32.3.4 Comparison of Tramadol and Ketorolacin Postoperative Pain After Maxillofacial Surgery

Original Article

 

Comparison of Tramadol and Ketorolacin Postoperative Pain

Comparison of Tramadol and Ketorolacin Postoperative Pain After Maxillofacial Surgery

Kashif Ali Channar1, Abdul Bari Memon2, Irfan Ahmed Shaikh1, Nadir Kalhoro1, Ajeet Kumar3 and Bashir Ahmed Jalbani2

ABSTRACT

Objective: To compare Tramadol and Ketorolac in the management of postoperative pain following maxillofacial surgery.

Study Design: Comparative cross sectional study

Place and Duration of Study: This study was conducted at the Department of Oral and Maxillofacial Surgery, Liaquat University of Medical and Health Sciences (LUMHS), Jamshoro form November 2017 to July 2018.

Materials and Methods: Total hundred patients were recruited. Patients were divided in 2equal groups by random allocation. Group 1 received ketorolac 30 mg (Trometh 30mg) intramuscular I.M. after the surgical procedure and group 2receivedtramal 100mg (Tramadol 100mg) intramuscular. Pain was evaluated using visual analog scale (VAS) during 2nd, 4th, 6th, 12th and 24th hours from the end of surgical procedure and recorded on Performa.

Results: Total 100 patients were included in this study. After receiving tramadol injection, 6% patients felt no pain after 2 hours while only 2% patients felt severe pain after 12 hours. While after receiving ketorolac injection, 2% patients felt no pain after 2 hours while in 4% patients felt severe pain after 12 hours. Mean score of pain after 24 hours was 1.09 ± 0.30 in Tramadol group while in ketorolac group is 3.70 ±0.45 Results were statistically significant P value 0.01.

Conclusion: Tramadol is a better pain killer and anti-inflammatory drug having longer duration of action to control post- operative pain and swelling after maxilla-facial surgery and is more effective than ketorolac.

Key Words: Ketorolac, Maxillofacial surgery, Pain, Tramadol

Citation of article: Channar KA, Memon AB, Shaikh IA, Kalhoro N, Kumar A, Jalbani BA. Comparison of Tramadol and Ketorolacin Postoperative Pain After Maxillofacial Surgery. Med Forum 2021;32(3):11-14.

 

 

INTRODUCTION

Surgery in the region of maxillofacial area needs comprehensive knowledge of anatomy, physiology and special training to deal many diseases, defects and maxillofacial trauma. Pain is an unwanted physical and emotional experience linked with tissue injury. Millions of cells are injured during oral surgical procedures which stimulate inflammatory cascade, releasing chemical mediators that activate the pain stimuli.1 To decrease postoperative pain (POP) in Oral & Maxillofacial surgery analgesics are predominantly prescribed worldwide.

 

 

1. Department of Oral and Maxillofacial Surgery, Liaquat University of medical and Health Sciences Jamshoro.

2. Bibi Aseefa Dental College @ SMBBMU Larkana.

3. Sir Syed Medical and Dental Collage Karachi.

 

 

Correspondence: Abdul Bari Memon, PhD Scholar (LUMHS) Jamshoro and Assistant Professor, Bibi Aseefa Dental College @ SMBBMU Larkana.

Contact No: 0300 2426578

Email: drabmemon@yahoo.com

 

 

Received:  September, 2020

Accepted:  November, 2020

Printed:      March, 2021

 

 

Analgesics are classified as opioids and non-steroidal anti-inflammatory drugs (NSAID’s)2. NSAID's act by preventing the cyclooxygenase (COX) enzymes which has key role in the production of prostaglandins but it may cause irritation and bleeding in gastrointestinal tract.3Opiod analgesic act by mimicking endogenous endorphins by stimulating opiod receptors in the central and peripheral nervous system which results in relief of pain.1

