Article (PDF Available)

Effect of Diclofenac Suppository on Tramadol Consumption in Posthysterectomy Pain

Department of Anaesthesia, The Aga Khan University Hospital, Karachi.
Journal of the College of Physicians and Surgeons--Pakistan: JCPSP (Impact Factor: 0.35). 10/2008; 18(9):533-7.
Source: PubMed
ABSTRACT
To determine reduction in dose of tramadol and side effects in posthysterectomy patients on addition of diclofenac on rectal suppository.
Randomized double blinded placebo controlled study.
The Aga Khan University Hospital, Karachi, Pakistan, from August 2004 to January 2006. Methodology: Seventy ASA I and II females, aged 20 and above, who underwent elective abdominal hysterectomy, were included in this study. Patients received identical looking suppository of either 100 mg diclofenac sodium or placebo after induction of anaesthesia and then 12 hourly for 24 hours. General anaesthesia was standardized and tramadol was given by patient controlled intravenous analgesia delivery system in the recovery.
The mean dose + SD of tramadol used in first 24 hours was found to be 317 +153 mg in the placebo-tramadol group compared to 258 +192 mg in the diclofenac-tramadol group (p = 0.15, 95% CI = 1.24 to -1.34, 6.63). Seventeen (49 %) patients in the placebo-tramadol group and 14 (40%) in the diclofenac-tramadol group used rescue analgesia (p=0.47). Sedation score was similar in both the groups and there was no difference in the incidence of nausea and vomiting and use of antiemetics between the groups.
This study did not show any reduction in tramadol consumption, given via patient controlled intravenous analgesia when rectal suppository of 100 mg diclofenac was added.

Full-text (PDF)

Available from: Fauzia Anis Khan
Journal of the College of Physicians and Surgeons Pakistan 2008, Vol. 18 (9): 533-537 533
INTRODUCTION
Opioids are commonly used for the management of
intraoperative and postoperative pain. Systemic
administration of high doses of opioids is associated
with a variety of adverse reactions such as pruritis,
sedation, nausea, vomiting, respiratory depression and
constipation.
1
The development of multimodal or
balanced analgesia techniques for postoperative
analgesia, involving the use of combinations of drugs,
has helped to improve quality of analgesia with
reduction in incidence and severity of these side
effects.
2
Opioid consumption can be significantly
reduced by combining them with non-opioid analgesic in
pain therapy. Non-steroidal anti-inflammatory drugs
(NSAIDs) effectively reduce opioid consumption by 20-
30% to improve analgesia and reduce side effects.
3,4
A
combined therapy of opioids and NSAIDs could result in
synergistic analgesia by acting through different
mechanisms.
5
In postoperative pain management, tramadol is an
alternative agent to morphine for Patient Controlled
Intravenous Analgesia (PCIA) treatment. Tramadol is a
centrally acting analgesic with opioid and non-opioid
modes of action. It is a weak
µ receptors agonist and its
analgesic activity is mostly via inhibition of re-uptake of
neurotransmitters like norepinephrine and serotonin in
the central nervous system.
6
The advantage of tramadol
over traditional opioids is minimal potential for tolerance
and respiratory depression but also has nausea and
vomiting as side effects which affect physician and
patients’ satisfaction.
7
NSAIDs are mainly used as co-analgesics for the
treatment of postoperative pain in moderate to major
surgery. They block the synthesis of prostaglandins by
inhibiting Cyclooxygenase (COX), thereby reducing
production of mediators of the acute inflammatory
response. By decreasing the inflammatory response to
surgical trauma, NSAIDs have been supposed to reduce
peripheral nociception. More recent studies also
suggest that the central response to painful stimuli may
be modulated by NSAIDs-induced inhibition of prosta-
glandin synthesis in the spinal cord.
1
There has been little published work on the synergism of
tramadol (opioid) and diclofenac (NSAIDs). The purpose
of this study was to determine whether addition of
diclofenac suppository reduced tramadol consumption
and side effects in posthysterectomy patients.
