Fentanyl Versus Tramadol As An Adjunct T
Fentanyl Versus Tramadol As An Adjunct T
1. Department of Anesthesia and Intensive Care, Faculty of Medicine, Aswan University, Egypt.
2. Department of Public Health, Faculty of Medicine, Aswan University, Egypt.
3. Department of Anesthesia and Intensive Care, Faculty of Medicine, Sohag University, Egypt.
Correspondence: Huda F. Ghazaly, PhD; Tel: +20 1098887555; E-mail: [email protected]
Abstract
Background & objective: There have been a lack of consensus among the anesthetists regarding the utility of different opioids
as adjuvants in brachial plexus blockade (BPB). The results vary and there is no agreement. We studied the utility of fentanyl
versus tramadol as an adjunct to local anesthetic bupivacaine in ultrasound-guided supraclavicular BPB.
Methodology: The study was conducted on 71 patients who were randomized in three groups for ultrasound-guided
supraclavicular brachial plexus block. Group B: received 20 ml bupivacaine 0.5% plus normal saline 2 ml; Group F received 20 ml
of bupivacaine 0.5% plus fentanyl 100 µg in 2 ml and Group T received 20 ml bupivacaine 0.5% plus tramadol 100 mg in 2 ml.
Data was collected for the onset and duration of sensory and motor block, time to first request for rescue analgesia and the total
analgesic consumption in first 24 h postoperatively.
Results: The onset of sensory blockade in Group T (8.36 ± 1.59 min) was significantly shorter compared to Group B [15.91 ± 3.21
min (p = 0.011)] and to Group F [10.64 ± 1.86 min (p = 0.011)]. The onset of motor blockade was also shorter in Group T (10.36 ±
1.92) compared to Group B [20.91 ± 3.22 min (p = 0.001)] and Group F [13.36 ± 1. 29 (p = 0.001) respectively. The time to first
analgesic requests was significantly longer in the Groups T and F than in the Group B (p = 0.001 and p = 0.021, respectively) and
significantly longer in the tramadol group compared to the fentanyl group (p = 0.041).
Conclusion: Tramadol as an adjuvant to bupivacaine in ultrasound-guided supraclavicular BPB, when compared to bupivacaine
alone or with fentanyl, has a shorter onset of sensory and motor blockade and produces a significantly prolonged analgesia.
Key words: Adjuvants; Analgesia; Bupivacaine; Fentanyl; Tramadol; Ultrasound-guided supraclavicular block
Abbreviations: BPB – brachial plexus blockade; VAS – visual analog scale; MBP – mean blood pressure; HR – heart rate; SpO2 –
peripheral oxygen saturation; LSD – test Least Significant Difference test
Citation: Ghazaly HF, Eldemrdash AM, Atito BE, Abdelrheem SS, Aly AAA. Fentanyl versus tramadol as an adjunct to bupivacaine
in ultrasound-guided supraclavicular brachial plexus blockade: pros and cons. Anaesth. pain intensive care 2021;25(4):450–457.
DOI: 10.35975/apic.v25i4.1565
Received: March 17, 2021. Reviewed: May 23, 2021. Accepted: June 17, 2021
www.apicareonline.com 450
Ghazaly FG et al adjuvants for brachial plexus block
Adjuvants are added to the local anesthetic in supplementary anesthesia were excluded from the
supraclavicular BPB to improve the quality of the study.
nerve blocks and prolong the duration of analgesia. Preoperatively, the procedure was explained to the
The addition of opioids as adjuvants not only affects patient in order to ensure cooperation and acceptance
the block properties by activating opioid receptors of being awake during surgery. Patients were shown a
outside the central nervous system but also decreases visual analog scale (VAS), which consisted of a
the need for postoperative opioids in patient controlled straight 10 cm line of which one end represented ‘no
intravenous analgesia thereby reducing the potential pain’ (0 cm) and the other end represented ‘The worst
side effects of opioids such as nausea, vomiting, and pain imaginable’ (10 cm).
