Medical

Communication

Biosci. Biotech. Res. Comm. 10(1): 51-55 (2017)

A comparative analysis of the in uence of adding

morphine and tramadol to lidocaine in para cervical

block on the level of post-operation analgesia among

the patients applying for curettage

Alireza Kamali

, Rahele Rezaei Ashtiyani

, Maryam Shokrpour

and Shirin Pazoki

Department of Anesthesia, Arak University of Medical Sciences, Arak, Iran

Department of Gynecology, Arak University of Medical Sciences, Arak, Iran

ABSTRACT

Curettage is one of the most common operations among women. Several methods are used to reduce post-operation pain. The

present research seeks to study the effect of adding morphine and tramadol to lidocaine in para cervical block on post-operation

analgesia. This is a double-blind clinical trial conducted on 120 women applying for curettage. The participants were divided into

three completely random groups. The  rst group received 5cc lidocaine 1.5% along with 1 mg (1cc) morphine (totally 6cc), the

second group received lidocaine 1.5% and 2 mg (1cc) tramadol, and the third group received 5cc lidocaine with 1cc distilled water

as placebo for para cervical block. The length and intensity of pain was registered based upon VAS table and time for requesting

painkiller after operation for all three groups. The pain score in the 0th, 30th, and 60th minute in those groups receiving morphine

and tramadol was less than what was observed in the group who had received lidocaine (P < 0.05), but the pain score in all times

in the group who had received tramadol was signi cantly less than other groups (P<0.05). The  rst painkiller in morphine and

tramadol groups was asked much later than lidocaine group (P < 0.05) but no signi cant difference was observed between the

morphine and tramadol groups. The side effects were similar in all groups with lower levels of Bradycardia observed in placebo

group (P < 0.05). Morphine and tramadol were more effective than lidocaine creating para cervical block and analgesia and reduc-

tion of pain following the operation but tramadol exhibited a lower pain score throughout the research. The average length of

analgesia in placebo group was less than what was observed in other two groups. However, no signi cant difference was observed

between tramadol and morphine groups in terms of the length of analgesia after operation.

KEY WORDS: CURETTAGE, MORPHINE, TRAMADOL, ANALGESIA

ARTICLE INFORMATION:

*Corresponding Author: Maryam_shokrpour@yahoo.com

Received 27

Nov, 2016

Accepted after revision 20

March, 2017

BBRC Print ISSN: 0974-6455

Online ISSN: 2321-4007 CODEN: USA BBRCBA

Thomson Reuters ISI ESC and Crossref Indexed Journal

NAAS Journal Score 2017: 4.31 Cosmos IF : 4.006

reserved.

Online Contents Available at: http//www.bbrc.in/

52 A COMPARATIVE ANALYSIS OF THE INFLUENCE OF ADDING MORPHINE AND TRAMADOL TO LIDOCAINE BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS

Alireza Kamali et al.

INTRODUCTION

Curettage is one of the most common types of gyneco-

logical operations in Iran and the whole world. As many

as 660 thousand curettages in the  rst three months of

pregnancy were carried out in the US in 2003. General,

local or para cervical block anesthesia is used in this

type of operation. General anesthesia exhibits a higher

level of bleeding, womb trauma, and even death as a

result of hypoventilation and aspiration. As a result,

merely 10% of clinics in the US utilize general anesthe-

sia. Local anesthesia with/without oral treatment is used

in 58% of the patients and intravenous sleep drug mixed

with local anesthesia is used in 32% of cases (Mankowski

et al. 2014 and Poornima 2014).

Para cervical block is one of these available meth-

ods. Para cervical block prevents transmission of pain.

The sympathetic and parasympathetic sensory  bers

are located in the internal surface of cervix before run-

ning through the womb. During cervix dilatation, pain

signals are transmitted through parasympathetic  bers

and the process continues along the vaginal and liga-

ment vessels. As a result, para cervical block takes place

within the 3

and 9

hours Kingston and Charles 2009).