ABSTRACT
Objective: To determine reduction in dose of tramadol and side effects in posthysterectomy patients on addition of
diclofenac on rectal suppository.
Study Design: Randomized double blinded placebo controlled study.
Place and Duration of Study: The Aga Khan University Hospital, Karachi, Pakistan, from August 2004 to January 2006.
Methodology: Seventy ASA I and II females, aged 20 and above, who underwent elective abdominal hysterectomy, were
included in this study. Patients received identical looking suppository of either 100 mg diclofenac sodium or placebo after
induction of anaesthesia and then 12 hourly for 24 hours. General anaesthesia was standardized and tramadol was given
by patient controlled intravenous analgesia delivery system in the recovery.
Results: The mean dose + SD of tramadol used in first 24 hours was found to be 317 +153 mg in the placebo-tramadol
group compared to 258 +192 mg in the diclofenac-tramadol group (p = 0.15, 95% CI = 1.24 to -1.34, 6.63). Seventeen
(49 %) patients in the placebo-tramadol group and 14 (40%) in the diclofenac-tramadol group used rescue analgesia
(p=0.47). Sedation score was similar in both the groups and there was no difference in the incidence of nausea and
vomiting and use of antiemetics between the groups.
Conclusion: This study did not show any reduction in tramadol consumption, given via patient controlled intravenous
analgesia when rectal suppository of 100 mg diclofenac was added.
Key words:
Postoperative pain management. Tramadol. Diclofenac sodium.
Department of Anaesthesia, The Aga Khan University Hospital,
Karachi.
*
Department of Gynaecology and Obstetrics, The Aga Khan
University Hospital, Karachi.
Correspondence: Dr. Aziza M. Hussain, Flat No. 306,
Mustafa Arcade, Block-A, Sindhi Muslim Society, Karachi.
E-mail: aziza.mohammad@aku.edu
Received December 15, 2007; accepted August 2, 2008.
Effect of Diclofenac Suppository on Tramadol
Consumption in Posthysterectomy Pain
Aziza Mohammad Hussain, Fauzia A. Khan and Lumaan Sheikh*
ORIGINAL ARTICLE
Page 1
METHODOLOGY
The study was conducted in the Aga Khan University
Hospital, Karachi, from August 2004 to January 2006.
After obtaining institutional ethical committee approval
and written informed consent from patients, 70 ASA I
and II female patients, aged 20 and above, undergoing
elective abdominal hysterectomy under Pfannenstiel
incision technique, were recruited in this randomized
double blind placebo controlled trial. Exclusion criteria
were hysterectomy under midline incision technique,
emergency surgery, surgery for malignancy, history of
chronic pain, peptic ulceration, bleeding disorders,
impaired renal or hepatic function, sensitivity to NSAID
or opioids, and patients’ inability to use Patient-
Controlled Analgesia (PCA).
Patients were randomly divided into two groups to either
receive diclofenac suppository or a placebo after
induction of anaesthesia. The randomization was done
by the pharmacy department. Patients were allocated
randomly according to a list of random numbers into two
groups in sealed opaque envelopes. The suppositories
were provided by the pharmacy and an appropriate
code number (case 1, case 2 and so on) was assigned.
The investigators were unaware of the group. During
pre-operative assessment, the patient were instructed
regarding Verbal Rating Score (VRS) of pain (0 = no
pain, 1 = mild pain, 2 = moderate pain and 3 = severe
pain)
8
and were also familiarized with the use of PCA
pump to minimize pain (obtaining a score less than 2).
The number of patients recruited was based on
detecting a difference of 30% in total tramadol
consumption between the two groups in 24 hours, an
alpha (
α) error of 5% and β error of 20% at a standard
deviation of 166. All the patients were then
premedicated with 7.5 mg midazolam tablet half to one
hour prior to surgery.
On arrival in the operating room, routine monitoring i.e.
electrocardiogram, non-invasive blood pressure and
pulse oximetry was instituted. A baseline reading of
systolic, diastolic and mean blood pressure, heart rate
and oxygen saturation was obtained after a resting
period of 5 minutes.