The ideal post-operative medicine is that who have analgesic effect for longer time, easy to use, not dangerous to any organ system and economical. Control of post operative pain is paramount for normal recovery and  in post operative hospital stay period but without undesirable side effects such as respiratory distress, Gastro-Intestinal tract, visceral motility, coagulation abnormality, drug tolerance and drug dependence.1,4,5

Tramadol drug is a centrally acting analgesic with no relevant effects on respiratory or cardio-vascular system as other opoids. The drug can be safely used in patients with mild cardiopulmonary function, overweight and smokers, or having liver and kidney diseases. Incidence of adverse effect ranges from 1.6 to 6.1%. Nausea, dizziness, drowsiness, sweating, vomiting and dry mouth are and should be avoided in head injury patients. 1,3, 6-8

Ketorolac is a member of pyrrole group of NSAID’s; it acts against pain, swelling and fever. Ketorolac is usually used for moderate to severe postoperative pain. Hypersensitivity is the prime contraindication.1 But it is well tolerated by patients, minimal amount of metabolism & decrease other side effects which are associated with NSAID's. 9-12

The common procedures of Maxillofacial  surgery are being performed are management of trauma patient , removal of cyst and tumors and ontological surgeries  average time needed is  between 3–5 hours.13 Post-operative pain is always felt as acute due to surgical insult to tissue, and duration of surgery. The researchers are continuously in search for many years for the aim to identify a more-effective analgesic for application after surgery.

The purpose of this study was to evaluate the efficacy of tramadol & ketorolac and more suitable for postoperative pain control, cost effective following maxillofacial surgery. The results of this study will help the professional / OMS for better management of post operative pain in Oral & Maxillofacial Surgery patients.

MATERIALS AND METHODS

This study was conducted in the O&MFS Department, LUMHS Jamshoro from November 2017 to July 2018. Total hundred patients were recruited. The simple random technique was used to select the patients for management of pain. The inclusion criteria of study were patient with maxillofacial trauma, patients with age from 12 to 65 and of either gender. Patients with history of hypersensitivity to tramadol or ketorolac, or patients with peptic ulcer, pregnantor breast feeding females were excluded.

Approval was sought from ethical committee. Written informed consent was taken from patients. Patients were divided into 2 groups by even & odd allocation. Group A receivedKetorolac30 mg (Trometh 30mg) intramuscular after the surgical procedure and repeated after 8 hrs and 16 hours from the end of the operation. Group B receivedTramadol100mg (Tramal 100mg) intramuscular after the surgical procedure and repeated after 8 hrs and 16 hours from the end of the operation. Pain assessment was done by verbal rating using Visual Analog Scale.10, 11 [0-1= No pain, 2-4= Mild pain,
5-7= Moderate pain, 8-10 =Severe pain]. Pain was assessed during 2nd, 4th, 8th, 12th and 24th hours after the surgical procedure and recorded on Performa..Data was analyzed by SPSS version 17.0. Frequency and percentage were calculated for categorical variables like gender. Mean + S.D were calculated for continuous variables like age, pain. To compare both groups independent t-test was applied. P value <0.05 was considered as significant
statistically.

RESULTS

Total 100 patients were divided equally in 2 groups. One group received tramadol while other group received Ketorolac. Mean age was 33.33± 12.49 years. Males were 71% and females were 29% (Table-1)

The preoperative pain recorded taking the values of Visual Analogue Scale (VAS) as No pain (29%), Mild (59%), Moderate (8%) and severe (4%) (Figur-1)

The comparisons of both groups are illustrated in table 3. All patients were monitored at the 2nd, 4th, 8th, 12th, and 24th post-operatively hour. Tramadol represent promising effect on pain control

Table No.1: Gender Distribution

Gender

Frequency

Percentage %

Male

71

71%

Female

29

29%

 

Figure No.1: Descriptive statistics of Pre operative pain

 

 

Table No.2: Comparison of post operative pain with treatment groups at different time duration

