Comparison of the effects of lidocaine pre-administration and local warming of the intravenous access site on propofol injection pain: Randomized, double-blind controlled trial

Esketamine prevents propofol-induced injection pain: Randomized controlled trial

Background: Propofol is widely used during anesthesia. However, propofol-induced injection pain (PIP) is considered an unpleasant perioperative outcome. This study aimed to investigate the efficacy of a mixture of esketamine and propofol in preventing propofol injection pain in patients undergoing general anesthesia.

Methods: This was a prospective, double-blind, multicenter, and randomized controlled trial. We included 252 adult patients with the American Society of Anesthesiologists physical status I to II who underwent surgery under general anesthesia. Patients were randomly allocated in a 1:1:1:1 ratio to four groups (n = 63 per group). Group NS received a mixture of 1% propofol (20 ml) and 0.9% normal saline (1 ml), group ESK-4 received a mixture of 1% propofol (20 ml) and esketamine 4 mg (diluted with 0.9% normal saline, 1 ml), group ESK-12 received a mixture of 1% propofol (20 ml) and esketamine 12 mg (diluted with 0.9% normal saline, 1 ml), and group ESK-20 received a mixture of 1% propofol (20 ml) and esketamine 20 mg (diluted with 0.9% normal saline, 1 ml) as sedative drugs during anesthesia. The primary outcome was the incidence and distribution of different degrees of PIP. The secondary outcomes were vital signs, characteristics of surgery and anesthesia, and adverse events.

Results: The incidence of PIP in group ESK-20 (33.3%) was significantly lower than that in groups NS, ESK-4, and ESK-12 (63.3%, 62.2%, and 49.1%, respectively; p < 0.01). The incidence of moderate PIP in group NS (33.3%) and group ESK-4 (22.6%) was higher than that in groups ESK-12 (7.5%) and ESK-20 (6.7%). The incidence of severe PIP in group NS (6.7%) and group ESK-4 (9.4%) was higher than that in groups ESK-12 (1.9%) and ESK-20 (0%). There were no differences in the vital signs, characteristics of surgery and anesthesia, or adverse events between the groups.

Conclusion: Our results indicated that the esketamine–propofol admixture reduced the incidence of PIP in patients undergoing general anesthesia without severe side effects.

Padded Dressing with Lidocaine HCL for Reducing Pain during Intravenous Cannulation in Adult Patients: A Randomized Controlled Clinical Trial

Objective. In this study, we aimed to evaluate the effect of administering lidocaine as a local anesthetic at the puncture site prior cannulation on reduction of pain during intravenous cannulation (IVC). Methods. A total of 77 patients were divided into two groups as the patients who received a local anesthetic prior IVC procedure ( $n=40$ ) and the control group ( $n=37$ ). Patients’ demographic data, including age, gender, height, weight and body mass index, IV gauge, IV site, heart rate (HR), and oxygen saturation (SpO2) were recorded and analyzed. Patients in both groups scored the pain they felt during IVC through the visual analog scale (VAS) and the verbal descriptor scale (VDS). Results. No statistically significant difference was found between the two groups in terms of the demographic features. There was no significant difference between the two groups in terms of the cannula gauges and site of IVC. The mean post-IVC HR value was statistically significantly higher compared to pre-IVC in the control group ( $p=0.032$ ), while no difference was found between the mean pre- and postprocedure HR in the lidocaine group. The mean VAS score was significantly lower in the lidocaine group compared to the control group ( $p<0.001$ ). There was a significant difference between the groups in terms of the current VDSs. The rate of the patients reporting mild pain was statistically significantly higher in the lidocaine group compared to the control subjects ( $p<0.001$ ). Conclusion. According to the results of this study, lidocaine HCL-impregnated padded dressing prior IV cannulation significantly reduced pain sensation during IVC.

Efficacy of Pre-Treatment with Remimazolam on Prevention of Propofol-Induced Injection Pain in Patients Undergoing Abortion or Curettage: A Prospective, Double-Blinded, Randomized and Placebo-Controlled Clinical Trial

Background

Propofol-induced injection pain (PIP) is a well-known problem in general anesthesia. We hypothesized that pre-treatment with remimazolam prevents PIP in patients undergoing abortion or curettage.