The most common type of medicine used for local anes-

thesia is lidocaine. Lidocaine is economically affordable

and it had less side effects compared to other anesthet-

ics. Tramadol is an opioid pain medication used to tran-

quilize mild to severe pains. Morphine is a strong opioid

derived from opium and it is considered to be the most

important effective compound of opium Gourlay, (1988),

Ejlersen, et al. (1992) and Bray eld, (2013) and Yektag

Gümü (2016).

Considering the side effects of general anesthesia

and in order to prevent blood loss among emergency

patients, para cervical block can be really effective. Para

cervical block is an anesthetics method carried out by

gynecologists and it doesn’t require the constant pres-

ence of anesthesiologist. As a result, it is the best method

in emergency conditions. Various researches have uti-

lized different medical compounds in para cervical block

the most common of which is lidocaine 2%. Consider-

ing the little analgesic effects of lidocaine in post-oper-

ational analgesia after para cervical block, we decided to

enhance the intensity and length of analgesia by adding

morphine and tramadol to the common local anesthetics

(lidocaine).

MATERIAL AND METHODS

This double-blind, random. Clinical trial was carried out

on 120 women aging 20 to 45 years old who had resorted

to Taleghani Hospital of Arak for curettage. Using the

table of randomized numbers, the participants were

randomly divided into three groups: lidocaine and mor-

phine, lidocaine and tramadol, and lidocaine and dis-

tilled water. Each group consisted of 40 participants. The

quali ed patients took part in the research after obtain-

ing their consent. After each full monitoring of vital sig-

nals (ECG, BP, RP, BP, SPO2), the patients received as

much as 3 to 5 cc/kg crystalloid liquid as the alternative

liquid. The patients were then asked to lie on their back

and all of them received 2mg Midazolam and 2cc (10

mg) Sufentanil as sedative. The patients were then asked

to assume a lithotomical position. They underwent para

cervical block in a fully esterilized condition.

The  rst group received 5cc lidocaine 1.5% along

with 1 mg (1cc) morphine (totally 6cc), the second group

received lidocaine 1.5% and 2 mg (1cc) tramadol, and

the third group received 5cc lidocaine with 1cc distilled

water as placebo for para cervical block. The length and

intensity of pain was registered based upon VAS table

and time for requesting painkiller after operation for

all three groups. 10 cc syringes containing the medi-

cine were prepared in advance by anesthesiologist and

marked with A, B, and C. The researchers were provided

with the syringes and para cervical block was carried

out. To make sure about accomplishment of full block

and analgesia, the level of patient’s cooperation at

the beginning of the operation was registered and the

patients were asked if the felt any pain.

Having made sure about the site of the above-said

blocks, curettage was conducted. Every 5 minutes dur-

ing the operation, the hemodynamic status of the patient

(including PR, BP) was registered in the questionnaire.

When the operation was over, the pain level of the

patients was measured 30 and 60 minutes later in the

recovery room using VAS (visual analog score) ruler.

The average length of patients analgesia was also meas-

ured by registering the time when the  rst painkiller

was requested. Finally, SPSS 16 was used to analyze the

information obtained by questionnaires.

RESULTS AND DISCUSSION

This research was conducted on 120 women aging 20

to 45 resorting to Taleghani Hospital of Arak for curet-

tage. The participants were randomly divided into three

groups: lidocaine with morphine, lidocaine with tram-

adol, and lidocaine with distilled water. Each group

consisted of 40 people. No signi cant difference was

observed among the patients in terms of the average age

and age of pregnancy (P ≥ 0.05). As P ≥ 0.05, no signi -

cant difference was observed between the three groups

in terms of average blood pressure, heart rate and levels

of arterial oxygen saturation.

Considering P ≤ 0.05, the average length of analgesia

in placebo group was much less than what was observed

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS A COMPARATIVE ANALYSIS OF THE INFLUENCE OF ADDING MORPHINE AND TRAMADOL TO LIDOCAINE 53

Alireza Kamali et al.

