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 Table of Contents  
Year : 2020  |  Volume : 7  |  Issue : 3  |  Page : 267-273

Tramadol as an adjuvant to peribulbar anesthesia

Department of Anesthesiology, Ain Shams University, Cairo, Egypt

Date of Submission15-Jun-2019
Date of Acceptance28-Apr-2020
Date of Web Publication29-Sep-2020

Correspondence Address:
MD Wail Abdelaal
Assistant Professor of Anesthesia Ain Shams University; Department of Anesthesiology, Intensive Care and Pain Management, Faculty of Medicine, Ain Shams University, Cairo
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/roaic.roaic_50_19

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Background A large number of additives have been used as an adjuvant to local anesthetic (LA) mixture in peribulbar block to fasten the onset, enhance the potency, and prolong the duration of the block to cover the long duration of vitreoretinal surgeries and provide better postoperative analgesia. The authors designed a prospective, randomized, double-blind, controlled clinical trial to assess the effect of adding tramadol 20 mg to standard LA mixture concerning the onset of lid and globe akinesia, time for satisfactory block, and duration of postoperative akinesia and analgesia.
Patients and methods A double-blind randomized study was done on 80 American Society of Anesthesiologists I and II patients scheduled for elective vitreoretinal surgery. Patients were chosen randomly into two groups, with 40 patients in each group. Group I (control group) received a mixture of bupivacaine 0.5% (4 ml)+lidocaine 2% (4 ml)+hyaluronidase 150 IU (1 ml) with 1 ml normal saline to a total volume of 10 ml. Group II (tramadol group) received a mixture of bupivacaine 0.5% (4 ml)+lidocaine 2% (4 ml)+hyaluronidase 150 IU (1 ml) supplemented with 20 mg tramadol in 1 ml normal saline to a total volume of 10 ml. The onset and duration of lid and globe akinesia and optimum time to begin surgery were recorded, in addition to postoperative visual analog score, duration of analgesia, and time to first rescue analgesic request.
Results The results show statistically significant differences between the two groups, as tramadol group had faster onset of akinesia, better akinesia score, and shorter time needed to start surgery. In addition, tramadol group also showed significantly prolonged postoperative analgesia and akinesia with lower median pain score and less postoperative analgesic requirements.
Conclusion The present study concluded that tramadol is a safe adjuvant to LA in peribulbar block that fastens the onset and prolongs the duration of lid and globe akinesia and improves the quality of analgesia without any obvious adverse effects.

Keywords: akinesia, analgesia, peribulbar anesthesia, tramadol, vitreoretinal surgery

How to cite this article:
Abdelaal W, Fahmy D, Atalla R. Tramadol as an adjuvant to peribulbar anesthesia. Res Opin Anesth Intensive Care 2020;7:267-73

How to cite this URL:
Abdelaal W, Fahmy D, Atalla R. Tramadol as an adjuvant to peribulbar anesthesia. Res Opin Anesth Intensive Care [serial online] 2020 [cited 2021 May 18];7:267-73. Available from: http://www.roaic.eg.net/text.asp?2020/7/3/267/296617

  Introduction Top

A large number of patients undergoing ophthalmic surgeries are elderly, with multiple chronic diseases, which make them at increased risk of morbidity and mortality under general anesthesia [1].

Different eye blocks have been experienced with great success. Peribulbar anesthesia is widely practiced now as a safe local block for eye surgeries compared with retrobulbar block owing to less frequency of complications such as globe perforation, brainstem anesthesia and retrobulbar hemorrhage; adequate ocular akinesia to start surgery takes longer time with peribulbar block compared with retrobulbar block; and the frequency of inadequate analgesia and need for supplemental injections are also more frequent with peribulbar block [2].

It is well known that surgeries for posterior segment are lengthy procedures and are usually associated with relatively significant postoperative pain [3]. The addition of several adjuvant to local anesthetics (LA) in peribulbar block is widely practiced nowadays aiming to enhance the onset and duration of akinesia and improve the quality of the block.

Tramadol is a μ-agonist opioid that inhibits reuptake of norepinephrine and serotonin. These neurotransmitters are involved in descending inhibitory pain pathways associated with pain relief. When used in peripheral nerve blocks (PNBs), tramadol has been demonstrated to increase the duration of analgesia [4]. Several studies have recently shown that tramadol has peripheral LA effects [5],[6]. As many investigators have confirmed that the addition of tramadol to LA solutions improves the onset and duration of analgesia in several PNBs [7],[8], we assumed that tramadol could enhance akinesia onset and duration as well as postoperative analgesia when co-administered with levobupivacaine for peribulbar eye block in vitreoretinal surgery.

