İsmailov Niyazali VAHİTOVİÇ, İbrahim AŞIK, Serkan ENÖN, Zekeriya ALANOĞLU, Bahattin DURU, Mehmet ORAL, Sacide DEMİRALP, Filiz TÜZÜNER, Hadi AKAY

Posttorakotomi ağrısında hasta kontrollü epidural analjezi ile morfin ve tramadol'ün karşılaştırılması

Bu çalışmada posttorakotomi ağrı tedavisinde hasta kontrollü epidural analjezi (HKEA) yöntemi ile epidural morfin ve tramadolün analjezik etkinlik ve yan etki açısından karşılaştırılmaları amaçlandı. Lokal etik komite onayı ve hastalardan açıklamalı onay alındıktan sonra, torakotomi geçirecek ASA I -II grubu 38 erişkin hastaya cerrahi işlem bitiminden hemen sonra T7 - T10 aralığından asılı damla tekniği ile epidural aralığa kateter yerleştirildi. Hastalar postoperatif dönemde rastgele iki gruba ayrıldı; I. Gruba (n=19) morfin (yükleme dozu 2 mg, bolus doz 0.5 mg, kilitli kalma 30 dk. ve 4 saatlik maksimum doz 10 mg), II. Gruba (n=19) tramadol (yükleme dozu 50 mg, bolus doz 25 mg, kilitli kalma 30 dk. ve 4 saatlik maksimum doz 200 mg) ağrı kontrolü amacıyla HKEA yöntemiyle uygulandı. Analjezi kalitesi (vizüel analog skala -VAS ile), kümülatif ek analjezik miktarı (Na diklofenak 75 mg), vital bulgular (kan basıncı, kalp atım hızı, solunum hızı, SpO2), plazma kortizol düzeyi ve yan etkiler postoperatif 48 saat süresince kaydedildi. Vital bulgularda gruplar arasında anlamlı fark bulunmadı. Postoperatif 6, 18, 30, 42 ve 48. saatlerde istirahat halinde (p

Anahtar Kelimeler:

Ağrı, ameliyat sonrası, Torakotomi, Analjezi, hasta kontrollü, Anestezi, epidural, Morfin, Tramadol

The comparison of epidural morphine and tramadol by using patient controlled analgesia for postthoracotomy pain

in the present study, we aimed to compare the analgesic efficacy and the side effects of epidural morphine and tramadol by usingpatient controlled epidural analgesia (PCEA) for postthoracotomy pain. After obtaining local ethic committee approval and informed consent, epidural catheters were inserted to 38 ASA I - II group adult patients undergoing thoracotomy through Th7-10 epidural space by using hanging drop technique at the end of the surgical procedure. Postoperatively patients were randomly allocated into two groups; Group I (n=19) received morphine (loading dose 2 mg, bolus dose 0.5 mg, lock out time 30 min, and 4 hour maximum dose 10 mg) and Group II (n=19) received tramadol (loading dose 50 mg, bolus dose 25 mg, lock out time 30 min, and 4 hour maximum dose 200 mg) by using PCEAfor posthoracotomy pain. The quality of analgesia (with visual analogue scale-VAS), cumulative dosage of additional analgesic (Na diclofenac 75 mg) and vital signs (arterial blood pressure, heart rate, respiratory rate, SpO2, blood cortisol levels and side effects were recorded 48 hours postoperatively. Vital findings were similar in both groups. VAS levels were significantly higher in tramadol group at rest ( 6,18, 30,42 and 48 hours postoperatively, p<0.05) and during movement (4,42 and 48 hours postoperatively, p<0.05). Additionally, the cumulative dosage ofrescue analgesic medication was higher in tramadol group at the end of 48 hours postoperatively (p<0.05). Blood cortisol levels were also higher after 24 and 36 hours postoperatively (p<0.05). The side effects were similar between the groups. in conclusion, epidural administration of morphine by using PCEA method resulted in superior analgesia compared with epidural tramadol without increase in side effects.

