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Re: Additional use of Tramadol in Parturients
- Mokhtar Elhakim, W.Abd El-Megid,A metry, A.El-hennawy and K,El-Queseny (21 February 2006)
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Re: Tramadol in Pregnancy
- mokhtar Elhakim, W.Abd El-Megid,A metry, A.El-hennawy and K,El-Queseny (21 February 2006)
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Re: Antacid properties of preoperative i.m. tramadol
- mokhtar Elhakim, W.Abd El-Megid,A metry, A.El-hennawy and K,El-Queseny (21 February 2006)
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Reply
- M Elhakim (15 February 2006)
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Tramadol in caesarean section under general anesthesia
- rajesh mahajan, aanju sharma rahul gupta (13 February 2006)
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Additional use of Tramadol in Parturients
- Dr Snehal Ramnath Kumbhare (9 January 2006)
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Tramadol in Pregnancy
- RACHNA SHANKAR (5 January 2006)
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Antacid properties of preoperative i.m. tramadol
- kingsley Barasua Pepple (3 January 2006)
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Mokhtar Elhakim, Professor of Anaesthesia Faculty of medicine , Ain-Shams university, W.Abd El-Megid,A metry, A.El-hennawy and K,El-Queseny
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We would like to thank Dr. Kumbhare for his important contribution. After general or regional anaesthesia, tramadol is known to be effective in preventing the development of shivering as well as in suppressing established shivering. Because it is important new topic, a study in our department was undergoing now to evaluate the preventive effect of epidural versus i.v. tramadol on postoperative shivering. Conflict of Interest:None declared |
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mokhtar Elhakim, Professor of Anaesthesia Faculty of medicine , Ain-Shams university, W.Abd El-Megid,A metry, A.El-hennawy and K,El-Queseny
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I agree with Dr. Shankar and Alpharma manufacturers on the lack of information relating to the safety of use of tramadol during pregnancy and lactation. In the current study, we could not attribute any problem to tramadol in our patients. Grinten et al1 recently reported that despite the difference in the renal elimination of active tramadol metabolite between neonates and adult in line with the slow maturation of renal function in neonates, i.m. tramadol at the recommended dosage during delivery appears to effective in relief of labour pain. Tramadol is less likely to causes neonatal respiratory depression compared with pethidine in parturients undergoing vaginal delivery2 ,3. Spinal anaesthesia is generally preferred for elective Caesarean section. But spinal anaesthesia cannot be considered safer than epidural or general anaesthesia for the fetus4. Even we can use i.m. tramadol in patients undergoing Caesarean delivery under regional anaesthesia as a part of multimodal analgesic regimen with antacid and anti-shivering properties. However, as already mentioned in the text, no conclusion can be drawn about safety from number of patients (30) used in our present study. References: 1-Claahsen-van der Grinten HL, Verbruggen I, van den Berg PP, Sporken JM, Kollee LA. Different pharmacokinetics of tramadol in mothers treated for labour pain and in their neonates. Eur J Clin Pharmacol 2005; 61:523-9. 2-Viegas OA, Khaw B, Ratnam SS. Tramadol in labour pain in primiparous patients. A prospective comparative clinical trial. Eur J Obstet Gynecol Reprod Biol. 1993; 49: 131-5 3-Jain S, Arya VK, Gopalan S, Jain V. Analgesic efficacy of intramuscular opioids versus epidural analgesia in labor. Int J Gynaecol Obstet 2003; 83:19-27. 4-Reynolds F, and Seed PT. Anaesthesia for Caesarean section and neonatal acid-base status: a meta-analysis. Anaesthesia 2005;60:636-653. Conflict of Interest:None declared |
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mokhtar Elhakim, Professor of Anaesthesia Faculty of medicine , Ain-Shams university, W.Abd El-Megid,A metry, A.El-hennawy and K,El-Queseny
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We thank Dr. Pepple for his interest in our study. It is true that spinal anaesthesia is generally preferred for elective Caesarean section. But spinal anaesthesia cannot be considered safer than epidural or general anaesthesia for the fetus1. Second, it is difficult clinically to use the same patient as suggested by Pepple to obtain baseline gastric pH value prior to the administration of tramadol and famotidine respectively. Minami et al2 reported that gastric pH was higher 3h after tramadol administration. The concentration time of tramadol in gastric mucosa still remains unknown but minimal effective serum concentrations of tramadol are maintained for nine and ten hours on average3. We believe that sample size determination of patients prior to start of study and our routine confirmation of correct position of Salem nasogastric tube inside stomach were avoided effectively any error in gastric juice pH measurement values. References: 1-Reynolds F, and Seed PT. Anaesthesia for Caesarean section and neonatal acid-base status: a meta-analysis. Anaesthesia 2005;60:636-653. 2-Minami K, Ogata J, Horishita T, Shiraishi M, Okamoto T, Sata T, Shigematsu A. Intramuscular tramadol increases gastric pH during anesthesia. Can J Anesth 2004; 51: 545-8 3- Lintz W, Beier H, Gerloff J. Bioavailability of tramadol after i.m. injection in comparison to i.v. infusion. Int J Clin Pharmacol Ther 1999; 37: 175-83. Conflict of Interest:None declared |
