Because of its relative lack of sedative action and respiratory depression,3 tramadol has been a subject of keen interest as an alternative to traditional opioids for post‐operative pain control. However, in many adult studies, data on the efficacy and optimal dose of tramadol in producing adequate pain relief after surgery have been conflicting. Fewer studies have been done in the paediatric population, in which it has been shown to be beneficial for post‐operative pain control when administered in varying doses and by different routes.2 3 5 The recommended dose of tramadol for children is 1–2 mg kg–1 three or four times daily (package insert). We chose to use 2 mg kg–1 as this dose has been shown to be more efficacious than 1 mg kg–1, with no increase in adverse events.3 Forty‐five per cent of the children in our study who received tramadol did not need a rescue analgesic in the recovery room. However, although this difference was significant compared with placebo, 55% of the children still required additional analgesia in the immediate recovery period. In adults, the optimal initial dose of tramadol would appear to be 3 mg kg–1 for acute pain of moderate to severe intensity. The pharmacokinetics of i.v. tramadol in children has only recently been investigated, and it appears that children require the same body weight‐related doses as adults.6 Therefore, it is possible that children also need a higher initial bolus dose of tramadol for effective pain relief. Whether higher doses of tramadol improve analgesia without increasing adverse events in the paediatric population warrants further investigation. Although 55% of the children receiving tramadol still needed pethidine in the recovery room, is tramadol stronger than fioricet, the total amount of pethidine required was significantly reduced compared with the placebo group. Only 18% of children in the tramadol group required at least two doses of pethidine compared with 43% in the placebo group, is tramadol stronger than fioricet. This opioid‐sparing effect of tramadol and its apparent lack of sedative effect3 may have been the reason for the equally rapid recovery in both study groups and, in our opinion, emphasizes the advantage of tramadol in day‐case surgery. The overall incidence of adverse events with tramadol in the 1–3 yr age group was low. Even the concomitant use of another opioid (alfentanil) during anaesthesia in our study, which would have been expected to increase the opioid effects of tramadol, did not delay the return of spontaneous ventilation or increase post‐operative vomiting compared with placebo. Our findings are in accordance with the study by Bösenberg and Ratcliffe, who reported a similar low incidence of post‐operative nausea and vomiting in older children with tramadol 2 mg kg–1.3 These investigators also demonstrated only minor respiratory depression with tramadol during spontaneous ventilation with halothane.3 Eighty‐five per cent of the children who received only rectal ibuprofen needed additional pethidine doses in the recovery room. The low efficacy of ibuprofen in providing analgesia may have been partly a result of the slow absorption of rectal ibuprofen or an inadequate dose in some children. However, our findings confirm that NSAIDs alone are often unable to provide sufficient analgesia after adenoidectomy even when given intravenously during surgery.1 In this respect, the intraoperative administration of tramadol may offer a useful addition to post‐operative pain control after surgery. Because of the comparatively long elimination half‐life of tramadol (6.4 h) and its metabolite M1 (10.6 h) in children,6 we expected it to reduce the need for analgesia at home. However, although the number of children given ibuprofen at home during the first 24 h after surgery was lower in the tramadol group (59% versus 74% in the placebo group) the difference did not reach statistical significance. The incidence of children requiring analgesia at home is consistent with the findings of Nikanne and colleagues1 on post‐operative pain after adenoidectomy, , and confirms the importance of regular analgesic treatment on the first few days after surgery, is tramadol stronger than fioricet.
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