Prevention of propofol-induced pain in children: combination of alfentanil and lidocaine vs alfentanil or lidocaine alone

Comparison of propofol-esketamine versus propofol-sufentanil for deep sedation and analgesia in children with autism: A randomized double-blind clinical trial

Propofol sedation, routinely used for endoscopic procedures, is safe and acceptable for children. Adjuvants, such as esketamine or sufentanil, are commonly added to improve the efficacy and safety of propofol sedation. This study aimed to compare the clinical efficacy and safety of propofol-esketamine (PE) versus propofol-sufentanil (PS) for deep sedation and analgesia in children with autism undergoing colonoscopy procedure. One hundred and twenty-four children with autism undergoing colonoscopy procedure were included in the study. Patients were randomly assigned to receive one of the two adjuvants: esketamine (0.3 mg/kg) or sufentanil (0.2 μg/kg), subsequently administered propofol 2.0 mg/kg to induce anesthesia. Additional doses of propofol (0.5-1.0 mg/kg) were administered as needed to ensure patient tolerance for the remaining duration of the procedure. Movement during the procedure, hemodynamic variables, the total dose of propofol, recovery time, and adverse events were recorded. The PE group exhibited a significantly lower incidence of severe movement during the procedure compared with the PS group (14.52% vs. 32.26%, p = 0.020). The PE group showed significantly lower incidence of respiratory depression, hypotension, and severe injection pain of propofol than the PS group during the procedure (all p < 0.05). The mean arterial pressure (MAP) decreased significantly after anesthesia induction in the PS group and remained lower than baseline (all p < 0.05). Compared with the combination of low-dose sufentanil (0.2 μg/mg) with propofol, the low-dose esketamine (0.3 mg/kg) combined with propofol provided more stable hemodynamics, higher quality of sedation, and fewer adverse events in children with autism undergoing colonoscopy procedure.

Deep breathing alleviates propofol-induced pain: a prospective, randomized, single-blind study

PURPOSE

Propofol is commonly used to induce general anesthesia; however, the pain caused during propofol injection is a disadvantage. This study aimed to assess whether deep breathing attenuates propofol injection pain.

METHODS

This prospective, single-blind, randomized controlled study included 200 patients who were scheduled to undergo elective surgery under general anesthesia and randomly and equally divided them into group D and group C. The observers were not blinded to the pain-relieving modality, but each patient was blinded. Group D patients were requested to repeatedly take deep breaths throughout general anesthesia induction with propofol. Group C patients were requested to breathe in the usual manner. The intensity of propofol injection pain was evaluated using the visual analog scale (VAS). Furthermore, we recorded the patients' pain expressions, including grimace or hand-withdrawal, and the recalled pain measured using a VAS in the post-anesthetic care units (PACU).

RESULTS

Compared with patients in group C, those in group D showed significantly reduced VAS scores for propofol injection pain (20 [interquartile range (IQR): 0-48] vs. 37 [IQR 9-65], P = 0.017) and recalled pain in the PACU (16 [IQR 0-32] vs. 26 [IQR 0.5-51], P = 0.031). Further, the grimace incidence was significantly lower in group D (18%) than in group C (45%) (P < 0.001). There was no significant difference in the incidence of pain at induction, recalled pain, or hand-withdrawal.

CONCLUSIONS

Deep breathing could be an easy, safe, and inexpensive method for reducing pain during propofol injection.

Efficacy of Intravenous Paracetamol in Combination with Lidocaine Pretreatment for Reducing Pain During Injection of Propofol

Introduction

The association of pain and discomfort of moderate to high severity and a high incidence with the intravenous (IV) administration of propofol is well known. Various physical and pharmacological methods are used to minimize propofol-induced pain, but the best intervention is still unknown. Therefore, our aim was to determine the analgesic efficacy of IV paracetamol when used in combination with lidocaine pretreatment in reducing propofol injection pain.

Materials and methods

This double-blind, randomized controlled trial was conducted after receiving the approval of our institutional research ethics board. A total of 74 patients were included after providing informed consent, and participants were placed into two equal groups: group A received IV paracetamol (1 g) in combination with lidocaine pretreatment prior to the injection of propofol, and group B received lidocaine pretreatment alone prior to propofol injection. After propofol injection, all participants were asked to evaluate pain on the visual analog scale.