Group

Ketorolac

Tramadol

P value

Duration

No Pain

Mild Pain

Moderate Pain

No pain

Mild Pain

Moderate Pain

Pain after 2hours

2 (4%)

30(60%)

18(36%)

3(6%)

40(80%)

7(14%)

 

0.036*

Pain after 4 hours

1(2%)

40(80%)

9(18%)

1(2%)

46(92%)

3(6%)

 

0.169

Pain after 8 hours

1(2%)

45(90%)

4(8%)

0(0%)

50(100%)

0(0%)

 

0.027*

Pain after 12 hours

41(82%)

9(18%)

_

49(98%)

1(2%)

 

_

 

0.004**

Pain after 24 hours

46(92%)

4(8%)

_

50(100%)

0(0%)

 

_

 

0.017*

 

 

DISCUSSION

In spite of advances in medical sciences still not a single drug has ideal post operative analgesic affect. Postoperative pain may have consequences of surgery that ultimately contribute increased in-hospital stay.14 In this study postoperative pain of maxillofacial surgery was managed with two types of drugs: NSAIDs and Narcotic analgesics.

Par-entral route is more effective & reliable route for pain control in any kind of surgery under general anesthesia.  Numbers of studies are published to compare efficacy of different analgesics used to control postoperative pain in maxillofacial surgeries.14, 16, 19

The Results of this study suggest thattramdol has adequate analgesic effect and also decreased the intensity and duration pain after maxillofacial surgery, which is an agreement with the study conducted by Shankariah et al15.

In this study very low moderate and severe pain was found in tramadol group as compare to Ketorolac group on the overall comparison of both groups. Tramadol showing significant better results as compare to ketorolac. Zackova M et al16 reported that there is no difference statistically between the groups in the pain scores measured. Shankaria et al16 reported marked decrease in pain intensity on follow up period in these two drugs, Tramadol was better pain control than its counterpart in post-operative hour (P < 0.050).

In this study after 2 hours mild pain was 60% and 80% moderate pain was 36% and 14%in ketorolac and tramadol group respectively showed the statistically significant difference of pain and after 4 hours mild pain was 80% and 92%, moderate pain was 92% and 6% respectively in ketorolac and Tramadol group showed the in-significant results. There was no moderate pain in both groups after 12 hours, while after24 hour’s there was no mild as well as moderate pain in tramadol group after 24 hours showing the statistically significant reduction of pain. Our results are similar to Shaik MM et al and Degala S,  Passi D,
et al 1718,19. Similarly some other studies also stated that Tramadol is better analgesic with little risk of development of tolerance or physical dependence.20,21

CONCLUSION

Within the light of limitations of current study, it was concluded that tramadol is better drug in terms of pain relieving and duration of action after maxillofacial surgery as compared to ketorolac

Author’s Contribution:

Concept & Design of Study:

Kashif Ali Channar

Drafting:

Abdul Bari Memon, Irfan Ahmed Shaikh

Data Analysis:

Nadir Kalhoro, Ajeet Kumar, Bashir Ahmed Jalbani

Revisiting Critically:

Kashif Ali Channar, Abdul Bari Memon

Final Approval of version:

Kashif Ali Channar

Conflict of Interest: The study has no conflict of interest to declare by any author.

REFERENCES

1.     Shankariah M, Mishra M, RajayKamath AD. Tramadol versus Ketorolac in the Treatment of Postoperative Pain Following Maxillofacial Surgery. J Maxillofac Surg 2012;11:315-21.

2.     Becker DE. Pain Management: Part 1: Managing Acute and Postoperative Dental Pain. Anesth Prog 2010;57:67-79.

3.     Sermet S, Akgun MA, SimşekSA.Analgesic prescription pattern in the management of dental pain among dentists in Istanbul. Marmara Pharmaceutical J 2012;16:41-47.

4.     Ridgway D. Analgesics for Acute Pain Meeting the United States Food and Drug Administration’s Requirements for Proof of Efficacy. Clin J Pain 2004;20:123–132.