Anaesthesia was induced with intravenous tramadol
2 mg kg-
1
, thiopentone 4-5 mg kg-
1
and atracurium 0.5
mg kg-
1
. After tracheal intubation, patients lungs were
mechanically ventilated and anaesthesia maintained
with 60% nitrous oxide, oxygen and isoflurane (MAC 1).
A rectal suppository, either diclofenac 100 mg or
placebo, was inserted before start of surgery. Heart rate
systolic, diastolic, and mean blood pressure and oxygen
saturation were monitored throughout the maintenance
period and documented at 10 minutes interval.
At the end of the surgery, residual neuromuscular
blockade was antagonized with neostigmine 2.5 mg and
glycopyrrolate 0.5 mg. In the recovery, a PCA pump was
connected to the patients, which contained 10mg ml-
1
tramadol. The bolus dose was set at 10 mg (1ml) with a
lock out interval of 10 minutes. There was no
background infusion. Patients had been previously
instructed to use PCA to minimize pain (i.e. maintain
pain score of less than 2).
Any side effects like nausea, vomiting and respiratory
depression were monitored. The level of sedation was
assessed by using the sedation score described by
Chernik
et al. (0 = awake, 1 = sleeping comfortably and
responding to vocal commands, 2 = somnolence, deep
sleep but responding to vocal commands, 3 = not
arousable, deep sleep).
9
Persistent nausea (defined as
feeling of nausea for more than 30 minutes) and
vomiting more than twice was treated with intravenous
metoclopramide 10 mg bolus. If patient was unable to
obtain adequate analgesia with two consecutive dose of
tramadol, 10 mg boluses of pethidine were administered
intravenously as rescue analgesia, to minimize pain.
Postoperatively, similar rectal suppository as given
intraoperatively (whether it was diclofenac or placebo)
was inserted 12 hourly for next 24 hours. Patients were
assessed at 6, 12 and 24 hours, postoperatively for
blood pressure, heart rate, respiratory rate, side effects
(nausea and vomiting and sedation) and for rescue
medication received. Blindness during the study period
was ensured by blinding the anaesthetist and the nurse
recording the parameters to the patient group. PCIA
pump used by the patient is called attempts. Good
attempts are those in which the drug is delivered to the
patient. Number of attempts (which include total
attempts and good attempts) and total tramadol dose
consumed (to minimize pain) was retrieved from the
PCA computer memory after 24 hours postoperatively.
Neither the pain score, nor the number of attempts at
different time intervals were assessed.
Using EpiData (version 3.1), frequencies, mean and
standard deviation of all quantitative variables were
generated. Independent samples t-test for quantitative
variable between the two groups (placebo and
diclofenac) were calculated. Repeated measures of
ANOVA were conducted to see the association within
group at different times and between groups (placebo
and diclofenac) for heart rate, systolic and diastolic
blood pressures. Association between placebo and
diclofenac group for nausea, vomiting and antiemetic
and rescue analgesia use were looked at by using
Chi-square test. Independent sample ‘t’ test was also
used to observe mean difference between groups
(placebo and diclofenac) for number of attempts
and total consumption of tramadol during 24 hours
postoperatively. A p-value of <0.05 was considered
statistically significant.
534 Journal of the College of Physicians and Surgeons Pakistan 2008, Vol. 18 (9): 533-537
Aziza Mohammad Hussain, Fauzia A. Khan and Lumaan Sheikh
Page 2
RESULTS
There were no dropouts during the study period. The
demographic data of both groups is given in Table I.
Both groups were comparable with respect to age, body
weight, ASA physical status and duration of surgery.
There was no difference in the systolic (SBP), diastolic
(DBP) mean arterial pressure (MAP) and heart rate
measured at corresponding time intervals (Table II), and
difference between the two groups (placebo and
diclofenac) at all times was found to be insignificant.