Keywords:

Pain, Postoperative, Thoracotomy, Analgesia, Patient-Controlled, Anesthesia, Epidural, Morphine, Tramadol,

___

1. Yaksh TL. The principles behind the use of spinal narcotics. Clin Anaesthesiol 1983; 1:219-32.
2. Cousins MJ, Mather LE. Intrathecal and epidural administration of opioids. Anesthesiology 1984;61:276-310.
3. Siddik-Sayyid S, Aouad-Maroun M, Sleiman D, Sfeir M, Baraka A. Epidural tramadol for post operative pain after Cesarean section. Can J Anaesth 1999; 46: 731-5.
4. Natalini CC, Robinson EP. Evaluation of the analgesic effects of epidurally administered morphine, alfentanil, butorphanol, tramadol, and U50488H in horses. AJVR 2000; 61: 1579-86.
5. Baraka A, Jabbour S, Ghabash M, Nader A, Khoury G, Sibai A. A comparison of epidural tramadol and epidural morphine forpostoperative analgesia. Can J Anaesth 1993; 40: 308-13.
6. Raffa RB, Friderichs E, Reimann W, Shank RP, Codd EE, Vaught JL. Opioid and nonopioid components independently contribute to the mechanism of action of tramadol, an 'atypical' opioid analgesic. J Pharmacol Exp Ther 1992; 260: 275-85.
7. Houmes R-JM, Voets MA, Verkaaik A, Erdmann W, Lacmann B. Efficacy and safety of tramadol versus morphine for moderate and severe postoperative pain with special regard to respiratory depression. Anesth Analg 1992; 74: 510-4.
8. Vickers MD, O'Flaherty D, Szekely SM, Read M, Yoshizumi J.Tramadol: pain relief by an opioid without depression of respiration. Anaesthesia 1992; 47: 291-6.
9. Egers KA, Power 1. Tramadol (editorial). Br J Anaesth 1995; 74: 247-9.
10. Sunshine A, Olson NZ, Zighelboim I, DeCastro A, Minn FL. Analgesic oral efficacy of tramadol hydrochloride in postoperative pain. Clin Pharmacol Ther 1992; 51: 740-6.
11. Peeters-Asdourian C, Gupta S. Choices in Pain Management Following Thoracotomy. Chest 1999; 115 : 122-4.
12. David O. Wamer MD, Richard B, et al. Preventing postoperative pulmonary complications. Anesthesiology 2000; 92: 75-8.
13. Ngai L, Guy K, Nicolas D, et al. A randomized, double - blind comparison of intrathecal morphine, sufentanil and their combination versus iv morphine patient-controlled analgesia for postthoracotomy pain. Anesth Analg 2001; 92:31-6.
14. Delikan AE, Vijayan R. Epidural tramadol for postoperative pain relief. Anaesthesia 1993; 48: 328-31.
15. Prosser DP, Davis A, Booker PD, Murray A. Caudal tramadol for postoperative analgesia in pediatric hvpospdias surgery. Br J Anaesth 1997:79: 293-6.
16. Senel AC, Akuol A, Dohman D, Solak M. Caudal bupivacaine-tramadol combination for postoperative analgesia in pediatric herniorrhaphy. Acta Anaesthesiol Scand 2001; 39 786-9.
17. Crace D, Fee JPH. İneffective analgesia after extradural tramadol hydrochloride in patients undergoing total knee repacement. Anaesthesia 1995; 50: 555-8.
18. Chrubasic J, Warfh L, Wuest H. analgesic potency of epidural tramadol after abdominal surgery. Anestheziol Reanim 1995; 20: 16-25.
19. Rawal N. Epidural end spinai agents for postoperative analgesia. Sur Clin Norm Am 1999: 79; 313-44.
20. Gündüz G, Özcengiz D, Özbek H, Işık G. A comparison of single dose caudal tramadol, tramadol plus bupivacaine and bupivacaine administration for postoperative analgesia in children. Paediatr Anaesth 2001; 11: 323-6.
21. Fu Yp, Chan KH, Lee TK, Chang JC. Daiy YP, Lee T. Epidural tramadol for postoperative pain relief. Acta Anaesthesiol Scand 1991; 29: 648-52.