Materials and Methods

In this prospective, single-center, double-blinded, randomized, placebo-controlled clinical trial, adult patients aged 18 to 60 undergoing abortion or curettage were randomly assigned to three groups. Group Lido received system lidocaine (a bolus of 0.5 mg kg⁻¹, iv). Group Remi received remimazolam (a bolus of 0.1 mg kg⁻¹, iv). Group NS received identical volumes of 0.9% normal saline. Sixty seconds after the injection of lidocaine, remimazolam or saline, patients were injected with propofol at a rate of 12 mL/min until the loss of consciousness. The primary outcome was the incidence of PIP at the time of induction using 4-point scale. Secondary outcomes included propofol-induced injection pain, vital signs, the characteristics of anesthesia and surgery, and adverse events.

Results

The incidence of patients with PIP was higher in group NS than that in group Lido and group Remi (75.7, 44.3, and 42.9%, respectively, p < 0.001). The percentages of patients with moderate PIP were higher in group NS than that in group Lido and group Remi (20.0, 2.9, and 1.4%, respectively, p < 0.001). Moreover, the consumption of propofol and the incidence of adverse event (hypoxemia and chin lifting) in group Remi were lower than that in group NS and Lido, and less patients got physical movement and cough in group Remi. The recovery time in group NS was longer than that in group Lido and Remi.

Conclusion

Our findings indicate that pre-treatment with remimazolam reduced the incidence and intensity of PIP in abortion or curettage patients, equivalent to that of lidocaine without severe adverse effects.

Trial Registration

Chinese Clinical Trial Registry (identifier: ChiCTR2100041805).

Median Effective Dose of Lidocaine for the Prevention of Pain Caused by the Injection of Propofol Formulated with Medium- and Long-Chain Triglycerides Based on Lean Body Weight

OBJECTIVE

To determine the median effective dose (ED50) of prophylactic intravenous lidocaine for the prevention of propofol medium-chain triglyceride/long-chain triglyceride (MCT/LCT) emulsion injection pain.

DESIGN

Prospective trial, Dixon up-and-down sequential method.

SETTING

Operating room of a single hospital.

PATIENTS

Thirty patients aged 18-65 years with American Society of Anesthesiologists (ASA) status I or II who were scheduled for elective surgery under general anesthesia (GA) were included.

INTERVENTIONS

The initial dose of prophylactic lidocaine before propofol MCT/LCT emulsion injection was set at 0.5 mg/kg lean body weight (LBW). The lidocaine dose was adjusted according to the degree of patients' injection pain using the Dixon up-and-down sequential method.

MEASUREMENTS

The ED50 and 95% confidence intervals (CIs) of lidocaine were calculated using the Dixon-Massey formula. Vital signs and adverse effects were recorded. In the postanesthesia care unit (PACU), patients were asked if they recalled feeling any injection pain with visual analog scale (VAS) evaluation.

RESULTS

The ED50 of lidocaine for the prevention of propofol MCT/LCT emulsion injection pain was 0.306 mg/kg LBW (95% CI, 0.262-0.357 mg/kg LBW). No adverse reactions to lidocaine occurred. In the PACU, 90.9% of patients who experienced injection pain recalled this pain (VAS score, 2.8±1.8).

CONCLUSIONS

Prophylactic intravenous lidocaine (0.306 mg/kg LBW) effectively prevented propofol MCT/LCT emulsion injection pain in 50% of patients scheduled for elective surgery under GA with no adverse reaction occurring.

Pharmacological control of pain during propofol injection: a systematic review and meta-analysis

OBJECTIVE

A research was performed to review the effect of pharmacological interventions to control the propofol injection pain.

METHODS

A search of databases was performed. Randomized clinical trials comparing pharmacological interventions with placebo or active compound to reduce of propofol injection pain were selected. The outcome was the frequency of pain. Data were analyzed in three subgroups according to type of control. Random effect model was used to calculate relative risk (RR) with 95% confidence intervals (CIs).

RESULTS

Fifty-two articles with 105 studies on 7315 adults were included. The incidence of pain in intervention and control group was 40.91% and 66.27%. Combination therapy with two drugs (RR = 0.29 95% CI = (0.11, 0.75)), opioids (RR = 0.39 95% CI = (0.28, 0.54)) and 5 HT3 antagonists (RR = 0.39 95% CI = (0.30, 0.50)) were the most effective interventions compared to placebo. Combination therapy was the most effective intervention compared to lidocaine as control (RR = 0.51 95% CI = (0.46, 0.55)). Opioids were the most effective intervention compared to long chain triglyceride propofol as control (RR = 0.27 95% CI = (0.15, 0.49)).