respiratory depression. 3
All patients were fasting for at least 6 h before the
Tramadol is a synthetic 4-phenylpiperidine analog of procedure. On arrival at the operating room, standard
codeine that has a unique mode of action. It stimulates monitoring was connected and peripheral intravenous
the μ receptor and to a lesser extent the δ and κ-opioids (I.V.) line with an 18G cannula was secured in the
receptors. By its non-opioid mechanism, it motivates contralateral hand. Ringer lactate infusion started, and
spinal inhibition of pain by decreasing the reuptake of midazolam 0.05 mg/kg was given intravenously for
norepinephrine and serotonin from nerve endings and sedation. We measured the mean blood pressure
strengthens the effect of local anesthetics when mixed (MBP), heart rate (HR), peripheral oxygen saturation
in peripheral regional nerve block. It has far less (SpO2) before the block (0 min) and at 5, 10, 15, and
respiratory depressant effect than the opioids due to 30 min then at 1, 2, 3, 6, 12, 18, and 24 h after the
weak μ receptor affinity.4 block.
Fentanyl is a potent synthetic μ–receptor stimulating 2.1. Randomization and blinding
opioid. The addition of fentanyl to local anesthetics
has different effects on the quality of brachial plexus Patients were randomly divided into three groups
blocks. 5 Many controversies have been noted among using computer-generated randomization tables and
the previous studies for the use of different opioids as the group allocation was hidden in sealed opaque
adjuvants in BPB, 6 Moreover, only a few studies envelopes.
compared the use of fentanyl versus tramadol as an Group B (bupivacaine group): patients received 20 ml
adjunct to bupivacaine supraclavicular BPB. bupivacaine 0.5 % + 2 ml normal saline.
We investigated the analgesic efficacy of fentanyl Group F (fentanyl group): patients received 20 ml
versus tramadol as an adjunct to bupivacaine in bupivacaine 0.5 % + fentanyl [100 µg (2 ml)].
patients undergoing elbow and forearm surgery using Group T (tramadol group): patients received 20 ml
ultrasound-guided supraclavicular BPB. bupivacaine 0.5 % + tramadol [100 mg (2 ml)].
One of the authors who was not involved in the
2. Methodology conduct of the study received serially numbered sealed
After approval from the institutional review board and envelopes indicating the B, F, or T codes for preparing
Clinical Trials Registry (NCT04666337), this the anesthetic mixture to be administered. The
prospective, randomized, double-blinded controlled surgeon, attending anesthesiologists, data collecting
study was conducted on 71 patients who were personnel and the patient were blinded to the group
scheduled for elbow and forearm surgeries. The assignment
patients had been taught about the study and gave their Ultrasound-guided supraclavicular brachial plexus
consent in a written form. block7 was performed using a 5–10 MHz linear probe.
Patients aged between 18 and 60 y, of both genders, 2.2. Patient evaluation
and belonging to the ASA physical status I/II were
included in the study. Patients who had bleeding The primary outcome was the onset time of sensory
and motor blockade. The onset of sensory blockade
disorders, received opioid analgesics before surgery,
was checked with a gauze piece soaked in iced normal
had a history of seizures, respiratory or cardiac
saline with a three-point scale4: Grade 0 = normal
diseases, local infections at the site where needle for sensation; Grade 1 = loss of cold sensation (analgesia),
the block was to be inserted, pregnant women or Grade 2 = loss of touch sensation (anesthesia). Every
patients with unsatisfactory block effect requiring patient was checked for the onset of motor blockade
Table 2: Sensory and motor block characteristics after drug administration in the study groups
Table 3: First time for rescue analgesia and total analgesic consumption in the study groups
Parameters Group B Group F Group T p-value LSD post hoc
(N = 22) (N = 22) (N = 22)
Mean ± SD Mean ± SD Mean ± SD
(Range) (Range) (Range)
The first time for rescue 4.55 ± 1.42 7.33 ± 2.22 9.52 ± 3.01 0.042 Pa = 0.021
analgesia (h): (3–7) (5–9) (6–12) Pb = 0.001
Pc = 0.041
Total morphine sulfate 9.05 ± 1.5 5.91 ± 1.43 3.72 ± 0.51 0.022 Pa = 0.011
consumption (mg) in 1st 24 h (3 – 15) (3–10) (0–5) Pb = 0.001
postoperatively Pc = 0.045
Group B: bupivacaine group; Group T: tramadol group; Group F: fentanyl group; LSD: least significant difference. Pa: bupivacaine
group versus fentanyl group; Pb: bupivacaine group versus tramadol group; Pc: fentanyl group versus tramadol group.
