Paediatric Anaesthesia 2001

11: 459464

Comparison of caudal morphine and tramadol for postoperative pain control in children undergoing inguinal herniorrhaphy
D . O Z C E N G I Z , M . G U N D U Z , H . O Z B E K A N D G. I S I K
Department of Anaesthesiology, Faculty of Medicine, Cukurova University, Adana, Turkey

Objectives: We compared the quality and duration of analgesia, the effect on perioperative sevourane requirement after a single, presurgical caudal block with either tramadol or morphine in children undergoing inguinal herniorrhaphy. Our study was also designed to evaluate the preemptive analgesic efcacy of morphine administered caudally in children. Methods: Patients were randomly divided into three groups to receive 2 mgkg1 tramadol (group T, preemptive group) or morphine sulphate 0.03 mgkg1 (group M, preemptive group). The patients in control group (group C, postincisional group) received morphine sulphate 0.03 mgkg1 at the end of surgery, caudally. Cardiorespiratory data, sedation and pain were recorded for 24 h following recovery from anaesthesia. Results: There were no differences between the three groups in baseline blood pressure or heart rate; or duration of anaesthesia, surgery. The inhaled sevourane concentration was signicantly lower in group M and group T than in the control group. The quality and duration of postoperative pain relief did not differ between the three groups. There were no intergroup differences in postoperative nausea, vomiting, or other complications. Conclusions: Caudal tramadol (2 mgkg1) provided reliable postoperative analgesia similar to caudal morphine (0.03 mgkg1) in quality and duration of pain relief in our study children who were undergoing herniorrhaphy. We also concluded that presurgical caudal morphine or tramadol reduced perioperative sevourane requirements and either presurgical or postsurgical caudal morphine did not make any difference to postoperative analgesia. Keywords: caudal morphine; caudal tramadol; postoperative analgesia

Summary

Correspondence to: D. Ozcengiz, Cukurova University Faculty of Medicine, Department of Anaesthesiology 01330 Balcal 1, Adana, Turkey (e-mail: ecenaz@mail.cu.edu.tr). 2001 Blackwell Science Ltd

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Introduction
Epidural narcotics have been shown to provide effective analgesia in paediatric patients (14). Caudal administration of morphine is a widely used epidural narcotic technique in children. Although morphine produces long-lasting, potent analgesia after epidural administration, it also produces important dose-limiting side-effects, including sedation and potentially fatal respiratory depression. Tramadol is a centrally acting analgesic which acts at opioid receptors and also appears to modify the transmission of pain impulses by inhibition of monoamine reuptake (5). A few studies have shown that epidural tramadol can provide postoperative analgesia safely without any serious side-effects (69). Woolf and Chong proposed that adequate prevention of nociceptive neurone sensitization in the spinal cord could signicantly enhance postoperative pain relief (10). Blocking noxious stimuli before surgical incision may provide better pain relief with a lower analgesic requirement than postoperative analgesic administration. The objective of this study was to compare the quality and duration of analgesia, the effect on perioperative sevourane requirement after a single, presurgical caudal block with either tramadol or morphine in children undergoing inguinal herniorrhaphy. Our study was also designed to evaluate the preemptive analgesic efcacy of morphine administered caudally in children.

Table 1 Patient characteristics Group control (n 38) (postsurgical morphine) 6.76 1.76 24.21 4.06 17/21 Group M (n 40) (preincisional morphine) 6.85 1.80 25.85 4.42 18/22 Group T (n 38) (preincisional tramadol) 6.97 1.76 25.65 4.37 15/23

Variable Age (years) Weight (kg) Gender (girl/boy)