The aim of this research was to evaluate the effect of adding tramadol 20 mg to standard LA mixture in peribulbar anesthesia.

  Patients and methods Top

This prospective double-blind randomized study was approved by the Institutional Ethical Committee. Written informed was obtained from 80 adult patients aged 18–75 years, of both sexes, American Society of Anesthesiologists I–II, listed for elective retinal detachment surgery without scleral buckle or encircling procedures under peribulbar anesthesia. They were included in this prospective double-blinded randomized study at Ain Shams University Hospitals. Akinesia and expected surgical time to be less than 3 h were other inclusion criteria for this study. Exclusion criteria included age younger than 18 years, patients refusing LA, patients with a single eye, allergy to LA solutions, coagulopathy or history of anticoagulant therapy, history of sleep apnea, impaired mental status, drug abuse, axial length greater than 28, increased intraocular pressure, posterior staphyloma, and local infection at the site of injection.

Patients who fulfilled the criteria were randomly allocated into two equally sized groups: I (control group) and II (tramadol group), with 40 patients each.

Randomization was done using computer-generated random numbers and sealed envelope technique done by a nurse anesthetist who was blinded to the study groups.

Premedication with iv midazolam 0.02 mg/kg and topical anesthesia using tetracaine 0.5% were applied to all patients before performing the peribulbar block as follows:
  1. Group I (control group) received a mixture of bupivacaine 0.5% (4 ml)+lidocaine 2% (4 ml)+hyaluronidase 150 IU (1 ml) with 1 ml normal saline to a total volume of 10 ml.

  2. Group II (tramadol group) received a mixture of bupivacaine 0.5% (4 ml)+lidocaine 2% (4 ml)+hyaluronidase 150 IU (1 ml) supplemented with 20 mg tramadol in 1 ml normal saline to a total volume of 10 ml.

The studied LA solutions were prepared at the bedside before the injection and provided in patient-specific, sealed packaging by a member of staff not involved in the study. All peribulbar blocks were performed by a senior anesthetist experienced in the technique who was also blinded to the kind of LA solution used.

Patients fasted for 8 h before being admitted to the operating room. A peripheral intravenous catheter was inserted and standard monitoring was conducted and recorded, including heart rate, noninvasive arterial blood pressure, ECG (five leads), and peripheral oxygen saturation (SPaO2). A nasal cannula was applied, and supplemental oxygen was given during the procedure at 4 l/min.

The patients who were blinded to the LA solution used received a single peribulbar block using a 25 G, 25-mm cutting bevel disposable needle, with the eye fixed in the primary gaze position. The injection was done at the junction between the lateral one-third and the medial two-thirds of the inferior orbital margin. The needle was advanced in an anteroposterior direction for half of its length and then obliquely in the direction of foramen. After negative aspiration, 7–10 ml of the LA mixture was slowly injected over 30–40 s until the presence of a complete drop of the upper eye lid and/or fullness of the orbit. Gentle orbital massage was then applied for 2 min in both groups.

The onset of the sensory and motor block was assessed from the time of injection of LA using the following measurements: onset of sensory block was assessed by gentle sensory touch to the conjunctiva using a cotton swab starting from the time of injection and then every minute until complete disappearance of the sensation.

Motor block was evaluated by the assessment of globe akinesia in the four quadrants; patients were asked to look in the four directions of the gaze: lateral, medial, superior, inferior. Scoring was done using a three-point scoring system, which was categorized as follows: 0=akinesia, 1=partial akinesia, and 2=normal movement, with a total score ranging from 0 to 8 for the four muscles. Lid akinesia was assessed by informing the patient to open both eye lids widely followed by squeezing them maximally to assess orbicularis oculi and levator palpebral muscles on a scale of 0–2 (0 = complete akinesia, 1 = partial akinesia, and 2 = pronounced movement). Evaluation of akinesia score was done before peribulbar block and at 1, 3, 5, 8, 10, and 15 min after performing the block.

Time to adequate condition to start surgery was recorded after completion of the block using a stopwatch and was defined as the presence of corneal anesthesia together with eye lid squeezing score of 0 and ocular movement score less than or equal 1. If adequate condition to start surgery was not obtained at the end of 15 min after performing the block, supplemental injection of 4 ml of the standard LA was done either inferotemporally or medially, and this patient was excluded from the study. The duration of globe akinesia was assessed every 15 min after the end of surgery until complete recovery of ocular and eye lid movements (score of 8).

