Addition of 100 mg of Tramadol to 40 mL of 0.5% Ropivacaine for Interscalene Brachial Plexus Block Improves Postoperative Analgesia in Patients Undergoing Shoulder Surgeries as Compared to Ropivacaine Alone—A Randomized Controlled Study

Abstract

Background and objectives: Brachial plexus block is commonly used in shoulder surgery, as it provides satisfactory surgical conditions and adequate postoperative pain control. However, there are contradictory reports regarding the addition of tramadol to the injected regional anesthetic solution. We performed a prospective randomized study to evaluate the effectiveness of tramadol as an adjuvant to ropivacaine during interscalene brachial plexus block and assess its impact on the opioid consumption and the early postoperative pain in patients that underwent shoulder surgery. Materials and Methods: Eighty patients scheduled for elective shoulder surgery and anesthesia via interscalene brachial plexus block were randomly divided into two groups. In group A (n = 40), a solution of 40 mL of ropivacaine 0.5% and 2 mL (100 mg) of tramadol was administered during the brachial plexus block, while in group B (n = 40), a solution of 40 mL of ropivacaine 0.5% and 2 mL NaCl 0.9% (placebo) was administered. The effectiveness and duration of sensory and motor blocks were recorded in both groups. The sensory block was assessed recording the loss of sensation to pin prick test over the skin distribution of the axillary, radial, and musculocutaneous nerves. The motor block was assessed using the modified 3-point Bromage score (0–2 points). Cumulative morphine consumption and pain, using the Visual Analog Scale (VAS), were evaluated in both groups at 2, 4, 8, and 24 h after surgery. Results: Sensory block onset was achieved earlier in group A than in group B (5.21 ± 3.15 minutes (min) vs. 7.1 ± 4.51 min, p = 0.029). The motor block onset was similar between the two groups (13.08 ± 6.23 min vs. 13.28 ± 6.59 min; p = 0.932). The duration of the sensory block was longer in group A as compared to group B (13 ± 2.3 h vs. 12 ± 2.8 h; p = 0.013). The duration of the motor block did not present any difference between the groups (10 ± 2.2 h vs. 10 ± 2.8 h; p = 0.308). Differences in morphine administration were not significant at 2, 4, and 8 h, however, morphine consumption was found to be decreased in group A 24 h postoperatively A (p = 0.04). The values of VAS were similar at 2, 4, and 8 h, however, they were lower in group A at 24 h (p < 0.013). Conclusions: Combined regional administration of tramadol and ropivacaine during interscalene brachial plexus block improves the time of onset and the duration of the sensory block, while it is associated with reduced morphine consumption during the first 24 h after shoulder surgery.

Impact of adding opioids to paravertebral blocks in breast cancer surgery patients: A systematic review and meta-analysis

“…Such varied results with local anesthetic adjuvants have been reported with other nerve blocks as well. Soulioti et al [ 34 ] in an RCT reported improved outcomes with the addition of 100 mg of tramadol to brachial plexus block with ropivacaine. In contrast, no such benefit was noted by Kesimci et al [ 35 ] using a similar dose of tramadol with ropivacaine.…”

Analgesic effects of different concentrations of ropivacaine in transversalis fascia plane block during laparotomy

“…The Bruggrmann comfort scale (BCS) [ 13 ] was used to evaluate the comfort level of patients in the three groups, in which 0 points were considered as continuous pain, 1 point as no pain at rest and severe pain during deep breathing or coughing, 2 points as no pain when lying at rest and slight pain during deep breathing or coughing, 3 points as no pain during deep breathing, and 4 points as no pain during coughing.…”

Adjuvant Drugs for Peripheral Nerve Blocks: The Role of Alpha-2 Agonists, Dexamethasone, Midazolam, and Non-steroidal Anti-inflammatory Drugs

“…Tramadol's effectiveness and safety as an adjuvant to LA for PNB are inconsistent (17,19,36,51). Several studies and systematic reviews have investigated tramadol as an adjuvant in BPB but often yielded contradictory results (52,79).…”

“…Reviews by Koyyalamudi et al and Kirksey et al investigate tramadol with different local anesthetics (like bupivacaine, levobupivacaine, mepivacaine, and ropivacaine) in various PNBs (interscalene, axillary brachial plexus) reveal the often contradictory nature of the results (19,36). Recently, a 2019 RCT found that 100 mg tramadol with 0.5% ropivacaine for interscalene BPB lowered pain scores and cumulative morphine consumption 24h post-surgery (79). The authors claimed that the low incidence of complications suggests the safety of tramadol-ropivacaine combination to improve postoperative analgesia (79).…”

“…Recently, a 2019 RCT found that 100 mg tramadol with 0.5% ropivacaine for interscalene BPB lowered pain scores and cumulative morphine consumption 24h post-surgery (79). The authors claimed that the low incidence of complications suggests the safety of tramadol-ropivacaine combination to improve postoperative analgesia (79). Won Shin et al's 2017 meta-analysis of 16 RCTs reported 100 mg tramadol as prolonging sensory block, motor block and analgesia (high-quality evidence), and quickening sensory and motor block onsets for BPB in upper extremity surgeries (52).…”