Results

Patients who received the lidocaine-paracetamol combination reported significantly more pain-free responses (51.35%) than those from patients who received lidocaine pretreatment alone (8.11%; P<0.05). The analgesic efficacy of group A was positive in 36 patients (97.3%), and for group B, the analgesic efficacy was positive in 24 patients (64.9%).

Conclusion

The administration of IV paracetamol with lidocaine pretreatment was more effective than lidocaine pretreatment alone in reducing the pain caused by the injection of propofol. Physicians should consider using IV paracetamol in combination with lidocaine pretreatment when patients require IV propofol to ease patient suffering and reduce pain, which may help provide optimal patient care.

Efficacy of lidocaine on preventing incidence and severity of pain associated with propofol using in pediatric patients: A PRISMA-compliant meta-analysis of randomized controlled trials

BACKGROUND

Propofol injection pain was considered as one conundrum during clinical anesthesia. The systematic review about the effect of lidocaine in reducing injection pain among children has not been established. The aim of the study was to systematically evaluate the efficacy and safety of such intervention.

METHODS

The literature search was performed from the inception to the May 31, 2016 in PubMed, Ovid EMBASE, and Cochrane database. All randomized controlled trials that using lidocaine for propofol injection pain in children were enrolled. The primary outcome included the incidence of injection pain and the incidence of propofol injection pain in different degrees. The data were combined to calculate the relative ratio and relevant 95% confidence interval. A meta-analysis was performed following the guidelines of the Cochrane Reviewer's Handbook and the PRISMA statement.

RESULTS

Data from the included 11 studies indicated that the incidence of injection pain was lower in lidocaine group than the incidence in saline control group and in propofol lipuro (medium- and long-chain triglycerides) group (pain occurrence: 22.1% in lidocaine vs 66.8% in saline, RR with 95% 0.34 [0.26, 0.43], I = 38%; 30.5% in lidocaine vs 46.9% in propofol lipuro, RR with 95% 0.68 [0.46, 1.00], I = 9%). There was no difference between lidocaine and ketamine/alfentanil both in reducing pain occurrence and in reducing pain severity (pain occurrence: 29.7% in lidocaine vs 25.8% in ketamine, RR with 95% 1.47 [0.16, 13.43], I = 94%; 31.0% in lidocaine vs 30.7% in alfentanil, RR with 95% 1.01 [0.69, 1.46], I = 11%). And the reported side effects revealed that the safety of lidocaine in pediatric patients was acceptable.

CONCLUSION

Compared with ketamine and alfentanil, lidocaine would be served as one more effective treatment in consideration of its well-matched efficacy, acceptable accessibility, and reasonable safety. However, more high-quality evidences in pediatric patients are necessary.

The safety and efficacy of alfentanil-based induction in bronchoscopy sedation: A randomized, double-blind, controlled trial

BACKGROUND

Alfentanil in combination with propofol produces a synergistic sedative effect in patients undergoing flexible bronchoscopy (FB). However, the use of this combination is controversial due to the risk of cardiopulmonary depression. The aim of this study was to evaluate the proper induction regimen of alfentanil in propofol target-controlled infusion for FB sedation.

METHODS

One hundred seventy-three patients were assigned randomly into 5 regimens: Group 1 and 2, alfentanil 2.5 and 5 μg/kg, respectively, immediately before propofol administration; Group 3 and 4, alfentanil 2.5 and 5 μg/kg, respectively, 2 minutes before propofol administration; and Group 5, propofol administration alone to achieve the observer assessment of alertness and sedation scale 3∼2. The bronchoscopists, physicians in charge of sedation, and patients were blind to the regimens. Adverse events, drug dose, induction, procedure and recovery time, cough severity, and propofol injection related pain were recorded.

RESULTS

The patients in groups 2 and 4 required a lower dose of propofol (P = 0.031 and 0.019, respectively) and shorter time (P = 0.035 and 0.010) than group 5 for induction. Patients in group 2 experienced more hypoxemia than those in group 5 during induction (P = 0.031). The physician in charge of sedation scored a lower severity of cough in the patients in group 4 than in groups 3 and 5. There were no differences in terms of propofol injection related pain among the groups.

CONCLUSION

Alfentanil 5 μg/kg given immediately before propofol infusion cannot be recommended. Further study is required to define conclusions about alfentanil 2.5 and 5 μg/kg because of the low power rating of subgroup in the present study.