The mean +
SD dose of tramadol used in the first
24 hours postoperatively in the placebo-tramadol group
was 317 +153 mg and 258 +192 mg in the diclofenac-
tramadol group to relieve pain (Table III). Though
clinically, the dose was less in the diclofenac-tramadol
group, the difference was not statistically significant
(p= 0.159). When use of rescue analgesia was
compared in both the groups, 17 (49%) patients used
rescue analgesia in the placebo-tramadol group
compared to 14 (40%) patients in the diclofenac-
tramadol group, but this difference was not significant
(p=0.47). Rescue analgesia was needed in both groups
on arrival in recovery but the requirements decreased
subsequently and after 12 hours no rescue analgesia
was required in either of the groups. The average
number of attempts in the diclofenac - tramadol group
was greater (184.94 +
257) than in the placebo-
tramadol group (153.86 +177) but this was not
significant (p=0.557, Table III).
Occurrence of nausea and/or vomiting was similar in
both placebo-tramadol and diclofenac-tramadol groups.
Twelve (34%) patients had nausea in both the groups.
Vomiting occurred in 4 (11%) patients in placebo-
tramadol group and 5 (14%) in diclofenac- tramadol
group. These differences were not statistically
significant. Nineteen (54%) patients in the placebo-
tramadol group and 16 (46%) in the diclofenac group
were given antiemetic but the use was not statistically
significant. (
χ
2
= 0.514, df=1, p=0.473).
In the recovery room, none of the patient had respiratory
rate less than 10 breaths per minute. Eleven (31%) of
patients were somnolent but rousable (score of 2) in the
placebo-tramadol group compared to 14 (40%) in the
diclofenac - tramadol group. Six hours postoperatively,
only 2 patients (6%) in the placebo-tramadol group
compared to 01 (3%) in the diclofenac- tramadol group
had a score of 2. None of the patients had a score of 3
at any time during the study period.
DISCUSSION
This study has demonstrated that in patients undergoing
abdominal hysterectomy, diclofenac 100 mg rectally,
at the time of induction, did not significantly reduce
PCA tramadol consumption to obtain VAS of less than 2,
in the first 24 hours after surgery.
Tramadol has a similar efficacy to morphine when used
as an analgesic in abdominal surgery.
10
It is a weak mµ
agonist with a multimodal mechanism of action. The mµ
agonist effect enhances the function of spinal
descending inhibitory pathway by inhibition of re-uptake
of both 5 Hydroxytryptamine (5HT) and nor epinephrine
together with pre-synaptic stimulation of 5HT release.
11
Journal of the College of Physicians and Surgeons Pakistan 2008, Vol. 18 (9): 533-537 535
Effect of diclofenac suppository on tramadol consumption in posthysterectomy pain
Table I: Demographic characteristics and duration of surgery. Mean
(SD).
Variable Tramadol and Tramadol and 95% confidence
placebo diclofenac for the difference
(n=35) sodium group SD. (upper and
(n=35) range)
Age (years) 43.2 (5.19) 44.3 (5.22) 1.24 (-1.34, 6.63)
Weight (kg) 67.0 (12.22) 69.7 (10.92) 2.7 (-2.83, 8.23)
Duration of anaesthesia
(minutes) 122.6 (40.33) 122.2 ( 41.20) -9.8 (-19.98, 19.19)
ASA physical status (I:II) 21:14 17:18
Table II: Systolic (SBP), diastolic (DBP) mean arterial pressure
(MAP) and heart rate (HR), mean (SD).
Variable Hours after Tramadol and Tramadol and
operation placebo diclofenac sodium
(n=35) (n=35)
HR (beat/ min)
0 80.74 ± 13.4 82.60 ± 14.6
6 83.11 ± 7.8 81.57 ± 9.3
12 84.83 ± 6.8 80.71 ± 9.4
24 84.89 ± 7.8 81.06 ± 8.9
SBP (mm Hg)
0 126.74 ± 14.9 128.83 ± 16.1
6 122.40 ± 11.2 125.31 ± 10.3
12 122.60 ± 9.9 122.34 ± 9.6
24 123.31 ± 9.8 122.14 ± 8.8
DBP (mm Hg)
0 72.69 ± 10.7 76.77 ± 10.0
6 77.71 ± 7.7 78.31 ± 8.2
12 76.80 ± 7.4 78.71 ± 7.0
24 78.54 ± 7.48 77.83 ± 7.4
MAP (mm Hg)
0 94.09 ± 11.0 95.06 ± 12.0
6 92.63 ± 6.6 93.69 ± 7.9
12 91.60 ± 7.7 93.11 ± 6.3
24 93.46 ± 7.3 92.66 ± 6.4
Table III: Dosing pattern and use of rescue analgesia. Mean (SD or
percentage).