Postoperative pain was assessed at the end of surgery (T0) and at 1 h, 2 h, 3 h, 4 h, and 5 h postoperatively. Assessment was done by visual analog score (VAS) on a scale of 0–10 where 0 indicates no pain, and 10 worst imaginable pain. If the VAS for pain was greater than or equal to 5, diclofenac Na 1 mg/kg was given intramuscularly 3 ml ampoule 25 mg/ml in a maximum frequency of 6 h, and three doses maximally per 24 h. The total diclofenac Na consumption (mg) was recorded, and the time for first analgesic request (defined as the time interval between injection of LA solution to the first requirement of postoperative analgesia) was also recorded. At the end of surgery, all surgeons and patients were asked to rate their satisfaction using a two-point scale simple questionnaire (1=comfortable and 0=uncomfortable).

The incidence of any complications of the block was routinely recorded (hemorrhage, globe perforation, brain stem anesthesia, drowsiness, bradycardia, hypotension, nausea, and vomiting), and appropriate management was done according to standard protocol.

  Results Top

A total of 40 patients were enrolled in each group. All of them underwent vitreoretinal surgery under peribulbar anesthesia. Regarding demographic characteristics, sex distribution (male/female) was 18/22 in group I and 15/25 in group II, average age of group I was 50.70±15.05 in comparison with 49.98±10.01 in group II, and time of the procedure was 126.10±1.57 in group I in comparison with 126.20±1.09 in group II. Demographic characteristics showed nonsignificant difference among both groups ([Table 1]).
Table 1 Descriptive analysis of the patients’ demographic data in each group.

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Onset of sensory block was significantly shorter in tramadol group. Regarding the onset of globe akinesia, lid akinesia, and adequate time to start surgery, all of them were significantly reduced in tramadol group compared with the control group.

There was a statistically significant difference between the two groups regarding the duration of lid and globe akinesia; tramadol group had significantly longer duration of both lid and globe akinesia ([Table 2]).
Table 2 Block characteristics

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Globe akinesia score was found to be significantly less at 1, 3, 5, and 8 min after the block in tramadol group compared with the control group, and at 10 and 15 min, there was no significant difference between the two groups. Comparing lid akinesia score between the two groups showed that tramadol group had significantly lesser values at 1, 3, and 5 min after the block, whereas no significant difference was recorded between the two groups at 8, 10, and 15 min. At the end of 15 min, all patients had satisfactory block, and none of them required supplemental injections ([Table 3]).
Table 3 Comparison between the two groups regarding the median values of the two scores at the specified time points (min)

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Postoperative mean VAS was significantly higher in control group at 2, 3, and 4 h compared with the tramadol group. Time to first rescue analgesic was also significantly prolonged in tramadol group. However, total diclofenac consumption showed no significant difference between the two groups ([Table 4]).
Table 4 Pain assessment and analgesic requirements

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[Figure 2] showed that patient satisfaction and surgeon satisfaction were best achieved in tramadol group.
Figure 2 Number of satisfied and unsatisfied surgeons in each group (P=0.038).

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We did not observe any adverse effect in our study whether related to the peribulbar block or to the use of tramadol, and also there was no statistically significant differences between the two groups in heart rate, noninvasive arterial blood pressure, and peripheral oxygen saturation.

Statistical analysis

Data were analyzed using Statistical Package for the Social Sciences version 21.0 (SPSS Inc., Chicago, Illinois, USA). Quantitative data were expressed as mean±SD. Qualitative data were expressed as count and percentage. The independent-samples t-test was used to compare between means in the two groups. Skewed numerical data are presented as median (range), and independent samples-median test was used to compare between medians in both groups. χ

2-test was used to compare proportions between two qualitative parameters. P less than 0.05 was considered significant, and P less than 0.01 was considered highly significant.

  Discussion Top

As it is well known that vitreoretinal surgery is a lengthy procedure and associated with significant pain [3], it has traditionally been performed under general anesthesia but LA has increased in popularity in recent years [9].

On the contrary, the retrobulbar block can provide adequate anesthesia and akinesia as well as postoperative analgesia [10]. It is associated with many complications [11] compared with the peribulbar block, which is considered to be a safer technique. However, peribulbar block has the disadvantage of slower onset of akinesia which may need a larger volume or repeated injections of anesthetic solution to achieve adequate anesthesia and akinesia, and this may be owing to limited diffusion of LA [2]. Aiming to improve the quality of the peribulbar block, the use of several adjuvants such as clonidine, fentanyl, epinephrine, corticosteroids, and alkalinization, is widely practiced nowadays [12],[13],[14].