Adult and pediatric anesthesia/sedation for gastrointestinal procedures outside of the operating room

PURPOSE OF REVIEW

This review presents current trends of safe and efficient anesthesia and sedation for adults and children for gastrointestinal procedures outside of the operating room with a special focus on total intravenous anesthesia (TIVA), target-controlled infusion (TCI), intravenous or topical lidocaine, and the use of the video laryngoscope.

RECENT FINDINGS

The concepts of a well tolerated and adequate anesthesia or sedation for gastrointestinal procedures outside of the operating room have to meet the needs of the adult and pediatric patients and the special requests of the gastroenterologists. Anesthesia and sedation of adults for gastrointestinal procedures with TIVA or TCI and spontaneous breathing is well established. Many institutions perform anesthesia for pediatric patients undergoing gastrointestinal procedures with an inhalational agent, especially in young children and for short procedures. Unlike adults, in young children the airways frequently must be secured with a tracheal tube or laryngeal mask. Respiration may be spontaneous, assisted, or controlled. TIVA and TCI are increasingly chosen for older children and longer procedures. A local anesthetic administered intravenously or topically to the upper airways and the use of the video laryngoscope can facilitate the insertion of the endoscope.

SUMMARY

Both anesthesiologists and nonanesthesiologists have to achieve a consensus and develop quality-improvement strategies to provide safe and efficient anesthesia and sedation for gastrointestinal procedures outside of the operating room for pediatric and adult patients. Techniques using TIVA, TCI, intravenous or topical application of lidocaine, and the video laryngoscope may improve and facilitate gastrointestinal procedures for the patients, the anesthesiologists, and the gastroenterologists.

Lidocaine for reducing propofol-induced pain on induction of anaesthesia in adults

BACKGROUND

Pain on propofol injection is an untoward effect and this condition can reduce patient satisfaction. Intravenous lidocaine injection has been commonly used to attenuate pain on propofol injection. Although many studies have reported that lidocaine was effective in reducing the incidence and severity of pain, nevertheless, no systematic review focusing on lidocaine for preventing high-intensity pain has been published.

OBJECTIVES

The objective of this review was to determine the efficacy and adverse effects of lidocaine in preventing high-intensity pain on propofol injection.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 10), Ovid MEDLINE (1950 To October 2014), Ovid EMBASE (1988 to October 2014), LILACS (1992 to October 2014) and searched reference lists of articles.We reran the search in November 2015. We found 11potential studies of interest, those studies were added to the list of 'Studies awaiting classification' and will be fully incorporated into the formal review findings when we update the review.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) using intravenous lidocaine injection as an intervention to decrease pain on propofol injection in adults. We excluded studies without a placebo or control group.

DATA COLLECTION AND ANALYSIS

We collected selected studies with relevant criteria. We identified risk of bias in five domains according to the following criteria: random sequence generation, allocation concealment, adequacy of blinding, completeness of outcome data and selective reporting. We performed meta-analysis by direct comparisons of intervention versus control. We estimated the summary odds ratios (ORs) and 95% confidence intervals using the random-effects Mantel-Haenszel method in RevMan 5.3. We used the I(2) statistic to assess statistical heterogeneity. We assessed overall quality of evidence using the GRADE approach.

MAIN RESULTS

We included 87 studies, 84 of which (10,460 participants) were eligible for quantitative analysis in the review. All participants, aged 13 years to 89 years, were American Society of Anesthesiologists (ASA) I-III patients undergoing elective surgery. Each study was conducted in a single centre in high- , middle- and low-income countries worldwide. According to the risk of bias assessment, all except five studies were identified as being of satisfactory methodological quality, allowing 84 studies to be combined in the meta-analysis. Five of the 84 studies were assessed as high risk of bias: one for participant and personnel blinding, one for incomplete outcome data, and three for other potential sources of bias.The overall incidence of pain and high-intensity pain following propofol injection in the control group were 64% (95% CI 60% to 67.9%) and 38.1% (95% CI 33.4% to 43.1%), respectively while those in the lidocaine group were 30.2% (95% CI 26.7% to 33.7%) and 11.8% (95% CI 9.7% to 13.8%). Both lidocaine admixture and pretreatment were effective in reducing pain on propofol injection (lidocaine admixture OR 0.19, 95% CI 0.15 to 0.25, 31 studies, 4927 participants, high-quality evidence; lidocaine pretreatment OR 0.13, 95% CI 0.10 to 0.18, 43 RCTs, 4028 participants, high-quality evidence). Similarly, lidocaine administration could considerably decrease the incidence of pain when premixed with the propofol (OR 0.19, 95% CI 0.15 to 0.24, 36 studies, 5628 participants, high-quality evidence) or pretreated prior to propofol injection (OR 0.14, 95% CI 0.11 to 0.18, 52 studies, 4832 participants, high-quality evidence). Adverse effects of lidocaine administration were rare. Thrombophlebitis was reported in only two studies (OR not estimated, low-quality evidence). No studies reported patient satisfaction.