Tramadol and Tramadol and 95% confidence
Variable placebo diclofenac interval for the
(n=35) sodium group difference. SD
(n=35) (upper and lower
range)
Mean dose (mg) 317 (153) 258 (192) 1.24 (-1.34, 6.63)
Median dose (mg) 320 (153) 210 (192)
Rescue
Analgesia used 17 (49 %) 14 (40%)
Average attempts 153.86 (176.5) 184.94 (256.8) 52.68 (-74.04, 136.21)
Page 3
536 Journal of the College of Physicians and Surgeons Pakistan 2008, Vol. 18 (9): 533-537
Aziza Mohammad Hussain, Fauzia A. Khan and Lumaan Sheikh
It has emerged as an alternative drug to morphine for
I.V. PCA
12
and has shown good efficacy after major
orthopaedic surgery.
12,13
Its particular advantage is its
lesser potential of respiratory depression.
14
One of the
limitations of its use in PCA is the incidence of its side
effects specially nausea and vomiting.
15
One of the
ways to tackle this issue by using combination of
tramadol with other non-narcotic analgesic drugs and
thus decreases the opioid requirements and lessening
the incidence of side effects. Combinations that have
been investigated with variable results are intravenous
(I.V.) tramadol and ketorolac infusion for major
abdominal surgery, I.V. tramadol and metamizol, I.V.
tramadol and ketoprofen, I.V. tramadol and lysine
acetyl salicylate, an injectable aspirin, and tramadol
piroxican combination.
16-20
Diclofenac is an NSAID that reduces morphine
consumption after total abdominal hysterectomy.
21
Most
but not all studies with narcotic NSAID combination
have shown a decrease in opioid requirement.
22
Rectal
NSAID is a cost-effective method in the management of
surgical pain and has been shown to decrease
morphine consumption by 50 % in patients undergoing
abdominal hysterectomy.
23,24
Not much literature is
available on the combination of these two i.e. tramadol
and diclofenac. The total morphine dosage administered
I.V. by PCA over a particular period of time has been
used as a measure of efficacy of postoperative
analgesia by several studies as used in this
methodology.
25
We used an intravenous bolus dose of
tramadol of 10 mg with a lockout interval of 10 minutes
for a period of 24 hours. Background infusion as the
method would not be appropriate to evaluate a decrease
in narcotic demand.
26
The routine institutional practice is
to discontinue PCA after 24 hours in order to encourage
patients to ambulate. The present results demonstrated
a slight decrease in total tramadol requests in the
diclofenac group but this did not achieve statistical
significance.
The most commonly reported side effect was nausea
(34% in each group) and vomiting (11% placebo vs.
14% in diclofenac group). Excessive sedation was not
seen in either group. Evidence supporting increased
bleeding with NSAIDS is equivocal,
27
but excessive
bleeding was not reported in any of our patients.
Diarrhea, a rarely reported side effects of diclofenac
suppository was also not seen.
24
This study, therefore,
did not demonstrate any significant effect of diclofenac
suppository in reducing side effects due to tramadol. Ng
et al. all demonstrated a reduction in morphine
consumption with diclofenac suppository given after
induction of anaesthesia in total abdominal
hysterectomy but side effects were not decreased.
28,29
This fact has also been commented upon by other
authors with other drug combinations.
21,24
It is
hypothesized that only if addition of diclofenac
decreases morphine consumption by 50%, only then a
reduction in side effects is seen.
21
Negative findings have also been reported in several
other studies, with either diclofenac morphine
combination or other narcotic and non opioid
combinations of postoperative pain.