The mean time for the onset of sensory block in Group post hoc showed that the time for onset of sensory
B, Group F, and Group T was 15.91 ± 3.21 min, 10.64 block in Group T was significantly faster compared to
± 1.86, and 8.36 ± 1.59 min, respectively. The LSD Group B (p = 0.001), and Group F (p = 0.045) (Table
2). The mean time for
the duration of
sensory block in
Group T was
significantly
prolonged compared
to Group B (p =
0.021) and Group F
(p = 0.015), as shown
in Table 2.
The mean time for the
onset of motor block
was different in the
study groups. The
mean time for Group
B was 20.91 ± 3.21,
Group F was 13.36 ±
1.29 and Group T was
10.36 ± 1.92 min
(Table 2). Statistical
analysis by The LSD
post hoc showed that
the time for the onset
of motor block in
Group T was
significantly faster
compared to
bupivacaine and
fentanyl groups (p <
0.001, p < 0.022,
respectively). The
respectively), and
significantly
prolonged in the
tramadol group
compared to the
fentanyl group (p =
0.041).
The ANOVA test
showed that the total
consumed doses of
morphine sulfate in
the first 24 h were
statistically
significant (p = 0.022)
among the three study
groups. LSD post hoc
analysis revealed that
patients in the
tramadol group
received fewer
analgesic doses than
those in the
bupivacaine and
fentanyl groups (p =
0.001 and p = 0.045,
respectively) (Table
3).
As shown in the
graph, there was no
significant difference
in heart rate (p > 0.05)
time for the duration of the motor blockade between between the three groups as shown in (Figure 3). The
the three groups showed no statistically significant mean arterial blood pressure between the three study
difference (p = 0.072) but statistical analysis by the groups was comparable, with no significant difference
LSD post hoc showed that the duration of the motor (p > 0.05), as shown in Figure 4. The statistical
blockade was prolonged in Group T compared to analysis by ANOVA ’F’ test showed that there was no
Group B (p = 0.041) as shown in Table 2. significant difference in arterial oxygen saturation
The statistical analysis by ANOVA test showed that between the three groups (p > 0.05) (Figure 5).
the mean VAS score among the three groups differed There were no significant differences in side effects
significantly at the 4th (p < 0.033), 6th (p < 0.031), between the three groups. The side effects were
12th (p < 0.011), and at the 24th (p < 0.001) hours after transient and did not require any therapeutic
surgery. intervention.
The three groups had an average VAS score below 4
cm in the first 4 h after completion of surgery and 4. Discussion
required no rescue analgesia (Figure 2). Time taken for Supraclavicular BPB provides complete and reliable
the first rescue analgesic dosage was significantly anesthesia for the upper limb surgeries. It has been
prolonged in tramadol and fentanyl groups compared associated with a shorter hospital stay, low financial
to the bupivacaine group (p = 0.001, p = 0.021, burden, and it avoids complications associated with
general anesthesia. Bupivacaine, when used alone for patients in tramadol (BT) group had a shorter time of
supraclavicular BPB provides perfect operative onset and a longer duration of sensory and motor
situations with a brief duration of postoperative blockade than the bupivacaine alone (B) group. In
analgesia. Hence, the ideal adjuvant to achieve quick, addition, the mean duration of analgesia in BT (7.06 ±
dense block with prolonged postoperative analgesia is 2.894 h) was longer than Group B (3.42 ± 0.283 h).
still being investigated. The earlier onset of sensory block and prolonged
Earlier studies used empirical single doses of analgesia in the fentanyl group compared to the
perineural tramadol ranging from 50-100 mg and bupivacaine group in the current study is also
fentanyl ranging from 50-100 μg with significant consistent with Kaniyil and Radhakrishnan
differences in outcomes; however, the optimal doses observations.11 They noticed that the onset time of
that provide the greatest improvement in block complete sensory and motor block was significantly
parameters with the fewest side effects remain prolonged in the fentanyl group and compared to the
unknown. 9-15 In our clinical trial, we investigated the bupivacaine group. The total duration of analgesia was
pros and cons of 100 μg (1 μg /kg) fentanyl versus 100 also significantly prolonged (p <0.001) in fentanyl
mg (1 mg/kg) tramadol as a bupivacaine adjunct in group compared to bupivacaine group.