AUTHORS' CONCLUSIONS

Overall, the quality of the evidence was high. Currently available data from RCTs are sufficient to confirm that both lidocaine admixture and pretreatment were effective in reducing pain on propofol injection. Furthermore, there were no significant differences of effect between the two techniques.

Dexmedetomidine pretreatment alleviates propofol injection pain

OBJECTIVE

The incidence of propofol injection pain during induction of general anesthesia varies from 28% to 90%. This prospective, randomized, double-blind, placebo-controlled study evaluated the effect of dexmedetomidine (DEX) for reducing the incidence and severity of propofol injection pain.

METHODS

Patients undergoing elective surgical procedures were randomly allocated into seven groups of 30 patients each. Experimental treatments were intravenously administered over 10 min (total volume 10 mL) prior to intravenous propofol injection, as follows: group I, the control group, was given isotonic saline. Patients in groups II, III, and IV received DEX 0.25 µg/kg, 0.5 µg/kg, or 1.0 µg/kg, respectively, mixed with isotonic saline immediately before propofol injection. Patients in groups V, VI, and VII received DEX as above, but 5 minutes before propofol injection. Propofol consisted of 1% long-chain triglyceride propofol (2.5 mg/kg) injected at 1 mL/s.

RESULTS

Median propofol injection pain score was 0.00 (IQR 0.00-3.00) in patients who received 1.0 µg/kg DEX 5 min before the propofol injection (group VII), and only 1 patient (of 30) in this group received a pain score >2. The median pain score and number of patients with pain scores >2 in group VII were both significantly less than in the control (group I; p = 0.000, both). There were no differences in either mean arterial pressure or heart rate at any time point after DEX injection among the groups.

CONCLUSIONS

Pretreatment with intravenous DEX 1 µg/kg 5 min prior to injection of long-chain triglyceride propofol is effective and safe in reducing the incidence and severity of pain due to propofol injection.

Preemptive dexmedetomidine to prevent propofol injection pain in children

BACKGROUND

The incidence of propofol injection pain is high in children, but no methods have been found to suppress it completely. This study intends to evaluate the efficacy of dexmedetomidine-midazolam in preventing propofol injection pain in children.

METHODS

One-hundred ASA I patients, aged 3-12 years, weighing 15-53 kg, undergoing elective surgery were randomized into two groups of 50 each, using computer-generated random numbers. Normal saline 0.15 ml/kg in Group C or dexmedetomidine 0.6 μg/kg in Group D was infused IV over 10 min. Then midazolam 0.06 mg/kg was administered immediately; 2 min after aforementioned treatments in each group, all patients received propofol 2 mg/kg (propofol was mixed with lidocaine 1 mg/ml in Group C) at an average rate of 0.2 ml per 1 s. Another anesthesiologist, blind to the pretreatment, recorded the occurrence of injection pain using a four-graded pain scale: 1 = no pain (no reaction to injection), 2 = slight pain (minor verbal/facial response or motor reaction to injection), 3 = moderate pain (clear verbal/facial response or motor reaction to injection) and 4 = severe pain (the patient both complained of pain and withdrew the arm).

RESULTS

Forty (80 %) patients in Group C (control) had injection pain; however, none of patients in Group D had any injection pain. The total incidence of profol-induced pain in Group C was significantly higher (P < 0.01). There were no instances of bradycardia or low blood pressure with either treatment in this study.

CONCLUSIONS

Pretreatment with dexmedetomidine 0.6 μg/kg, then midazolam 0.06 mg/kg could suppress propofol injection pain in children.

