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Department of Anaesthesia and Intensive Care, Yan Chai Hospital, Tsuen Wan, New Territories, Hong Kong SAR, China
To the Editor:
I read with interest the study by Bloch et al. (1). I have some questions about the study. First, why did the authors choose to have a thoracic epidural catheter inserted, and then not give any local anesthetics through it in the postoperative period? Might not the results have been somewhat different if an intravenous infusion of tramadol had been compared with epidural local anesthetic plus morphine instead? I say this because in my experience, epidural morphine alone is notoriously inadequate for postthoracotomy pain relief.
Second, I was somewhat disappointed that there was no comparison made between the groups with respect to postoperative nausea and vomiting, since this is obviously a common problem in all patients who receive opioids or tramadol. I am wondering if the lack of difference shown in the requirements of rescue analgesics between the tramadol and epidural morphine groups might not indicate that the two modalities wereequally unsatisfactory at pain relief.
Finally, the risk-benefit ratio for inserting a thoracic epidural catheter, then infusing with local anesthetic and opioid might be more acceptable compared to inserting the catheter and then only giving epidural opioid alone.
Reference
Medical Simulation and Training Centre, Imperial College Faculty of Medicine, Chelsea and Westminster Hospital, London, United Kingdom
In Response:
Here is our response to the above questions from Dr. Chua, which we addressed while designing this trial:
We chose not to use postoperative epidural local anesthesia, since we were concerned about postoperative bleeding and hemodynamic instability in a patient population group with a high proportion of resections for pulmonary tuberculosis.
Although some studies have suggested that the analgesic combination of choice via the thoracic epidural route is low concentration local anesthetic plus a lipophilic opioid (1), adding local anesthetic to morphine in our complex surgical population could simply generate more side effects without increasing efficacy significantly, precisely what we are trying to avoid.
The scores for the tramadol group were at least as good as those for epidural morphine until 16 hours postoperatively, and the amount of rescue medication in the tramadol group was significantly lower than that required in the epidural morphine group. The high pain scores in the first hour in the current study are in keeping with the demonstrated time to peak analgesic effect of one hour for tramadol, which is similar to that of epidural morphine administered at the dermatomal level of nociceptive input.
We did compare the incidence of postoperative nausea and vomiting and found the incidence to be low in the epidural group (two patients) and zero in the tramadol group. This is compatible with our clinical experience; those patients requiring tramadol for severe pain do not seem to experience the same incidence of nausea and vomiting as those with a lower nociceptive input.
The aim of the study was to look at the effectiveness of tramadol as an analgesic regimen for postthoracotomy pain relief, when compared with our currently favored method, thoracic epidural morphine, and patient-controlled analgesia employing intravenous morphine. We were hoping to explore an alternative modality that may be equally effective, and have less associated risks than the currently employed method, with an added benefit of a decreased demand on available resources.
Reference
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