Yeditepe Medical Journal 2013;7(25): 590-597 EFFECT OF TRAMADOL ON ABSTRACT BISPECTRAL INDEX Purpose: This prospective, randomized, DURING ANESTHESIA double-blind, controlled study was designed to investigate the effects of WITH SEVOFLURANE AND tramadol on the bispectral index (BIS) N2O during anesthesia with sevoflurane and N2O. Orıgınal Artıcle Methods: 60 ASA class 1 and 2 patients, scheduled for elective lumbar SEVOFLURAN VE N2O İLE microdiscectomy operation under general UYGULANAN GENEL anesthesia, were included in this study. None of the patients were premedicated; ANESTEZİ SIRASINDA anesthesia was induced with thiopental 5 TRAMADOL’ÜN mg.kg-1 and rocuronium 0,6 mg.kg-1, and maintained with 40% N2O-O2 mixture BİSPEKTRAL İNDEKS and sevoflurane. At induction of ÜZERİNE ETKİSİ anesthesia, subjects were randomly allocated into 2 groups to receive either saline (control group), or tramadol 2 mg kg-1 (T group) intravenously. Hemodynamic data and BIS values were Murat Haliloglu then recorded until the completion of the Yeditepe University Hospital, Department of Anesthesiology operation, during which time the concentrations of sevoflurane were not Mehtap Ozdemir modified. Umraniye Education and Research Hospital, Departman of Anesthesiology Results: The BIS values were significantly different between groups throughout the Ozkan Bozkurt operation. No significant changes in the Umraniye Education and Research Hospital, hemodynamics were noted, except mean Departman of Anesthesiology arterial blood pressure in the T group which was significantly high in the first 5 Nurten Bakan minutes of entubation. Umraniye Education and Research Hospital, Departman of Anesthesiology Conclusıons: There were no patients that has BİS values more than 60 or who presented explicit recall of events under Corresponding Author anesthesia. Tramadol didn’t seem to cause a problem with respect to depth of Murat Haliloglu, M.D. anesthesia and can be safely administered Yeditepe University Hospital, Department of perioperatively. Anesthesiology Istanbul/Turkey e-mail: [email protected] Key Words: bispectral index; awareness; general anesthesia; sevoflurane; tramadol. 590 Yeditepe Medical Journal 2013;7(25):590- 597 Haliloglu M. et al ÖZET Amaç: Bu prospektif, randomize, çift-kör, anesthesia as it prevents severe kontrollü çalışmada sevofluran ve N20 ile postoperative pain and reduces the uygulanan genel anestezi sırasında demand for opioid analgesic significantly kullanılan tramadolün bispektral indekse (2-4). Hovewer intraoperative olan etkisi araştırıldı. administration of tramadol was reported to cause dose-dependent activation of the Method: Çalışmaya genel anestezi altında electroencephalogram (EEG) during mikrodiskektomi operasyonu geçirecek volatile anaesthesia (5). For this reason, it ASA grup 1 ve 2 olan 60 hasta dahil edildi. has been suggested that the use of Hiçbir hastaya premedikasyon tramadol could increase the risk of uygulanmadı, anestezi indüksiyonu 5 mg awareness (5,6). kg-1 tiopental ile yapıldı, kas gevşetici olarak rokuronyum uygulandı; idame Bispectral index (BIS) provides a N2O-O2 ve sevofloran ile sağlandı. continuous age-independent monitoring of İndüksiyonda hastalar rastgele iki gruba hypnotic state induced by the most widely ayrıldı: tramadol grubuna (T grup) 2 mg used sedative-hypnotic agent and has kg-1 tramadol, kontrol grubuna ise serum been used to asess the induction quality, fizyolojik uygulandı. Hemodinamik ve BİS depth of anesthesia, intraopertive değerleri operasyon boyunca kayıt edildi, requirement of anesthetics, postoperative bu sırada sevofluran değerleri değiştirilmedi. recovery, and to reduce the intraoperative recall awareness. BIS value of 0 Bulgular:Operasyon boyunca BİS represents an isoelectric değerleri tramadol grubunda kontrol electroencephalogram and 100 represents grubundan farklı bulundu. Hemodinamik an awake state, whereas 40 to 60 reflect parametrelerde önemli değişiklikler gözlenmedi, yalnızca entübasyon sonrası adequate hypnotic effect for general ilk 5 dakikada ortalama arter basıncı T anesthesia (7-9). grubunda yüksek seyretti. Tramadol has a risk of intra-operative Sonuç: Hiçbir hasta intraoperatif olayları awareness but there are limited data on hatırladığını belirtmedi ve hiçbirinin BİS this issue. This study aim to identify the değerleri 60’ın üzerinde gözlenmedi. effects of tramadol on the BIS and Tramadolün anestezi derinliği açısından hemodynamic changes during general sorun yaratmayacağı ve güvenli olarak pre inhalational anesthesia using sevoflurane. ve intraoperatif olarak uygulanabileceği sonucuna varıldı. METHODS Anahtar kelimeler: Bispektral indeks; After obtaining approval from the farkındalık; genel anestezi; sevofluran; Institutional Ethics Committee (Date: tramadol. 