Table 1. Comparing the length of analgesia among patients applying for curettage in

three groups

Groups Tramadol Morphine Placebo P-value statistical test

Average length of analgesia

(Mean ± SD)

2.29 ± 3.1 2.25 ± 3.8 1.55 ± 4.1 Kruskal-Wallis P ≤ 0.05

Signi cant

Table 2. Comparing the average pain score among the patients applying for curettage in three groups

Group Tramadol Morphine Placebo P-value Statistical test

Pain score in recovery room

(Mean ± SD)

2.35 ± 4.8 3.3 ± 4.2 4.1 ± 5.1 Kruskal-Wallis P ≤ 0.05

Signi cant

Pain score 30 minutes after operation

(Mean ± SD)

2.8 ± 4.1 3.8 ± 4.4 4.45 ± 3.2 Kruskal-Wallis P ≤ 0.05

Signi cant

Pain score 1 hour after operation

(Mean ± SD)

3.6 ± 3.5 4.1 ± 4.2 4.9 ± 4.5 Kruskal-Wallis P ≤ 0.05

Signi cant

in the other two groups, but no statistically signi -

cant difference was observed between tramadol and

morphine groups in terms of post-operation analgesia

(table 1).

Considering P ≤ 0.05, pain score in the recovery room

in the recovery group was much less than what was

observed for the other two groups. On the other hand,

a less pain score was observed for morphine group in

recovery room compared to placebo group. Pain score in

tramadol group 30 minutes after the operation was less

than other groups (P ≤ 0.05). This pain score in morphine

group was also less than placebo group. 1 hour after

the operation, the pain score in tramadol group was less

than other groups (P ≤ 0.05). Again, a lower pain score

was reported in tramadol group compared to what was

observed in other groups. In other words, the pain score

in tramadol group was less than what was observed in

other groups throughout the research (table 2).

As P ≥ 0.05, no statistically signi cant difference was

observed between the three groups in recovery room in

terms of blood pressure, heart rate, and arterial oxygen

saturation levels among mothers applying for curet-

tage. No signi cant difference was observed between

the three groups in terms of post-operation nausea and

occurrence of hypotension after operation (P ≥ 0.05). A

signi cant difference was observed between the three

groups in terms of Bradycardia after operation (P ≤ 0.05)

and the occurrence of Bradycardia in placebo group was

less than what was observed in other two groups.

The present research seeks to study the analgesic

effects of lidocaine mixed with morphine or tramadol

and the cases when only lidocaine is used on creating

analgesia and killing pain after operation. According to

the results of this research, morphine and tramadol had

no in uence on hemodynamic parameters and arterial

oxygen, but they helped cause higher levels of analgesia

than placebo. The average length of analgesia in pla-

cebo group was shorter than other groups. However. No

statistically signi cant difference was observed between

the two groups of tramadol and morphine in terms of

post-operation analgesia.

The pain score in the recovery room in tramadol group

was less than the other two groups. On the other hand,

the pain score in the recovery room in morphine group

was less than placebo. 30 minutes after operation, a lower

pain score was reported in tramadol group compared to

other groups and this score in morphine group was less

than placebo. 1 hour after operation, a lower pain score

was reported in tramadol group compared to other groups

and this score in morphine group was less than placebo.

In other words, the pain score in tramadol group was less

than the other groups throughout the research.

No signi cant difference was observed between the

three groups in terms of the occurrence of post operation

nausea and vomiting and hypotension. However, a sig-

ni cant difference was observed in terms of the brady-

cardia and occurrence of bradycardia in placebo group

was less than the other two groups.

Various researches have pointed to the fact that

sensory signals sent by the injured organs during an

operation stimulate the central nervous system. The

present research focuses on controlling the central

nervous system. For a preventive treatment and con-

trolling environmental sensitivity, Nonsteroidal anti-

in ammatory drugs, local anesthetics and opioids are

utilized and an effective treatment for post operation

analgesia needs to focus on impeding both the central

and environmental sensitivity, Eide et al., (1995). Para

cervical block is accomplished by blocking the sympa-

thetic and parasympathetic sensory  bers before then

enter the womb through internal whole. The most com-

mon medicine used for this purpose is lidocaine 1% used

in the 5

and 7

hour after cervix, Mankowski et al.