Injection pain of propofol in children: A comparison of two formulations without added lidocaine

Background:

Propofol emulsion in medium and long-chain triglycerides (MCT/LCT) has been reported to cause less injection pain than other propofol solutions in adult studies. The aim of this study was to compare the injection pain of two different propofol emulsions using two different pain scales on the pediatric population.

Materials and Methods:

100 children scheduled for general anesthesia were divided into two groups. Patients were randomly assigned to receive propofol LCT or propofol MCT/LCT. Assessment and evaluation of the Ontario Children's Hospital Pain Scale (mCHEOPS) and the Wong-Baker Faces Scale (WBFS) were performed at the start of the injection until the patients lose consciousness.

Results:

There were no significant differences between groups in terms of demographic data. According to the mCHEOPS scale, the pain incidence of propofol LCT was 5%, whereas for propofol MCT/LCT it was 15% (P < 0.05). According to the WBFS Pain Scale, the pain incidence of propofol LCT was 17%, whereas for propofol MCT/LCT it was 21% (P > 0.05).

Conclusions:

Propofol MCT/LCT does not decrease injection pain; contrary to the general assumption, it causes more pain than propofol LCT in children.

Prevention of propofol injection pain in children: a comparison of pretreatment with tramadol and propofol-lidocaine mixture

BACKGROUND

The pain on propofol injection is considered to be a common and difficult to eliminate problem in children. In this study, we aimed to compare the efficacy of pretreatment with tramadol 1 mg.kg(-1)and propofol-lidocaine 20 mg mixture for prevention of propofol induced pain in children.

METHODS

One hundred and twenty ASA I-II patients undergoing orthopedic and otolaryngological surgery were included in this study and were divided into three groups with random table numbers. Group C (n=39) received normal saline placebo and Group T (n=40) received 1 mg.kg(-1) tramadol 60 sec before propofol (180 mg 1% propofol with 2 ml normal saline) whereas Group L (n=40) received normal saline placebo before propofol-lidocaine mixture (180 mg 1% propofol with 2 ml %1 lidocaine). One patient in Group C was dropped out from the study because of difficulty in inserting an iv cannula. Thus, one hundred and nineteen patients were analyzed for the study. After given the calculated dose of propofol, a blinded observer assessed the pain with a four-point behavioral scale.

RESULTS

There were no significant differences in patient characteristics and intraoperative variables (p>0.05) except intraoperative fentanyl consumption and analgesic requirement one hr after surgery among the groups (p<0.05). Both tramadol 1 mg.kg(-1) and lidocaine 20 mg mixture significantly reduced propofol pain when compared with control group. Moderate and severe pain were found higher in control group (p<0.05). The incidence of overall pain was 79.4% in the control group, 35% in tramadol group, 25% in lidocaine group respectively (p<0.001).

CONCLUSIONS

Pretreatment with tramadol 60 sec before propofol injection and propofol-lidocaine mixture were significantly reduced propofol injection pain when compared to placebo in children.

Prevention of pain with the injection of microemulsion propofol: a comparison of a combination of lidocaine and ketamine with lidocaine or ketamine alone

Background

Aquafol, a microemulsion propofol, causes more severe and frequent pain on injection than propofol. The purpose of this study was to compare a combination of lidocaine and ketamine on aquafol-induced pain with lidocaine or ketamine alone during the induction of anesthesia.

Methods

In this prospective, randomized, double-blinded study, 130 healthy patients who were undergoing elective surgery under general anesthesia were enrolled. The patients received IV lidocaine 40 mg plus ketamine 25 mg (Group LK, n = 43), lidocaine 40 mg (Group L, n = 42), or ketamine 25 mg (Group K, n = 45) with a rubber tourniquet on the forearm 1 min before the injection of microemulsion propofol. The pain score was assessed by a 4-point verbal rating scale (VRS) at 10 seconds after injection of microemulsion propofol 30 mg and during the injection of the remaining total dose.

Results

The incidence and severity of pain was significantly lower in Group LK than Group L or Group K at 10 seconds after the injection of microemulsion propofol 30 mg (P < 0.05). And the incidence and severity of pain was significantly lower in Group LK and Group K than Group L during the injection of the remaining total dose (P < 0.05).

Conclusions

Pretreatment with IV lidocaine 40 mg plus ketamine 25 mg with a rubber tourniquet on the forearm 1 min before the injection of microemulsion propofol is more effective than lidocaine 40 mg or ketamine 25 mg alone in preventing pain from the injection of microemulsion propofol.