29,30
In the present
study, reasons could be several. Firstly, surgery was
performed by different surgeons. Variations in dissection
and surgical techniques can lead to a difference in
postoperative analgesic requirements. The timing of
administration of analgesic drug has also been
implicated in lack of opioid sparing effect.
30
Vandermeulen et al. suggested that lack of opioid sparing
effects with NSAIDs after certain operations may have
resulted because of its postoperative use only.
31
Certain
pharmacokinetic characteristics, such as low lipid
solubility and high protein binding, may also prevent the
central effect.
32
This has been reported with tenoxicam.
Individual variations in pain perception and scores may
also not show a significant effect.
32
As the number of
boluses requested/delivered by the PCA pump at each
hour were not assessed, therefore, the differences
between the immediate and late postoperative periods
could not be observed. Other patient factors like patient
suffering from pain but not demanding analgesia are
also a possibility.
CONCLUSION
The addition of diclofenac suppository 100 mg (inserted
after induction) to PCA with tramadol offered no
advantage in pain relief or opioid consumption for the
first 24 hours after total abdominal hysterectomy.
Acknowledgement: This study was supported by seed
money grant from our institution (Aga Khan University).
The authors wish to acknowledge the help of Miss
Salwa Zubair, Pharmacist, for preparing the
suppositories, Mr. Syed Iqbal Azam (Statistician),
Assistant Professor, Community Health Sciences,
AKUH for statistical support and Mrs. Riffat Amir, Acute
Pain Nurse, Department of Anaesthesia, AKUH, in
recording the parameters postoperatively.
REFERENCES
1. White PF. The role of non-opioid analgesic techniques in the
management of pain after ambulatory surgery. Anesth Analg 2002;
94: 577-85.
2. Montes A, Warmer W, Puig MM. Use of intravenous patient-
controlled analgesia for the documentation of synergy between
tramadol and metamizol.
Br J Anaesth 2000; 85: 217-23.
3. Kolesnikov YA, Wilson RS, Pasternak GW. The synergistic
analgesic interactions between hydrocodone and ibuprofen.
Anesth Analg 2003; 97:1721-3.
4. Kehlet K, Holte K. Effect of postoperative analgesia on surgical
outcome. Br J Anaesth 2001; 87:62-72.
5. Hanna MH, Elliott KM, Stuart-Taylor ME, Roberts DR, Buggy D,
Arthurs GJ. Comparative study of analgesic efficacy and
morphine-sparing effect of intramuscular dexketoprofen
trometamol with ketoprofen or placebo after major orthopaedic
Page 4
Journal of the College of Physicians and Surgeons Pakistan 2008, Vol. 18 (9): 533-537 537
Effect of diclofenac suppository on tramadol consumption in posthysterectomy pain
surgery. Br J Clin Pharmacol 2003; 55:126-33.
6. Webb AR, Leong S, Myles PS, Burn SJ. The addition of a
tramadol infusion to morphine patient-controlled analgesia after
abdominal surgery: double-blinded, placebo-controlled
randomized trial. Anesth Analg 2002; 95:1713-8.
7. Silvasti M, Svartling N, Pitkanen M, Rosenberg PH. Comparison
of intravenous patient-controlled analgesia with tramadol
versus morphine after microvascular breast reconstruction.
Eur J Anaesthesiol 2000; 17:448-55.
8. Jensen MP, Karoly P, Braver S. The measurement of clinical
pain intensity: a comparison of six methods.
Pain 1986; 27:117-
26.
9. Chernik DA, Gilling D, Taine H. Validity and reliability of the
observer’s assessment of alertness/sedation scale: study with
intravenous midazolam. J Clin Psychol Pharmacol 1990; 10: 244-57.
10. Vickers MD, Paravicini D. Comparison of tramadol with
morphine for postoperative pain following abdominal surgery.
Eur J Anaesthesiol 1995; 12:265-71.