11.01.2011 Chairperson: Ahmet Göçmen, MD) and written informed consent, a total INTRODUCTION of 60 adults, 18 to 65 years ofage, physical status ASA (American Society of Tramadol is a synthetic, centrally acting Anesthesiologists) I and II, scheduled for opioid analgesic with a potent opioid an elective single space lumbar disc metabolite (1). surgery under general anesthesia were included in this study. All of the surgical It has been frequently used for pain procedures were performed by the same control during administration of inhaled surgical team. The demographic data of 591 Yeditepe Medical Journal 2013;7(25):590- 597 Haliloglu M. et al the patients and their ASA values were After 5 minutes of preoxygenation with recorded. 100% O2, anesthesia was induced with thiopental sodium 5 mgkg-1and Exclusion criteria were history of rocuronium 0,6 mgkg-1 was given as hearing loss, language or communication muscle relaxant. Manual ventilation was difficulties, chronic pain on analgesic done with sevoflurane 2 vol %, O2 1,5 L medications, allergy to any drugs used in -1 -1 min , N2O 2 L min . After 3 minutes the study, central nervous system larngoscopy was done with Magill diseases, hemodynamic instability, laryngoscope blade and trachea was ischemic heart diseases, renal or hepatic intubated with cuffed polyvinyl chloride failure, therapies with drugs affecting EEG tube size 7,5 mm for female and 8,0 mm -2 activity, body mass index˃35kg m . In internal diameter for male. Controlled the preoperative stage, all patients were ventilation was adjusted to maintain informed about visual analog scale (VAS) normocapnia. Anesthesia was maintaned (0=no pain at all to 10=intolerable pain). with 66% nitrous oxide in oxygen and the All enrolled patients were randomly sevoflurane vaporizer was adjusted to divided into group C (controle), or group T maintain an end-expired sevoflurane (tramadol) (n=30 in each group) concentration of 1,7%. During according to SNOSE way (10). At the intraoperative stage, muscle relaxation induction of anesthesia before was maintained with 10 mg rocuronium. intratracheal intubation, one of two study In addition, a 2 µg kg-1 fentanyl bolus was solutions was slowly given to patients by planned for use in cases when the mean the first author of this study according to arterial pressure and heart rate rose 20% a randomised, double-blinded and above basal values. All hemodynamic and placebo-controlled protocol. The study BİS variables, ETCO2 (mmHg), SpO2, were solutions (C, T) were prepared by hospital recorded at following time interval: at pharmacist within two 10 ml syringes, so baseline and 1,3,5,15,30,45,60,90 that C, T syringes contained 10 ml serum minutes after intubation; at this time, the -1 physiologic as placebo, 20 mg ml concentration of inhaled anesthetics was tramadol respectively. The syringes were not adjusted. At the termination of marked only with a coded label to surgery, sevoflurane and N20 were maintain the double-blind nature of the discontinued and the residual study. Thus, while 30 patients in group-C neuromuscular block was reversed and received 1ml saline per 10 kg, and 30 extubation was done when patients were patients in group-T received 1ml tramadol awake and respiration was regular and -1 per 10 kg (2 mg kg ); these syringes adequate. were consecutively used. Injection of these solutions was done within at least 3 In the recovery area, all patients min advocated by Radburch et al (11). received 35% oxygen by mask. Pain intensity was assessed by the patient and None of the patients were premedicated anesthesist on arrival recovery room and for preoperative sedation and hypnosis, every 15 minutes thereafter using a visual and after they arrived at the operating analogue scale. In addition, the presence room, we monitored their of nausea and vomiting was recorded and electrocardiograms, non-invasive blood the success of antiemetic therapy noted. pressure and peripheral oxygen saturation Patients who requested additional pain - (SpO2). We attached the BIS (BIS A-2000, relief were given meperidine 0,5 mg kg software version 3.30, Aspect Medical 1i.v. Nausea was treated with ondansetron Systems, USA) at the frontal area of head 4 mg i.v. Data were recorded for 90 according to the way recommended by the minutes min in the recovery area or until manufacturing company and with more patients received additional analgesia. than 95 on the signal quality index (SQI), BIS values were measured and recorded. 592 Yeditepe Medical Journal 2013;7(25):590- 597 Haliloglu M. et al In the postanesthesia care unit just before transfer to the ward, the patients A) were interviewed using modified Brice interview (12); this aims to evaluate the 160 possible occurrence of awareness. 140 120 STATISTICS