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AMBULATORY ANESTHESIA

Postoperative Analgesia at Home After Ambulatory Hand Surgery: A Controlled Comparison of Tramadol, Metamizol, and Paracetamol

Narinder Rawal, MD, PhD^*, Renée Allvin, CRNA, BSc^*, Anders Amilon, MD, Torbjörn Ohlsson, CRN, M Soc Sci, and Jan Hallén, MD^*

Departments of *Anesthesiology and Intensive Care and Hand Surgery, Örebro Medical Center Hospital, Örebro, Sweden

Address correspondence and reprint requests to Narinder Rawal, MD, PhD, Department of Anesthesiology and Intensive Care, Örebro Medical Center Hospital, SE-701 85 Örebro, Sweden. Address e-mail to n.rawal{at}orebroll.se

We compared in a prospective, randomized, double-blinded study the analgesic efficacy of three drugs in 120 ASA I and II patients scheduled to undergo ambulatory hand surgery with IV regional anesthesia. At discharge, oral analgesic tablets were prescribed as follows: tramadol 100 mg every 6 h, metamizol 1 g every 6 h, and paracetamol (acetaminophen) 1 g every 6 h. Rescue medication consisted of oral dextropropoxyphene 100 mg on demand. Analgesic efficacy was evaluated by self-assessment of pain intensity by visual analog score at six different time intervals during the 48-h study period. Patients also recorded global pain relief on a 5-grade scale, total number of study and rescue analgesic tablets, frequency and severity of adverse effects, sleep pattern, and overall satisfaction. None of the study drugs alone provided effective analgesia in all patients. The percentage of patients who required supplementary analgesics was 23% with tramadol, 31% with metamizol, and 42% with acetaminophen. Tramadol was the most effective analgesic, as evidenced by low pain scores, least rescue medication, and fewest number of patients with sleep disturbance. However, the incidence of side effects was also increased with tramadol. Seven patients (17.5%) withdrew from the study because of the severity of nausea and dizziness associated with the use of tramadol. Metamizol and acetaminophen provided good analgesia in about 70% and 60% of patients, respectively, with a decreased incidence of side effects. Despite receiving oral analgesic medication, up to 40% of patients undergoing hand surgery experienced inadequate analgesia in this controlled trial. Although tramadol was more effective, its use was associated with the highest frequency and intensity of adverse effects and the most patient dissatisfaction. Metamizol and acetaminophen provided good analgesia with a small incidence of side effects. For patients undergoing ambulatory hand surgery, postoperative pain can last longer than 2–3 days, and there is a need for both better education before the procedure and oral analgesic therapy at home.

Implications: Despite pain medication, up to 40% of patients experienced pain at home after ambulatory hand surgery. Of the three analgesic drugs evaluated in this double-blinded study, tramadol was the most effective but was also associated with most patient dissatisfaction because of an increased incidence of nausea and dizziness. Metamizol provided somewhat better analgesia than acetaminophen. There is a need for better oral pain medication at home.

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