11. Bamigbade TA, Davidson C, Langford RM, Stamford JA. Actions
of tramadol, its enantiomers and principal metabolite,
O-desmethyltramadol, on serotonin (5-HT) efflux and uptake in
the rat dorsal raphe nucleus. Br J Anaesth 1997; 79: 353-6.
12. Stamer UM, Maier C, Grond S, Veh-Schmidt B, Klaschik E,
Lehmann KA. Tramadol in the management of postoperative
pain: a double blind, placebo and active drug-controlled study.
Eur J Anesthesiol 1997; 14:646-54.
13. Hopkins D, Shipton EA, Potgieter D, Van derMerwe CA, Boon J,
De Wet C,
et al. The comparison of tramadol and morphine via
subcutaneous PCA following major orthopaedic surgery.
Can J Anaesth 1998; 45:435-42.
14. Shipton FA. Tramadol present and future.
Anaesth Intensive Care
2000; 28:363-74.
15. Pang WW, Mok MS, Lin CH, Yang TF, Huang MH. Comparison
of patient-controlled analgesia (PCA) with tramadol versus
morphine.
Can J Anaesth 1999; 46:1030-5.
16. Pieri M, Meacci L, Santini L, Santini G, Dollorenzo R, Sansevero
A. Control of acute pain after major abdominal surgery in 585
patients given tramadol and ketorolac by intravenous infusion.
Drugs Exp Clin Res 2002; 28:113-8.
17. Montes A, Warner W, Puig MM. Use of intravenous patient-
controlled analgesia for the documentation of synergy between
tramadol and metamizol. Br J Anaesthesia 2000; 85: 217-23.
18. Tuncer S, Pirbudak L, Balat O, Capar M. Adding ketoprofen to
intravenous patient-controlled analgesia with tramadol after
major gynaecological cancer surgery: a double-blinded,
randomized, placebo-controlled clinical trial. Eur J Gynaecol Oncol
2003; 24:181-4.
19. Pang W, Huang S, Tung CC, Huang MH. Patient-controlled
analgesia with tramadol versus tramadol plus lysine acetyl
salicylate.
Anesth Analg 2000; 91:1226-9.
20. Lauretti CR, Mattos AL, Lima IC. Tramadol and beta-
cyclodextrin piroxicam: effective multimodal balanced analgesia
for the intra and postoperative period.
Reg Anesth 1997; 22: 243-8.
21. Cobby TF, Crighton IM, Kyriakides K, Hobbs GJ. Rectal
paracetamol has a significant morphine sparing effect after
hysterectomy. Br J Anaesth 1999; 83: 253-6.
22. Dhal JB, Kehlet H. Non-steroidal anti-inflammatory drugs:
rationale for use in severe postoperative pain. Br J Anaesth 1991;
66:703-12.
23. Forse A, El-Beheiry H, Bulter PO, Pace RF. Indomethacin and
ketorolac given pre-operatively are equally effective in reducing
early postoperative pain after laparoscopic cholecystectomy.
Can J Surg 1996; 39:26-30.
24. Scott RM, Jenssings PN. Rectal diclofenac analgesia after
abdominal hysterectomy. Aust NZ J Obstet Gynaecol 1997; 37:112-4.
25. Oberhofer D, Skok J, Nesek-Adam V. Intravenous Ketoprofen in
postoperative pain treatment after major abdominal surgery.
World J Surg 2005; 29: 446-9.
26. Parker RK, Holtmann B, White PF. Patient-controlled analgesia.
Does a concurrent opioid infusion improve pain management
after surgery? JAMA 1991; 266:1947-52.
27. Moiniche S, Romsing J, Dahl JB, Tramer MR. Non-steroidal
anti-inflammatory drugs and the risk of operative bleeding after
tonsillectomy of quantitative systematic review. Anesth Analg 2003;
96: 68-77.
28. Ng A, Parker J, Toogood L, Cotton BR, Smith G. Does the opioid
sparing effect of rectal diclofenac following total abdominal
hysterectomy benefit the patient?
Br J Anaesth 2002; 88:714-6.