Materials and methods

After hospital ethics committee and written informed consent, a randomized double-blind study was undertaken on children, ASA I or II, aged 410 years, who were undergoing elective inguinal herniorrhaphy (Table 1). Patients were excluded from the study if a bleeding diathesis, aspirin or any analgesic drug ingestion in the preceding week, or preexisting neurological or spinal diseases were present. No child received preoperative medication. Anaesthesia was induced via a facemask with sevourane 8% and nitrous oxide 67% in oxygen and maintained with 0.52.5% sevourane and nitrous oxide 67% in oxygen. Upon loss of the eyelash reex, ventilation was assisted manually to

maintain the endtidal CO2 at 4.24.7 kPa (32 36 mmHg). After insertion of an intravenous line, uid replacement consisted of 2% glucose in lactated Ringer's solution at a rate of 35 mlkg1h1. Systemic blood pressure (SBP and DBP, measured with an automatic device), heart rate (HR) (from the ECG), SpO2 and endtidal CO2 (PECO2) were monitored and recorded before induction and intraoperatively at 2-min intervals. Sevourane concentration was monitored by capnograph (Datex Engstrom Capnomac) and recorded at the same intervals. After insertion of a laryngeal mask airwayTM, the patient was placed in the left lateral decubitus position. Under sterile conditions, a 22 or 20-gauge Teon intravenous catheter with an inner stylet was inserted through the sacrococcygeal ligament into the caudal space. The stylet was then removed and the catheter was advanced 0.51 cm. Patients were randomly divided into three groups (number table method) and received 2 mgkg1 tramadol (group T, preemptive group) or morphine sulphate 0.03 mgkg1 (group M, preemptive group). Those in the control group (group C, postincisional group) received morphine sulphate 0.03 mgkg1 at the end of surgery, caudally. The volume of caudal solution administered, by diluting tramadol or morphine sulphate with normal saline, to each child was 0.5 mlkg1. Adequate level of anaesthesia was determined by clinical signs such as purposeful or nonpurposeful movement, change in arterial pressure greater than 20% of the baseline value, or change in heart rate greater than 20% of baseline (if accompanied by similar trend in blood pressure) sweating, lacrimation or reaction against to LMA. Adequate anaesthesia level was determined for each patient every 2 min during surgery. The preselected endtidal sevourane concentration was maintained for a minimum of 15 min before the incision. The surgical incision was made if the patient had adequate
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anaesthesia determined by clinical signs of depth of anaesthesia. SBP, DBP, HR, SpO2, respiratory rate (RR), sedation and pain were recorded at 5, 10, 15 and 30 min, and at 1, 3, 4, 6, 12 and 24 h following recovery from anaesthesia. Recovery time was dened as the time between the end of surgery and the rst evidence of spontaneous movement, spontaneous eye opening, crying, grimacing, restlessness and cooperation on talking to the child. The analgesic effect of caudal block was evaluated using Objective Pain Scale (OPS), ranging from 0 to 10 points and based on blood pressure, movement, agitation, crying and verbalization of pain. Duration of analgesia was dened as the time from caudal injection to the rst need for systemic analgesic. A pain score <5 was considered adequate analgesia. Sedation was assessed using a sedation 5 points score (0 awake, 1 mild sedation, 2 tending to sleep, 3 sleeping, but rousable, 4 deep sleep, unable to rouse) (Table 2). These observations were made by an experienced anaesthesiologist blinded to the treatment groups. Whenever the child had an OPS score of 5, a rescue dose of i.m. morphine (0.1 mgkg1) was administered. This rst analgesia time was calculated as the time from the performance of the caudal block to the rst rescue dose. The number of supplementary analgesics required by each child in a 24-h period, and any local or systemic complications, were recorded. All patients were observed in the hospital for at least 24 h because of the possible side-effects of caudal opioids. Statistical analyses were performed using data from the intent-to-treat population using the statistical package SPSS version 9.0 (Chicago, IL, USA). Statistical comparisons among three groups were

performed by using a one-way ANOVA with posthoc analysis using Tukey and Dunnet. The incidence of complications was analysed by using Kruskal Wallis H nonparametric test. Unless otherwise specied, data are given as mean SD, and P<0.05 was considered statistically signicant.