ultrasound-guided supraclavicular brachial plexus
blockade. Rajkhowa et al.12 found that using fentanyl as an
The main findings of our study show that the onset of adjuvant in BPB extends sensory and motor duration
sensory blockade was significantly faster in the by 3 h, and they speculate that the mechanism of
tramadol group compared to bupivacaine and fentanyl fentanyl in prolonging analgesia could be due to the
groups (p = 0.001 and p = 0.045; respectively) and presence of peripheral functional opioid receptors.
earlier in the fentanyl group than the bupivacaine However, Kiran et al. 13 discovered that the onset time
group (p = 0.012). Patients in the tramadol group have of the sensory block in the fentanyl group was delayed
a longer time for the first rescue analgesic dosage with compared to the control group (p = 0.01). This
a prolonged analgesia time than patients in fentanyl difference from our results could be explained by the
and bupivacaine groups. Also, the total duration of different local anesthetics (bupivacaine 0.5% 20 mL +
sensory block in the tramadol group was significantly lignocaine 2% 20 mL) and dose of fentanyl (50 µg)
longer than in the fentanyl and bupivacaine groups (p used during their work.
= 0.015, p = 0.021; respectively). Sensory Allene et al. compared the efficacy of 100 mg tramadol
prolongation was also observed in the fentanyl group versus 50 µg fentanyl as an adjuvant to 0.25%
compared to the bupivacaine group (p = 0.040). bupivacaine for axillary block and founded that the
Consistent with our results, Nagpal et al. in their study onset of complete sensory and motor block was shorter
confirmed that when tramadol plus bupivacaine were in the fentanyl group compared to both the tramadol
injected perineurally for supraclavicular brachial and bupivacaine groups (P < 0.001).14 Furthermore,
plexus block, they sped up the onset of sensory block, the tramadol group had significantly longer mean
motor block and prolonged the time to rescue analgesia duration of sensory and motor blockade. The most
as compared to the other two groups in which tramadol likely explanation for this dissimilarity from our
was either injected intravenously (systemic group) or results is due to factors related to the difference in the
was not given at all (control group). 4 approach of axillary approach versus supraclavicular
Shin et al. in a systematic review and meta-analysis BPB.
included 16 studies that examined the impact of the Our findings are consistent with those of Nagpal et al.4
addition of tramadol to local anesthetics (LA) for BPB who observed that most patients who received
perineurally tramadol for supraclavicular brachial
and indicates that use of tramadol as an adjuvant to LA
plexus block required their first analgesic dose after 6
in PBP prolongs the duration of sensory block, motor
h of surgery, and that the delayed requirement of
block, and shortens the time to onset of sensory block analgesia postoperatively in these patients was
and motor block without any change in adverse statistically significant compared to control group. The
effects.10 prolonged analgesia in the tramadol group could be
Matching with previous results, Kumaran and due to the local anesthetic effect of tramadol on
Haribaskar1 evaluated the efficacy of tramadol (2 peripheral nerves as demonstrated by Yu-Chan Tsai et
mg/kg) as an adjuvant to bupivacaine (0.25%) in the al. 15
supraclavicular block in a study of 60 patients There was no significant difference in the
undergoing upper limb surgery. They found that hemodynamic parameters between the study groups.
This finding was consistent with what Suman 5. Sahi P, Kumar R, Sethi C, Gupta N, Singh A, Saxena P.
Chattopadhyay et al. had discovered. 16 Likewise, no Comparative Evaluation of the Effects of Fentanyl and
major side effects such as respiratory depression, Dexmedetomidine as an Adjuvants in Supraclavicular
pneumothorax, signs, or symptoms of local anesthetic Brachial Plexus Block Achieved with Ropivacaine. Int J Con
Med Res. 2018;5(1):25–9. [FreeFullText]
toxicity were observed in any study group.
6. Brummett CM, Williams BA. Additives to local anesthetics for
peripheral nerve blockade. Int Anesthesiol Clin. 2011
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10.1097/AIA.0b013e31820e4a49
It is a small, single-center study. Large-scale
multicenter studies are recommended to highlight the 7. Chan VWS, Perlas A, Rawson R, Odukoya O. Ultrasound-
differences between fentanyl and tramadol in guided supraclavicular brachial plexus block. Anesth Analg.
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