29. Colquhoun AD, Fell D. Failure of rectal diclofenac to augment
opioid analgesia after cholecystectomy. Anaesthesia 1989; 44:
57-60.
30. Danou F, Paraskeve A, Vassilakopoulo T, Fassoulaki A. The
analgesic efficacy of intravenous tenoxicam as an adjuvant to
patient controlled analgesia in total abdominal hysterectomy.
Anesth Analg 2000; 90: 672-6.
31. Vandermeulen EP, Van Aken H, Scholtes JL, Singelyn F,
Buelens A, Haazen L. Intravenous administration of tenoxicam
40 mg for postoperative analgesia: a double-blind, placebo-
controlled multi centre study. Eur J Anaesth 1997; 14: 250-7.
32. Todd PA, Clessold SP. Tenoxicam; an update of its
pharmacology and therapeutic efficacy in rheumatic diseases.
Drugs 1991; 41: 625-46.
●●●●●●●●●●
Page 5
  • [Show abstract] [Hide abstract] ABSTRACT: Pain is the most common complaint in all kinds of diseases. Considering side effects of chemical medicines as well as unnecessary continuation of pain after surgery, the present study aimed at evaluating anti-pain effect of Chelledaghi herbal extract on mitigation of pain after hysterectomy surgery. This study was conducted on 90 randomly selected patients. The subjects were divided into three groups each of them consisting of 30 cases. One group was regarded as control and two other groups as case groups. The group A (control group) received the placebo from 24 h before surgery to 24 h after surgery. The group B (case I) received placebo 24 h before surgery and medicine containing Chelledaghi herbal extract for 24 h after surgery. The group C (case II) received medicine containing Chelledaghi herbal extract which was prepared as a suppository from 24 before to 24 h after surgery for every 12 h. Then, pain severity based on VAS within different time intervals after surgery. Mitigation rate of pain after surgery, need to use sedatives, low dosage of the consumed anti-pain medicine and pain severity after surgery were all better in the groups B and C in comparison with the placebo group. Rate of complications after surgery was the same for all three groups and there was not any statistically meaningful difference in this regard. Chelledaghi herbal extract can be effectively used to mitigate pain after surgery in the selected patients without any significant side effects.
    No preview · Article · Sep 2013 · Pakistan Journal of Biological Sciences
  • Source
    [Show abstract] [Hide abstract] ABSTRACT: Background: Simple and efficient way of pain management after Coronary Artery Bypass Graft (CABG) surgery is an important aspect of patients' care. Objectives: This study aimed to compare the effects of morphine and diclofenac suppositories on postoperative pain management. Patients and Methods: In this double-blinded clinical trial study, 120 patients aged 30-65 years old, undergone CABG, were equally divided into two groups of A (morphine) and B (diclofenac). All patients were anesthetized with intravenous fentanyl 10 μg/kg, etomidate 0.2 mg/kg and cisatracurium 0.2 mg/kg. Anesthesia was maintained with oxygen 50% and air 50%, propofol 50 μg/kg/min, fentanyl 1-2 μg/kg/h and atracurium 0.6 mg/kg/h. Analgesics were administered after the operation at intensive care unit (ICU) and Visual Analogue Score (VAS) was evaluated in both groups in 4-hour intervals after extubation for 24 hours. After extubation in case of VAS > 3, morphine suppository 10 mg (group A) or diclofenac suppository 50 mg (group B) was administered for patients. Results: No significant statistical relationship was found between the two groups regarding gender, age, BMI, paracetamol consumption, length of operation time, cardiopulmonary bypass pump (CPB) time, and stay time at ICU (P Value ≥ 0.05). Total dosage of used morphine was 22 ± 8.3 mg in each patient and total dosage of used diclofenac was 94 ± 32.01 mg. Average variation of VAS at measured intervals was significant (P Value ≤ 0.0001), but these variations were not significantly different when comparing the two groups (P Value = 0.023). Conclusions: Both morphine and diclofenac suppositories reduced pain significantly and similarly after CABG surgery.
    Full-text · Article · Oct 2014 · Anesthesiology and Pain Medicine