Comparision of analgesic efficacy of tramadol infusion versus tramadol plus ondansetron infusion in medical intensive care unit
Kartik Munta, Surya Yarramalle, Pradeep Venkategowda, Sagar Sunka, Sai Dudam
Analgesia, ondansetron, tramadol
Citation Information :
Munta K, Yarramalle S, Venkategowda P, Sunka S, Dudam S. Comparision of analgesic efficacy of tramadol infusion versus tramadol plus ondansetron infusion in medical intensive care unit. Indian J Crit Care Med 2018; 22 (5):353-356.
Background: Tramadol, a preferred analgesic due to its less respiratory depression. It also has a central action that blocks the reuptake and enhances the release of serotonin at spinal antinociceptive pathways. Ondansetron, an antiemetic is a serotonin receptor antagonist. Due to the contradictory actions of the two drugs, co-administration of these drugs resulted in higher usage of tramadol. All these studies were done in the postoperative period.
Aim: The aim of this study is to evaluate the analgesic efficacy of tramadol infusion versus tramadol plus ondansetron infusion in Medical Intensive Care Unit (ICU) patients.
Materials and Methods: After Institutional Ethical Committee approval, 50 patients who experience pain other than postoperative pain were enrolled and randomized into two groups. Both the groups initially received 50 mg of tramadol intravenously over 10 min followed by Group T+O received 10 mg/h tramadol + 0.4 mg/h ondansetron as an infusion. Group T received 10 mg/h tramadol as infusion. Hemodynamic parameters along with pain assessment using Verbal Rating Scale (VRS) were analyzed at 0, 3, 6, 12, and 24 h. Rescue analgesia was administered if VRS >4. Side effects were noted by condition scoring criteria (CSC) scale.
Results: Rescue analgesia was administered at 3 h, for three patients in T+O Group and 1 patient in T Group, but this is not statistically significant (P = 0.153). No rescue analgesia was required in both the groups at any other point of time. There was fall in heart rate, systolic and diastolic blood pressures, respiratory rate at 0, 3, 6, 12, and 24 h in both the groups but not statistically significant. Grade 1 sedation of CSC scale was observed in two patients of Group T+O and one patient in Group T but not statistically significant (P = 0.153). No nausea and vomiting were seen.
Conclusions: We conclude that co-administration of tramadol and ondansetron can be practiced in medical ICU patients without any higher requirement in dosage of tramadol.
Milne RJ, Heel RC. Ondansetron. Therapeutic use as an antiemetic. Drugs 1991;41:574-95.
Lee CR, McTavish D, Sorkin EM. Tramadol: A preliminary review of its pharmacodynamic and pharmacokinetic properties, and therapeutic potential in acute and chronic pain states. Drugs 1993;46:313-40.
Millan MJ. The role of descending noradrenergic and serotoninergic pathways in the modulation of nociception: Focus on receptor multiplicity. In: Dickenson AH, Melmon KL, Besson JM, editors. Handbook of Experimental Pharmacology. Vol. 130. The pharmacology of pain, 6th ed. Heidelberg Springer-Verlag; 1997. p. 385-446.
Vickers MD. The efficacy of tramadol hydrochloride in the treatment of postoperative pain. Rev Contemp Pharmacother 1995;6:499-506.
Tramèr MR, Reynolds DJ, Stoner NS, Moore RA, McQuay HJ. Efficacy of 5-HT3 receptor antagonists in radiotherapy-induced nausea and vomiting: A quantitative systematic review. Eur J Cancer 1998;34:1836-44.
Arcioni R, Della Rocca M, Romanò S, Romano R, Pietropaoli P, Gasparetto A, et al. Ondansetron inhibits the analgesic effects of tramadol: A possible 5-HT(3) spinal receptor involvement in acute pain in humans. Anesth Analg 2002;94:1553-7.
Vale C, Oliveira F, Assunção J, Fontes-Ribeiro C, Pereira F. Co-administration of ondansetron decreases the analgesic efficacy of tramadol in humans. Pharmacology 2011;88:182-7.
Rauers NI, Stüber F, Lee EH, Musshoff F, Fimmers R, Barann M, et al. Antagonistic effects of ondansetron and tramadol? A randomized placebo and active drug controlled study. J Pain 2010;11:1274-81.
Dayer P, Desmeules J, Collart L. Pharmacology of tramadol. Drugs 1997;53 Suppl 2:18-24.
Fukuda K. Opioid analgesics. In: Miller RD, Cohen NH, Eriksson LI, Eleisher LA, Wiener-Kronish JP, Young WL, editors. Miller's Anesthesia. 8th ed. Philadelphia: Elsevier Saunders; 2015. p. 903-31.
Miotto K, Cho AK, Khalil MA, Blanco K, Sasaki JD, Rawson R, et al. Trends in tramadol: Pharmacology, metabolism, and misuse. Anesth Analg 2017;124:44-51.
Richardson BP, Bucheit KH. The pharmacology, distribution and function of 5-HT3 receptors. In: Osborne NN, Hamon M, editors. Neuronal Serotonin. Chichester: John Wiley and Sons; 1988. p. 465-506.
Kidd EJ, Laporte AM, Langlois X, Fattaccini CM, Doyen C, Lombard MC, et al. 5-HT3 receptors in the rat central nervous system are mainly located on nerve fibres and terminals. Brain Res 1993;612:289-98.
Ye JH, Mui WC, Ren J, Hunt TE, Wu WH, Zbuzek VK, et al. Ondansetron exhibits the properties of a local anesthetic. Anesth Analg 1997;85:1116-21.
Gregory RE, Ettinger DS. 5-HT3 receptor antagonists for the prevention of chemotherapy-induced nausea and vomiting. A comparison of their pharmacology and clinical efficacy. Drugs 1998;55:173-89.
Cui M, Feng Y, McAdoo DJ, Willis WD. Periaqueductal gray stimulation-induced inhibition of nociceptive dorsal horn neurons in rats is associated with the release of norepinephrine, serotonin, and amino acids. J Pharmacol Exp Ther 1999;289:868-76.
Rao SM, Netke B, Ponavala T, Kumar S, Dharmarakshak A. Post-operative pain relief by PCA v/s oral tramadol in cardiac surgery. Ann Card Anaesth 2001;4:13-6.
Rüd U, Fischer MV, Mewes R, Paravicini D. Postoperative analgesia with tramadol. Continuous infusion versus repetitive bolus administration. Anaesthesist 1994;43:316-21.