Tramadol is a synthetic 4-phenyl-piperidine analogue of codeine and acts as an analgesic via an affinity for μ-opioid receptors, by α-2 adrenoreceptor agonistic and serotoninergic effects and by inhibiting the re-uptake of noradrenaline and 5-hydroxytryptamine. Recent clinical and laboratory studies also proved that intradermal tramadol displays an LA effect equivalent to that of prilocaine. Tramadol also lacks the respiratory depressant effect, while having analgesic potency approximately equal to that of pethidine.

Clinical trials with tramadol as an adjuvant to LA in PNB to enhance the onset and duration of analgesia have been reported since 1990. To our knowledge, this is the only study in the literature using tramadol as an adjuvant with LA for peribulbar block.

The result of our research showed that addition of tramadol 20 mg to the LA mixture for peribulbar block for vitreoretinal surgery significantly fastened the onset of sensory block as well as the onset of both lid and globe akinesia with significantly better akinesia score compared with the control group, resulting in shortening of the optimal time needed to start surgery. Addition of tramadol also significantly prolonged the duration of lid and globe akinesia as well as the duration of postoperative analgesia. Our results are is in agreement with the results of the systemic review and meta-analysis by Hey Won Shin et al. [15], which indicates that use of tramadol as an adjuvant to LA in brachial plexus block prolongs the duration of sensory block, motor block, and analgesia and that it shortens the time to onset of sensory block and motor block without any change in adverse effects.

Similar results were obtained by Antonucci [16] who added tramadol to 20 ml of ropivacaine 7.5 mg/ml and proved significant reduction in the onset time of brachial plexus block and prolongation of the duration of anesthesia and postoperative analgesia. Shrestha et al. [17] also found that tramadol added to LA in brachial plexus block significantly prolonged postoperative analgesia. Kaabachi et al. [7] compared the addition of different doses of tramadol to lidocaine 1.5% (epinephrine 1/200 000) in axillary brachial plexus block and achieved significant prolongation of the sensory block and the time for first rescue analgesia associated with the addition of 200 mg tramadol, compared with low-dose tramadol 100 mg and lidocaine only. However, this benefit was limited by the slow onset of the block. Sükran et al. [18], showed that the addition of 100 mg of tramadol to LA mixtures for axillary brachial plexus block improves both the speed of block onset and the duration of sensory block.

It is of interest to note that another two studies evaluated tramadol as an adjuvant to mepivacaine in axillary brachial plexus blockade, and both proved that tramadol prolonged the motor and sensory blockade and improved the quality of postoperative analgesia [4],[8]. In contrast, Kesimci et al. [19]) investigated the effect of adding 100 mg of tramadol to ropivacaine, for axillary brachial plexus block, and reported that tramadol does not prolong the duration of motor and sensory block and analgesia. Sarsu et al. [20] performed axillary blockade with a mixture of 100 mg tramadol to a combination of levobupivacaine and lidocaine and concluded that tramadol was not effective on sensorial and motor block durations, onset time, and analgesia duration. Mannion et al. [21] also failed to demonstrate a significant increase in the duration of analgesia or decrease in postoperative opioid requirements with the addition of tramadol to bupivacaine for psoas compartment blockade. A number of studies have examined the efficacy of epidurally delivered tramadol, with doses ranging from 40 to 200 mg (1.5–2.0 mg/kg). There have been conflicting reports in children undergoing caudal epidurals, with some showing no benefit and others a decrease in postoperative analgesia requirements [22],[23],[24],[25]. Typical adverse effects of tramadol are headache, nausea, vomiting, dizziness, and sedation when it is used for analgesia [6]. We could not detect any differences in adverse effects between patients in our study, which could reflect low plasma concentrations of tramadol. No adverse effects were also observed in our study related to the peribulbar injection, and only one patient in the tramadol group experienced burning pain during injection.

  Conclusion Top

The addition of tramadol 20 mg to LA mixture for peribulbar block in patients undergoing vitreoretinal surgery fastens the onset lid and globe akinesia and provides better akinesia score, with more rapid establishment of optimum conditions to start surgery. Tramadol also prolongs the duration of postoperative akinesia and analgesia, decreases the need for postoperative analgesia, and offers more patient and surgeon satisfaction without any obvious adverse effects.


The manuscript has been read and approved by all authors.

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Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3], [Table 4]


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