5.     El Shenawy H, Aboelsoud NH, Zaki AH, El Zawahry M, Shaibeta A. Postoperative Pain Control in Patients after Lower Third Molar Extraction.  J  Am Sci 2010;6:1068-1072.

6.     Ong CK, Lirk P, Tan JM, Sow BW. The analgesic efficacy of intravenous versus oral tramadol for preventing postoperative pain after third molar surgery. J Oral Maxillofac Surg 2005;63(8):
1162-8.

7.     Kubota R, Komiyama T, Miwa Y, et al. Pharmacokinetics and postoperative analgesia of epidural tramadol: a prospective, pilot study. Current Therapeutic Res 2008;69(1):49–55.

8.     Christensen K, Daniels S, Bandy D, Ernst CC, Hamilton DA, Mermelstein FH, et al. A Double-Blind Placebo-Controlled Comparison of a Novel Formulation of Intravenous Diclofenac and Ketorolac for Postoperative Third Molar Extraction Pain. Anesth Prog 2011;58:73-81.

9.     Cohen MN, Christians U, Henthorn T, Vu Tran Z, Moll V, Zuk J, et al. Pharmacokinetics of Single-Dose Intravenous Ketorolac in Infants Aged 2–11 Months. Anesth Analg 2011;112: 655–60.

10.            Abbas SM, Kamal RS, Afshan G. Effect of Ketorolac on Postoperative Pain Relief in Dental Extraction cases – a comparative study with Pethidine. J Pak Med Assoc 2004;54:319-22.

11.            Lepri A, Sia S, Catinelli S, Casali R, Novelli G. Patient-controlled analgesia with tramadol versus tramadol plus ketorolac. Minerva Anestesiol 2006;72:59-67.

12.            Fujita I, Okumura T, Sakakibara A, Kita Y. Involvement of inflammation in severe post-operative pain demonstrated by pre-surgical and post-surgical treatment with piroxicam and ketorolac. J Pharm Pharmacol 2012;64(5):747-55.

13.            Shipton EA, Roelofse JA, BlignautRJ.An evaluation of analgesic efficacy and clinical acceptability of intravenous tramadol as an adjunct to propofol sedation for third molar surgery. Anesth Prog 2003;50(3):121–8.

14.            Loach A. The management of postoperative pain in orthopedic anesthesia. 2nd  ed. Edward Arnold, London,p65

15.            Shankariah M, Mishra M, Kamath RA Tramadol versus ketorolac in the treatment of postoperative pain following maxillofacial surgery. J Maxillofac Oral Surg 2012;11(3):264-70.

16.            Zackova M, Taddei S, Calò P, Bellocchio A, Zanello M. Department of Anesthesia and Intensive Care, Bellaria Hospital, Bologna, Italy. Minerva Anestesiologica 2001;67(9):641-646.

17.            Shaik MM, Kumar J, Mobina S, Satyanarayana N, Sunitha P. Comparative study of tramadol and ketorolac in the pain management of third molar tooth extraction. J Coll Med Sci Nepal 2010;6(1):35-43.

18.            Degala SNehal A

. Comparison of intravenous tramadol versus ketorolac in the management of postoperative pain after oral and maxillofacial surgery. Oral Maxillofac Surg 2018;22(3):275-280.

19.            Passi D, et al. Comparative Evaluation of Analgesic Efficacy of Oral Ketorolac and Tramadol after Impacted Mandibular Third Molar Surgery: Short Clinical Study with Literature Review. Ann Med Health Sci Res 2018;8:157-162.

20.            Recart A, Duchene D, White PF, et al. Efficacy and safety of fast-track recovery strategy for patients undergoing laparoscopic nephrectomy. J Endourol 2005;19:11-65.

21.           Stamer UM, Maier C, Grond S, Veh-Schmidt, Klaschik E, Lehman KA. Tramadol in the management of post- operative pain: a double-blind, placebo-and active drug-controlled study. Eur J Ana 1997;12(6):646-54.