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M Elhakim, Professor Ain-Sham University, Cairo Egypt
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We would like to thank Dr. Mahajan and colleagues for their interest in our article and their valuable comments. In regard to the emetic potential of tramadol, we believe that nausea and vomiting were avoided effectively over 24h after operation in our patients by administrating tramadol preoperatively. Propofol may be of value although its antiemetic properties appear short-lived in the first 6h after surgery1. The concern of Mahajan and enclosed recent meta-analysis regarding poor preemptive effect of tramadol requires clarification. It is widely accepted that tissues injury often results in a prolonged sensitization of the central nervous system, which is at least in part mediated by activation of NMDA receptors2. NMDA receptor antagonists are more effective when a trauma is rapid intense as in caesarean section. Nitrous oxide used in the present anaesthetic regimen, might have enhanced NMDA receptor inhibition by tramadol because nitrous oxide was also reported to exert NMDA antagonist action3. This may explain relative haemodynamic stability during induction delivery time in our tramadol patients, even before nalbuphine administration. Furthermore, Kohiitani et al.4 reported recently that NMDA receptor antagonists possibly inhibit noradrenergic noncholinergic lower esophageal sphincter relaxation via antagonism of the peripheral NMDA receptors. Lower esophageal sphincter contractility is one of the crucial factors in preventing regurgitation during general anaesthesia. This possible tramadol action may be balanced against its potential to increase in the volume of gastric secretion. References: 1- Reimer El, Montgomery CJ, Bevan JC, Merrick PM, Blackstock D, Popovic V. Propofol anesthesia reduces early postoperative vomiting after paediatric strabismus surgery. Can J Anaesth 1993; 40: 927-33. 2- Petrenko AB, Yamakura T, Baba H, Shimoji K. The role of N-methyl-D- aspartate (NMDA) receptors in pain: a review. Anesth Analg 2003; 97:1108- 16. 3- Jevtovic-Todorovic V, Todorovic SM, Mennerick S, et al. Nitrous oxide (laughing gas) is an NMDA antagonist, neuroprotectant and neurotoxin. Nature Med 1998;4:460-3. 4- Kohjitani A, Funahashi M, Miyawaki T, et al. Peripheral N-methyl- D- Aspartate receptors modulate nonadrenergic noncholinergic lower esophageal sphincter relaxation in rabbits. Anesth Analg 2005;101:1681-8. Conflict of Interest:None declared |
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rajesh mahajan, doctor ascoms, aanju sharma rahul gupta
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We were interested in the recent article by Elhakim and colleagues on the use of tramadol in patients undergoing cesarean section demonstrating its utility in decreasing gastric pH in addition to its usual analgesic effect without any significant increase in side effects1. However we have few reservations over the study design. First, authors have used propofol in dose of 2 mg .kg -1 in their study. The emetic potential of tramadol has been found even higher than morphine2, 3. Propofol even in subhypnotic doses of 1 mg .kg -1 has been found to significantly decrease the incidence of postoperative nausea and vomiting in patients going caesarean section4,5. Thus there is strong possibility that propofol may have suppressed the emetic effects of tramadol in the patients enrolled in this study. However administration of tramadol to parturient who under go induction of anesthesia with other agents like thiopentone may not yield similar favorable results for post operative nausea and vomiting in the patients .Further authors have demonstrated preemptive/preventive analgesic effect of opioid µ receptor agonist and NMDA antagonist, tramadol in this study. However recent meta- analysis regarding preventive analgesia has clearly demonstrated the poor efficacy of both opioids and NMDA antagonists in this regard. Rather a pronounced pre emptive effect with epidural analgesia, local infiltration and systemic NSAIDS has been demonstrated6, 7. Hence the results of better analgesic efficacy in group receiving tramadol are surprising. This better analgesic efficacy in patients receiving tramadol may in fact represent a synergistic /additive effect of tramadol with nalbuphine and not a preemptive effect. Considering these facts , it seems that use of tramadol may not be feasible with other iv induction agents expect propofol and although its use may negate the requirement of H- 2 receptor blockers to decrease pH before caesarean section ,this should be carefully balanced against its poor pre emptive efficacy and potential to increase the volume of gastric secretions. REFERENCES 1. Elhakim M, El-Megil WA , Metry A,EL-hennawiy , El-Queseny K. Anelgesia and antacid properties of i.m. tramadol given before caesearean section under general anaesthesia. Br J Anaesth 2005;95 ;811-5 2. Ng KF, Tsui SL, Yang JC, Ho ET. Increased nausea and dizziness when using tramadol for post-operative patient-controlled analgesia (PCA) compared with morphine after intraoperative loading with morphine. Eur J Anaesthesiol. 1998; 15:565-70 3. Pang WW, Mok MS, Lin CH, Yang TF, Huang MH. Comparison of patient- controlled analgesia (PCA) with tramadol or morphine. Can J Anaesth. 1999; 46: 1030-5. 4. Fujii Y, Numazaki M. Dose-range effects of propofol for reducing emetic symptoms during cesarean delivery. Obstet Gynecol. 2002; 99:75-9. 5. Numazaki M, Fujii Y. Subhypnotic dose of propofol for the prevention of nausea and vomiting during spinal anaesthesia for caesarean section. Anaesth Intensive Care. 2000; 28: 262-5. 6. Ong CKS, Lirk P, Seymour A, Jenkins BJ. The efficacy of preemptive analgesia for acute post -operative pain management: A meta- analysis. Anesth Analg 2005; 100:757-73 7. Kissin I. Preemptive analgesia on the cross road . Anesth Analg 2005;100:754-6 Conflict of Interest:NIL |