Results
Although 125 children were randomly allocated to medication, the anaesthetist was unable to place the caudal block in four older children, and ve children were eliminated to decrease the age range. Therefore, 116 children, aged 410 years, comprised the study population, and all were included in the analysis. The groups were comparable with regard to age, weight, duration of surgery and anaesthesia (Tables 1 and 3). There were no differences between the three groups in baseline blood pressure or heart rate; or duration of anaesthesia and surgery. After surgical incision, the three groups did not differ in intraoperative vital signs. The inhaled sevourane concentration was signicantly lower in group M and group T than in the control group. Control patients required a higher concentration of inhaled sevourane to maintain anaesthesia. The end of anaesthesia to awakening time was signicantly shorter in group M and T than in the control group (Table 3). The quality and duration of postoperative pain relief did not differ among the three groups. Thirtyseven (92.5%) children in the control group, 36 (94.73%) in group M and 92.1% in group T required no additional pain medication during the 24-h study period. Eight children (three given tramadol, three given preincisional morphine and two given

Table 2 Postoperative analgesia characteristics Variable OPS Supplementary doses needed Time to rst micturition (min) Nausea Pruritus *Data are presented mean SD. 2001 Blackwell Science Ltd, Paediatric Anaesthesia, 11, 459464

Group control (n 38) (postsurgical morphine) 0.65 1.74* 2 208.15 20.58* 2 3

Group M (n 40) (preincisional morphine) 0.77 1.90* 3 206.75 17.81* 2 3

Group T (n 38) (preincisional tramadol) 0.68 1.74* 3 203.28 16.93* 2 3

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Table 3 Clinical parameters Group control (n 38) (postsurgical morphine) Group M Group T (n 40) (n 38) (preincisional (preincisional morphine) tramadol) 60.50 4.05 38.25 5.25 61.05 4.37 37.89 5.15

Variable

Anaesthesia 60.92 3.83 duration (min) Surgery 37.89 5.15 duration (min) Sevourane (%) 1.54 0.50 End of anaesthesia to 17.52 1.99 awakening (min)

1.00 0.12* 1.02 0.13* 14.00 1.85* 14.02 1.89*

Data are presented mean standard deviation. *P<0.001: group II compared with group I, *P<0.001: group III compared with group I.

postsurgical morphine) required morphine in the recovery room. There were no intergroup differences in the postoperative nausea, vomiting, or other complications. No patient had deep sedation during the study period. Vital signs were comparable in three groups throughout the study period. No serious opioidrelated adverse effects were observed. Two patients in each group suffered nausea during the rst 4 h, while itching was also observed in three patients in each of the three groups.

Discussion
The present study demonstrates that 2 mgkg1 tramadol provides similar analgesic efcacy and prolongation of postoperative analgesia when compared with 0.03 mgkg1 morphine preincisional or postincisional during caudal anaesthesia in children aged between 4 and 10 years. All patients received the same 0.03 mgkg1 dose of caudal morphine, a dose in the low range of those reported (2,4,11). Krane et al. (4) found a higher incidence of side-effects in children receiving 0.1 mgkg1 (versus two lower doses) and recommended a dose of 0.03 mgkg1. The larger dose was associated with a signicant increase in adverse effects. Delayed respiratory depression after the caudal administration of 0.1 mgkg1 epidural morphine has also been reported (12). A lower dosage in our patients may have resulted in fewer side-effects, including respiratory depression. Another study (13) showed that, with 0.030.04 mgkg1 morphine