CONCLUSION

Pretreatment with two different drugs, opioids and surprisingly 5 HT3 antagonists were the most effective interventions compared to placebo. Combination therapy was the most effective versus lidocaine as control.

Intravenous Dexmedetomidine Administration Prior Anesthesia Induction With Propofol at 4°C Attenuates Propofol Injection Pain: A Double-Blind, Randomized, Placebo-Controlled Trial

Background: Propofol injection pain, despite various interventions, still occurs during the anesthesia induction and causes intense discomfort and anxiety in patients. This study aimed to explore the effect of intravenous dexmedetomidine on propofol injection pain prior to anesthesia induction with propofol at 4°C.

Methods: A total of 251 patients (American Society of Anesthesiologists I–II) who underwent oral and maxillofacial surgery were randomly assigned to a combination group (n = 63), lidocaine group (n = 62), dexmedetomidine group (n = 63), and placebo-control group (n = 63); they received 0.5 ug/kg dexmedetomidine prior to anesthesia induction with propofol at 4°C, 40 mg lidocaine, 0.5 ug/kg dexmedetomidine prior to anesthesia induction, and normal saline, respectively. Incidence of pain, pain intensity, and reaction to the pain stimulus were evaluated by using verbal categorial scoring (VCS), a numerical rating scale (NRS), and the Surgical Pleth Index (SPI), respectively. In addition, hemodynamic parameters such as heart rate (HR) and mean arterial pressure (MAP) were also measured. The VCS and NRS were evaluated at 5 s after propofol injection. In addition, SPI, HR, and MAP were evaluated at three time points (before anesthesia induction and 5 and 30 s after propofol injection).

Results: The incidence of pain in the combination group (51%) was significantly lower than that in the lidocaine group (71%), dexmedetomidine group (67%), or placebo-control group (94%) (p < 0.001). VCS and NRS scores in the combination group were also lower compared with the other three groups (p < 0.001), with no statistically significant differences between the lidocaine group and dexmedetomidine group (p > 0.05). The SPI of the combination group decreased significantly in comparison with the other three groups at 5 s after propofol injection (F = 96.23, p < 0.001) and 30 s after propofol injection (F = 4.46, p = 0.005). Further comparisons between HR and MAP revealed no significant differences across the groups (p > 0.05).

Conclusion: Because of the sedative nature of dexmedetomidine and analgesic effect of low temperature, this study showed that intravenous dexmedetomidine prior to anesthesia induction with propofol at 4°C is highly effective in attenuating the incidence and severity of pain during injection compared with lidocaine (40 mg), dexmedetomidine 0.5 ug/kg) and placebo. This approach was not associated with any anesthesia complications.

Clinical Trial Registration:ClinicalTrials.gov, identifier: ChiCTR-2000034663

Lidocaine coinfusion alleviates vascular pain induced by hypertonic saline infusion: a randomized, placebo-controlled trial

Background

Hypertonic saline solution has been frequently utilized in clinical practice. However, due to the nonphysiological osmolality, hypertonic saline infusion usually induces local vascular pain. We conducted this study to evaluate the effect of lidocaine coinfusion for alleviating vascular pain induced by hypertonic saline.

Methods

One hundred and six patients undergoing hypertonic saline volume preloading prior to spinal anesthesia were randomly allocated to two groups of 53 each. Group L received a 1 mg/kg lidocaine bolus followed by infusion of 2 mg/kg/h through the same IV line during hypertonic saline infusion; Group C received a bolus and infusion of normal saline of equivalent volume. Visual analogue scale (VAS) scores of vascular pain were recorded every 4 min.

Results

The vascular pain severity in Group L was significantly lower than that in Group C for each time slot (P < 0.05). The overall incidence of vascular pain during hypertonic saline infusion in Group L was 48.0%, which was significantly lower than the incidence (79.6%) in Group C (P < 0.05).

Conclusion

Lidocaine coinfusion could effectively alleviate vascular pain induced by hypertonic saline infusion.

Trial registration

Chinese Clinical Trial Registry, number: ChiCTR1900023753. Registered on 10 June 2019.

Intravenous Lidocaine Alleviates the Pain of Propofol Injection by Local Anesthetic and Central Analgesic Effects

Objective

Lidocaine alleviates propofol injection pain. However, whether lidocaine works through a local anesthetic effect at the site of intravenous injection or through a systemic effect on the central nervous system remains unknown. This study aimed to determine the pain-alleviating mechanism of lidocaine.