(2009).

Alireza Kamali et al.

54 A COMPARATIVE ANALYSIS OF THE INFLUENCE OF ADDING MORPHINE AND TRAMADOL TO LIDOCAINE BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS

The results of this research are in line with the

research conducted by Yektag and Gümüg (2016). They

arrived at the conclusion that prescribing tramadol for

local anesthesia has numerous clinical advantages such

as shorter commencement of sensory and mobile block

and reduction of pain and less need for painkillers and

better conditions during the operation. According to

the data achieved in our research, tramadol exhibited a

lower pain score throughout the research an increased

the analgesic length of patients. Another research con-

ducted by Byrne and Nolan (2016) failed to  nd a sig-

ni cant difference between additional morphine and

tramadol. Similar levels of anti-emetics were used in

both groups. No signi cant difference was also observed

in our research in terms of analgesia between the mor-

phine and tramadol groups.

Our results were by no means in line with the research

conducted by Oral and Hanci (2015) in order to compare

the effect of Levobupivacaine tenoxicam tramadol with

Levobupivacaine tenoxicam morphine on post-opera-

tion pain of patients undergoing knee surgery. Vas in

the saline group while the knee was resting or in  exion

position was signi cantly more than other groups. The

length of analgesia in groups T and N was signi cantly

longer than saline group. The difference between groups

T and M was signi cant. The number of painkillers

asked and used within 24 hours after operation in mor-

phine group was signi cantly less. Morphine resulted in

a more effective reduction of pain, longer analgesia and

less demand for painkiller compared to using tramadol.

These results are by no means in line with the results of

our research,( Oral and Hanci 2015).

In the research conducted by Thumwadee and Ussanee

(2013), no signi cant evidences were found to show that

para cervical block is better than local anesthesia and

systematic analgesia. The research conducted by Suvaya

et al (2013) failed to  nd a signi cant difference in the

pain scores recorded for morphine and tramadol groups.

These results contradict the  ndings of our research

where the pain score in tramadol group was shown to

be less. In another research conducted by Jazayeri et al

(2012), the pain score in tramadol and morphine group

was signi cantly less than when these medicines were

not used. Both of these local pain drugs can signi cantly

reduce pain during Arthroscopic knee surgery. Another

research conducted by Thongrong and Jarruwale (2011)

failed to  nd a signi cant difference in the pain score

of those patients who had undergone para cervical block

and those receiving intravenous morphine. As a result,

para cervical block can be another alternative to reduce

pain in curettage. The results of our research also point

to the fact that para cervical block can be a good method

to get rid of pain in curettage .

Another research was also conducted by Aslan and

Izde (2009) which showed lidocaine block with mor-

phine or tramadol helps enhance analgesia and sensory

block. These results were in line with our research. A

research conducted by Unlugenc and Vardar (2008)

failed to  nd a signi cant difference between morphine,

tramadol and Pethidine groups in terms of pain score

and side effects.

CONCLUSION

As previously mentioned, different studies have found

various results concerning the effects of tramadol and

morphine. These differences may be caused by different

types of surgery, various lengths of operations, selec-

tion of different patients, failing to achieve blindness

in researches and different designs of the research. The

participants studied in this researches were undergoing

the same type of operation and the type of operation

was not a heavy one where the abdominal organs are

exposed; in fact, we studied a light surgery where the

abdominal organs remain intact. The average length of

analgesia in placebo group was less than other groups

but no signi cant difference was observed between

the two groups of tramadol and morphine in terms of

the length of analgesia. Keeping in mind the fact that

patients had no background diseases and the operations

had a limited length, tramadol and morphine seem to

be effective medicines in causing anesthesia and anal-

gesia and reducing pain after operation. In all the times

studied in this research, tramadol exhibited a lower pain

score.

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