administered caudally, the minimum duration of pain relief was 6 h and the maximum duration was 24 h. Serlin et al. reported that 47% of patients required no parenteral analgesic for 12 h after receiving a single dose of epidural morphine (0.06 mgkg1) (14). Krane also reported that 0.033 mgkg1 of caudal morphine provided effective analgesia for more than 8 h in the most children (4). We used a smaller dose of morphine and the duration of analgesia was longer. Prosser et al. demonstrated that caudal tramadol (2 mgkg1) provided very effective analgesia for more than 10.7 (2.2) h and only 6.7% of patients required additional analgesia within 1 h (8). Delilkan et al. also noted that tramadol 100 mg given epidurally, in adult patients, had a long duration of action (9.4 versus 6 h) and gave very effective analgesia (7). In this study, 6% of tramadol recipients required rescue analgesics. We also found that caudal tramadol provided a very long duration of analgesia (24 h) in most patients and only 7.9% needed rescue analgesics. Baraka et al. reported that a single dose of epidural morphine (4 mg) or epidural tramadol (100 mg) as the sole analgesic agent in adult patients undergoing major abdominal surgery, could provide prolonged, low pain scores for 24 h after surgery (9). Our results show no signicant difference in the postoperative analgesia provided by caudal tramadol and morphine. According to Woolf and Chong's theory, optimal preemptive analgesia should begin before surgical incision to prevent noxious stimuli from overexciting the nociceptive system during and after surgery to achieve better postoperative pain relief (10). Several studies demonstrated that epidural anaesthesia provides superior analgesia when administered preoperatively, compared with postincisionally (15,16). However, there are still contradictory reports. Rice et al. and Holthusen et al. suggested that timing of caudal block placement does not affect duration and quality of postoperative analgesia in paediatric ambulatory patients (15,1719). The type of surgery may be one factor responsible for the differing results obtained by these clinical trials. However, Aida et al. reported that preemptive analgesia with epidural morphine alone was ineffective in patients who underwent gastrectomy, hysterectomy, herniorrhaphy and appendectomy (20). We also did not demonstrate any advantage of preoperative versus
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postoperative caudal block with morphine in postoperative pain after herniorrhaphy. On the other hand, it is well known that placing the block before the surgical incision provides intraoperative pain relief and reduces the general anaesthetic requirement (21). We also found that both preincisional tramadol and morphine reduced sevourane concentration. Postincisional group patients needed a higher concentration of inhaled sevourane to maintain their anaesthesia level. Previous clinical reports have also shown that parenteral morphine results in greater, and clinically important, respiratory depression than equianalgesic doses of parenteral tramadol (22,23). We did not observe any respiratory depression in our patients. Although, in our study, SpO2 of all the patients was higher than 96%, an effective noninvasive monitor of respiratory status should be obtained in children receiving spinal opioids. Valley et al. reported that four patients with respiratory depression associated with caudal morphine (0.07 mgkg1) had all received intraoperative caudal local anaesthetic (24). Residual sensory block from the local anaesthetic may have reduced nociceptive stimuli, unmasking any central nervous system depressant effects of the caudal morphine. Our patients were lightly sedated and no patient was oversedated. The other side-effects related to opioids, such as nausea and pruritus, did not differ among the three groups. It was suggested that the volume required to attain analgesic level (T10) in patients undergoing hernia repair is 0.66 mlkg1 of bupivacaine (25). According to our results, tramadol and morphine in the specied volume used in our study (0.5 mlkg1) was adequate for herniorrhaphy. In conclusion, caudal tramadol (2 mgkg1) provided reliable postoperative analgesia similar to caudal morphine (0.03 mgkg1) in quality and duration of pain relief in our study children who were undergoing herniorrhaphy. We also concluded that presurgical caudal morphine or tramadol reduced the perioperative sevourane requirement, and both presurgical or postsurgical caudal morphine provided the same postoperative analgesia.

