What is the maximum dose of tramadol (opioid analgesic) for plastic post-operative surgery?

Maximum Tramadol Injection Dose for Plastic Post-Operative Surgery

For postoperative pain management in plastic surgery, administer intravenous tramadol 1 to 1.5 mg/kg per dose, titrated to effect, with dosing intervals of every 4 to 6 hours, not exceeding a maximum daily dose of 400 mg in adults. 1, 2

Dosing by Clinical Setting

Immediate Postoperative Period (PACU)

• Administer tramadol 1 to 1.5 mg/kg IV, titrated to effect for breakthrough pain in the post-anesthesia care unit 1
• This dose should be carefully titrated based on pain response and tolerability 1

Ward-Based Management

• Continue tramadol 1 to 1.5 mg/kg IV every 4 to 6 hours with adequate monitoring for breakthrough pain on the ward 1
• The same weight-based dosing applies but requires appropriate monitoring infrastructure 1

Maximum Daily Limits

• The absolute maximum daily dose is 400 mg/day regardless of weight-based calculations 2
• For patients over 75 years old, reduce the maximum daily dose to 300 mg/day 2
• In patients with creatinine clearance <30 mL/min, extend dosing intervals to every 12 hours with a maximum of 200 mg/day 2

Route-Specific Considerations

The evidence strongly supports intravenous administration for postoperative plastic surgery:

• IV tramadol demonstrates efficacy equivalent to morphine 5-15 mg for moderate postoperative pain 3
• Intramuscular administration is equally effective but IV route allows for better titration 4, 3
• Oral tramadol should be reserved for transition to discharge, not acute postoperative management 1

Critical Dosing Algorithm

Step 1: Initial Loading

• Calculate 1 to 1.5 mg/kg based on actual body weight 1
• Administer slowly IV, titrating to pain relief 1

Step 2: Assess Response

• Evaluate pain reduction within 30 minutes using VAS scale 5
• If inadequate relief, consider alternative opioid rather than exceeding single-dose maximum 5

Step 3: Maintenance Dosing

• Repeat same weight-based dose every 4-6 hours as needed 1, 2
• Track cumulative daily dose to ensure <400 mg/day limit 2

Important Safety Caveats

Respiratory Depression Risk

• Tramadol causes less respiratory depression than morphine but monitoring remains essential 4, 3
• Respiratory depression has been observed rarely, primarily with infusion techniques 3

Combination with Other Analgesics

• Tramadol should be part of multimodal analgesia, not monotherapy 6
• Combining with acetaminophen and NSAIDs reduces total opioid requirements 6
• Avoid concurrent use with monoamine oxidase inhibitors and use caution with tricyclic antidepressants 7

Nausea Management

• Nausea is dose-dependent and more common with higher loading doses 7, 8
• Consider antiemetic prophylaxis, especially if starting with doses >100 mg 7

Duration of Therapy

Limit tramadol to 5-7 days maximum postoperatively 1

• The discharge prescription should explicitly state the recommended dose and duration 1
• Patients still requiring opioids at 90 days warrant evaluation for chronic post-surgical pain 1

Transition to Oral Route

• When transitioning to oral tramadol for discharge, prescribe 50-100 mg every 4-6 hours 2
• Start at the lower end (50 mg) and titrate upward to improve tolerability 2
• Maximum oral dose remains 400 mg/day (300 mg/day if >75 years old) 2

Special Population Adjustments

Elderly Patients

• Start at the low end of dosing range for patients >65 years 2
• Maximum 300 mg/day for patients >75 years 2

Hepatic Impairment

• Reduce to 50 mg every 12 hours in cirrhotic patients 2

Renal Impairment

• Extend to every 12 hours with 200 mg/day maximum when CrCl <30 mL/min 2
• Hemodialysis removes only 7% of tramadol; regular dosing can occur on dialysis days 2