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Dr Snehal Ramnath Kumbhare, Clinical Attachment in Anaesthetics Huddersfield Royal Infirmary
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I read, with interest, this article about the Analgesic and Antacid Properties of Tramadol. The safety factor of Tramadol during Pregnancy is debatable and as already mentioned in the article, the usage is not licensed. The brighter side is, no adverse effects have been reported. Furthermore, there is a supporting evidence (1) for usage of Tramadol in Pregnant patients although for a different purpose. Shivering is a common side effect after Anaesthesia, whether it’s general or spinal. Prevention is always better than cure and more so because it consumes a lot of calories and most importantly, the oxygen requirement increases especially in the post operative period. Tramadol is an effective way to prevent shivering (1,2,3,4) in patients undergoing Anaesthesia and also in parturients undergoing General Anaesthesia (1). Anti shivering properties makes tramadol more useful in the post- operative period, more so in pregnant patients and adds to its antacid and analgesic properties. References 1. Anesth Analg 2001;93:1288-1292 A Comparison of Tramadol, Amitriptyline, and Meperidine for Postepidural Anaesthetic Shivering in Parturients. Yu-Chuan Tsai, MD*, and Koung-Shing Chu, MD 2. Anaesth Intensive Care. 2001 Apr;29(2):149-54 Tramadol for postoperative shivering: a double-blind comparison with pethidine. Bhatnagar S, Saxena A, Kannan TR, Punj J, Panigrahi M, Mishra S 3. Indian J. Anaesth. 2005; 49(3): 208-212 Effect of Tramadol in prevention of postanaesthetic shivering following general anaesthesia for cholecystectomy. Dr. Enakshi Saha, Dr. Manjushree Ray, Dr. Gauri Mukherjee. 4. ASA, Annual Meeting Abstracts.A-1293 2004 Intraoperative Use of Tramadol Prevents Postoperative Shivering after Remifentanil-Based General Anesthesia. A Doubleblind, Placebocontrolled Study. Ulfert Grimm, Walter Roth, M.D., Juergen Jage, M.D., Prof. Department of Anesthesiology, University Hospital, Mainz, Germany Conflict of Interest:None declared |
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RACHNA SHANKAR, SHO/Anaesthetics Royal Liverpool Hospital
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Editor -It was very interesting to know few good things about tramadol,a drug which is more known for its side effects. Though increased gastric pH had been published before in Canadian Journal of Anaesthesia in 2004. I was more surprised that study was conducted in pregnant patients, whereas manufacturers advise caution in this group as well as during lactation. I made an enquiry with Alpharma, the major pharmaceutical manufacturers/ distributors for the drug and they quoted “ it is preferable to avoid the use during pregnancy. In humans there is insufficient data available to appropriately assess the safety of tramadol use in pregnant women. At the end of pregnancy even shortterm treatment may cause depression in the newborn.Tramadol and its metabolite have been detected in breast milk in small amounts. An infant could ingest .1% of the single dose given to mother.” And the levels in newborns were not measured Even BNF,Australian prescriber cautions its use in pregnancy and lactation. Another interesting thing was Alpharma wanted it to be reported to them if used in these subgroups. One thing I couldn’t understand was why such a large number (60) of women were posed to risks of general anaesthetic when there is increasing trend towards regional anaesthetic for elective caesarean section, more so in ASA 1. I think that safety of use of tramadol in pregnancy and lactation still needs to be evaluated. Rachna Shankar Liverpool,U.K. rachnas@rediffmail.com 1.Canadian Journal of Anaesthesia 5: 545-548: 2004. 2.Alpharma Limited ,N Devon EX328NS. Conflict of Interest:None declared |
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kingsley Barasua Pepple, SpR anaesthetic SGH none
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Editor- It is with great interest that I read this article tittled Analgesic and antacid properties of Im tramadol given before caesarean section under general anaesthesia published in your journal. Whilst some of the drawbacks of the study as stated by the investigator are well noted. Further clarafication on the indication for elective caesarean under general anaesthesia for the 60 ASA 1 patients enrolled in this study will help erase the thought that these patients were probably subjected to the hazards of general anaesthesia primary for this study. My other concern is the absence of a control arm to this study. ie not using the same patient as thier own control to obtain baseline gastric PH value prior to the administration of tramadol and famotidine respectively.The self control arm will undoubtedly standardize the gastric juice sample thus minimize the errors introduced by the varying positioning of the Salem nasogastric tube with respect to gastric juice PH measurement values obtained. Conflict of Interest:None declared |
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