References
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2 Glenski JA. Postoperative use of epidurally administered morphine in children and adolescents. Mayo Clin Proc 1984; 59: 530532. 3 Attia J, Ecoffey C, Sandouk P et al. Epidural morphine in children pharmacokinetics and CO2 sensitivity. Anesthesiology 1986; 65: 590594. 4 Krane EJ, Tyler DC, Jacobson LE. The dose response of caudal morphine in children. Anesthesiology 1989; 71: 4852. 5 Lee CR, McTavish D, Sorkin EM. Tramadol. Drugs 1993; 46: 313340. 6 Batra YK, Prasad MK, Arya VK et al. Comparison of caudal tramadol vs bupivacaine for post-operative analgesia in children undergoing hypospadias surgery. Int J Clin Pharmacol Ther 1999; 37: 238242. 7 Delilkan AE, Vijayan R. Epidural tramadol for postoperative pain relief. Anaesthesia 1993; 48: 328331. 8 Prosser DP, Davis A, Booker PD et al. Caudal tramadol for postoperative analgesia in paediatric hypospadias surgery. Br J Anaesth 1997; 79: 293296. 9 Baraka A, Jabbour S, Ghabash M et al. A comparison of epidural tramadol and epidural morphine for postoperative analgesia. Can J Anaesth 1993; 40: 308313. 10 Woolf CJ, Chong MS. Preemptive analgesia-treating postoperative analgesia by preventing the establishment of central sensitization. Anesth Analg 1993; 77: 362379. 11 Rosen KR, Rosen DA. Caudal epidural morphine for control of pain following open heart surgery in children. Anesthesiology 1989; 70: 418421. 12 Krane EJ. Delayed respiratory depression in a child after caudal epidural morphine. Anesth Analg 1988; 67: 7982. 13 Mayhew JF, Brodsky RC, Blakey D et al. Low-dose morphine for postoperative analgesia in infants and children: a report of 500 cases. J Clin Anesth 1995; 7: 640642. 14 Serlin S. Single-dose caudal epidural morphine in children: safe, effective, and easy. Clin Anesth 1991; 3: 386390. 15 Kundra P, Deepalakhmi K, Ravishankar M. Preemptive caudal bupivacaine and morphine for postoperative analgesia in children. Anesth Analg 1998; 87: 5256. 16 Wu CT, Yeh CC, Yu JC et al. Pre-incisional epidural ketamine, morphine and bupivacaine combined with epidural and general anaesthesia provides pre-emptive analgesia for upper abdominal surgery. Acta Anaesthesiol Scand 2000; 44: 6368. 17 Chiaretti A, Viola L, Pietrini D et al. Preemptive analgesia with tramadol and fentanyl in pediatric neurosurgery. Childs Nerv Syst 2000; 16: 9399. 18 Holthusen H, Eichwede F, Stevens M et al. Comparison of preoperative with postoperative caudal block on postoperative pain in children. Br J Anaesth 1994; 73: 440442. 19 Rice LJ, Pudimat MA, Hannallah RS. Timing of caudal block placement in relation to surgery does not affect duration of postoperative analgesia in paediatric ambulatory patients. Can J Anaesth 1990; 37: 429431. 20 Aida S, Baba H, Yamakura T et al. The effectiveness of preemptive analgesia varies according to the type of surgery: a randomized, double-blind study. Anesth Analg 1999; 99: 711716. 21 Hannallah RS, Broadman LM, Belman AB et al. Comparison of caudal and ilioinguinal/iliohypogastric nerve blocks for control of post-orchiopexy pain in pediatric ambulatory surgery. Anesthesiology 1987; 66: 832834. 22 Houmes R-JM, Voets MA, Verkaaik A et al. Efcacy and safety of tramadol venus morphine for moderate and severe postoperative pain with special regard to respiratory depression. Anesth Analg 1992; 75: 510514.

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23 Vickers MD, O'Flaherty D, Szekely SM et al. Tramadol: pain relief by an opioid without depression of respiration. Anaesthesia 1992; 47: 291296. 24 Valley RD, Bailey AG. Caudal morphine for postoperative analgesia in infants and children: a report of 138 cases. Anesth Analg 1991; 72: 120124.

25 Takasaki M, Dohi S, Kawabata Y et al. Dosage of lidocaine for caudal anesthesia in infants and children. Anesthesiology 1977; 47: 527529.

Accepted 14 December 2000

2001 Blackwell Science Ltd, Paediatric Anaesthesia, 11, 459464