Design

A randomized controlled study.

Setting

A gastroscopy facility.

Methods

The study was divided into two parts. Part 1 involved 717 patients who were randomly assigned into five groups. Groups PR, RL20, and RL40 received normal saline or saline containing 20 or 40 mg of lidocaine, injected via the vein on the right hand. Groups LL20 and LL40 received 20 or 40 mg of lidocaine, injected via the vein on the left hand. Part 2 involved 378 patients who were randomly assigned into five groups. Groups RL40, RL1.2, and RL1.5 received 40 mg, 1.2 mg/kg, and 1.5 mg/kg of lidocaine, injected via the vein on the right hand. Groups LL1.2 and LL1.5 received 1.2 or 1.5 mg/kg of lidocaine, injected via the vein on the left hand. All received 2 mg/kg of propofol via the vein on the right hand two minutes later. Injection pain and patient satisfaction were recorded.

Results

The incidence of pain of group RL40 was lower than that of group PR. The incidence of pain of group LL1.2 was higher than that of other groups.

Conclusions

A dosage of 40 mg lidocaine is an appropriate dosage to alleviate propofol injection pain within the same vein. Lidocaine reduces propofol injection pain through both a local anesthetic effect and a central analgesic effect when the dosage reaches 1.5 mg/kg.

The analgesic efficacy and duration of lidocaine on vascular pain induced by hypertonic saline infusion: a double-blinded, randomized control trial

PURPOSE

To determine the analgesic efficacy and analgesic duration of lidocaine 20 mg and 40 mg on eliminating the vascular pain associated with hypertonic saline infusion.

METHOD

Patients who complained pain during infusion of hypertonic saline were randomized into three groups. They received normal saline (Group C), or lidocaine 20 mg (Group L20), or lidocaine 40 mg (Group L40). An electronic stopwatch was used to record the time to onset (T1) and the time to termination (T2) of the analgesic effect, and the analgesic duration (AD) was calculated as T2 - T1.

RESULTS

The incidence of pain elimination was significantly higher in both of the lidocaine groups (83.3 and 56.1% in Groups L40 and L20, respectively) than in the saline group (16.3%). Furthermore, lidocaine 40 mg was significantly more effective than 20 mg in eliminating the pain. The analgesic duration was significantly longer in Group L40 than in Group L20 (211.4 ± 50.2 vs. 130.3 ± 39.5 s, P < 0.001) and Group C (211.4 ± 50.2 vs. 45.1 ± 14.5 s, P < 0.001), and the analgesic duration in Group L20 was significantly longer than in Group C (P < 0.001). The incidence of transient tinnitus/dizziness was significantly higher in Group L40 than in Group L20 (19.0 vs. 2.4%, P < 0.05).

CONCLUSION

A single bolus of Lidocaine was effective in eliminating the pain induced by hypertonic saline infusion, but just for a short period of time. Lidocaine (without venous occlusion) only provides a short analgesic duration for local vein.

Effects of warmed carrier fluid on nefopam injection-induced pain

Background

Nefopam is a non-opioid, non-steroidal analgesic drug with fewer adverse effects than narcotic analgesics and nonsteroidal anti-inflammatory drugs, and is widely used for postoperative pain control. Because nefopam sometimes causes side effects such as nausea, vomiting, somnolence, hyperhidrosis and injection-related pain, manufacturers are advised to infuse it slowly, over a duration of 15 minutes. Nevertheless, pain at the injection site is very common. Therefore, we investigated the effect of warmed carrier fluid on nefopam injection-induced pain.

Methods

A total of 48 patients were randomly selected and allocated to either a control or a warming group. Warming was performed by diluting 40 mg of nefopam in 100 ml of normal saline heated to 31–32℃ using two fluid warmers. The control group was administered 40 mg of nefopam dissolved in 100 ml of normal saline stored at room temperature (21–22℃) through the fluid warmers, but the fluid warmers were not activated.

Results

The pain intensity was lower in the warming group than in the control group (P < 0.001). The pain severity and tolerance measurements also showed statistically significant differences between groups (P < 0.001). In the analysis of vital signs before and after the injection, the mean blood pressure after the injection differed significantly between the groups (P = 0.005), but the heart rate did not. The incidence of hypertension also showed a significant difference between groups (P = 0.017).

Conclusions

Use of warmed carrier fluid for nefopam injection decreased injection-induced pain compared to mildly cool carrier fluid.