacaine [ 95 ] and bupivacaine [ 96 ]. Conflicting data were also noted from three studies comparing perineural tramadol to systemic tramadol.…”

Section: Resultsmentioning

confidence: 99%

Local Anesthetic Peripheral Nerve Block Adjuvants for Prolongation of Analgesia: A Systematic Qualitative Review

et al. 2015

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BackgroundThe use of peripheral nerve blocks for anesthesia and postoperative analgesia has increased significantly in recent years. Adjuvants are frequently added to local anesthetics to prolong analgesia following peripheral nerve blockade. Numerous randomized controlled trials and meta-analyses have examined the pros and cons of the use of various individual adjuvants.ObjectivesTo systematically review adjuvant-related randomized controlled trials and meta-analyses and provide clinical recommendations for the use of adjuvants in peripheral nerve blocks.MethodsRandomized controlled trials and meta-analyses that were published between 1990 and 2014 were included in the initial bibliographic search, which was conducted using Medline/PubMed, Cochrane Central Register of Controlled Trials, and EMBASE. Only studies that were published in English and listed block analgesic duration as an outcome were included. Trials that had already been published in the identified meta-analyses and included adjuvants not in widespread use and published without an Investigational New Drug application or equivalent status were excluded.ResultsSixty one novel clinical trials and meta-analyses were identified and included in this review. The clinical trials reported analgesic duration data for the following adjuvants: buprenorphine (6), morphine (6), fentanyl (10), epinephrine (3), clonidine (7), dexmedetomidine (7), dexamethasone (7), tramadol (8), and magnesium (4). Studies of perineural buprenorphine, clonidine, dexamethasone, dexmedetomidine, and magnesium most consistently demonstrated prolongation of peripheral nerve blocks.ConclusionsBuprenorphine, clonidine, dexamethasone, magnesium, and dexmedetomidine are promising agents for use in prolongation of local anesthetic peripheral nerve blocks, and further studies of safety and efficacy are merited. However, caution is recommended with use of any perineural adjuvant, as none have Food and Drug Administration approval, and concerns for side effects and potential toxicity persist.

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“…A couple of studies have shown Tramadol to increase the analgesic efficacy[ 64 , 66 ]. However, there have been other studies which have shown limited or no benefit of Tramadol when used as an adjuvant to local anesthetics for peripheral nerve blocks[ 65 , 68 - 72 ]. Hence, except for postoperative epidural infusions, present day anesthesia practice does not recommend routine use of Tramadol as a local anesthetic adjuvant.…”

Section: Discussionmentioning

confidence: 99%

Adjuvants to local anesthetics: Current understanding and future trends

Swain

Nag

Sahu

et al. 2017

WJCC

206

138

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Although beneficial in acute and chronic pain management, the use of local anaesthetics is limited by its duration of action and the dose dependent adverse effects on the cardiac and central nervous system. Adjuvants or additives are often used with local anaesthetics for its synergistic effect by prolonging the duration of sensory-motor block and limiting the cumulative dose requirement of local anaesthetics. The armamentarium of local anesthetic adjuvants have evolved over time from classical opioids to a wide array of drugs spanning several groups and varying mechanisms of action. A large array of opioids ranging from morphine, fentanyl and sufentanyl to hydromorphone, buprenorphine and tramadol has been used with varying success. However, their use has been limited by their adverse effect like respiratory depression, nausea, vomiting and pruritus, especially with its neuraxial use. Epinephrine potentiates the local anesthetics by its antinociceptive properties mediated by alpha-2 adrenoreceptor activation along with its vasoconstrictive properties limiting the systemic absorption of local anesthetics. Alpha 2 adrenoreceptor antagonists like clonidine and dexmedetomidine are one of the most widely used class of local anesthetic adjuvants. Other drugs like steroids (dexamethasone), anti-inflammatory agents (parecoxib and lornoxicam), midazolam, ketamine, magnesium sulfate and neostigmine have also been used with mixed success. The concern regarding the safety profile of these adjuvants is due to its potential neurotoxicity and neurological complications which necessitate further research in this direction. Current research is directed towards a search for agents and techniques which would prolong local anaesthetic action without its deleterious effects. This includes novel approaches like use of charged molecules to produce local anaesthetic action (tonicaine and n butyl tetracaine), new age delivery mechanisms for prolonged bioavailability (liposomal, microspheres and cyclodextrin systems) and further studies with other drugs (adenosine, neuromuscular blockers, dextrans).

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Role of ketamine and tramadol as adjuncts to bupivacaine 0.5% in paravertebral block for breast surgery: A randomized double-blind study

Cited by 12 publications

References 33 publications

PROSPECT guideline for oncological breast surgery: a systematic review and procedure‐specific postoperative pain management recommendations

PROSPECT guideline for oncological breast surgery: a systematic review and procedure‐specific postoperative pain management recommendations

Local Anesthetic Peripheral Nerve Block Adjuvants for Prolongation of Analgesia: A Systematic Qualitative Review

Adjuvants to local anesthetics: Current understanding and future trends

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