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Leff PJ, Dinner BA, Chuang KY, Leff DB. Characteristics that increase the risk for pain on propofol injection. BMC Anesthesiol 2024; 24:190. [PMID: 38807072 PMCID: PMC11131289 DOI: 10.1186/s12871-024-02573-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Accepted: 05/22/2024] [Indexed: 05/30/2024] Open
Abstract
BACKGROUND Propofol for anesthesia has become increasingly popular for endoscopic procedures. However, pain on propofol injection (POPI) remains an issue with administration. The primary endpoint of this study was to identify patient characteristics and factors, such as IV site and gauge, that could predict the occurrence of POPI. METHODS This was a prospective chart review study of 291 patients undergoing endoscopic procedures. The patient's demographics, intravenous (IV) site, and gauge were extrapolated. POPI was scored 0-3: 0 for no pain, 1 for minimal discomfort or awareness of sensation, 2 for discomfort but manageable/tolerable, and 3 for severe discomfort with writhing. RESULTS 291 patient charts were reviewed. One patient was excluded for a lower extremity IV site. 225 (77.6%) had no pain, 48 (16.6%) grade 1 pain, 16 (5.5%) grade 2 pain, and 1 (0.3%) grade 3 pain. 137, 13, and 140 patients respectively had antecubital (AC), forearm, and hand IVs. Zero patients with an AC IV experienced a score greater than 1. Compared to AC, forearm IVs with pain of 2-3 had a univariate odds ratio (OR) of 11.3 (0.66,1.92; p-value < 0.001), and hand IVs had a univariate OR of 18.8 (2.46,143.3; p-value < 0.001) with a multivariable OR 15.2 (1.93,118.9; p-value 0.004). Patients with anxiety/depression and pain had a univariate OR 2.31 (1.09, 7.27; p-value 0.031) with a multivariable OR 2.85 (1.06, 7.74; p-value 0.039). SSRI/SNRI use had a univariate OR 1.56 (0.57,4.28; p-value 0.38). Alcohol use had a univariate OR 1.24 (0.39,3.91; p-value 0.71). Narcotic use had a Univariate OR 6.18 (1.49,25.6; p-value 0.012). Diabetic patients had a univariate OR of 1.42 (0.45,4.48; p-value 0.55). Chronic pain had a univariate OR of 3.11 (1.04,9.28; p-value 0.042). Females had a univariate OR 0.98 (0.37,2.63; p-value 0.95). CONCLUSION This study identified potential characteristics for having POPI. The incidence of POPI was statistically significant in patients with hand and forearm IVs compared to AC IV sites, larger IV gauges, history of depression/anxiety, history of chronic narcotic use, fibromyalgia, and chronic pain syndromes. This shows the potential of premedicating with analgesics or using AC sites on these select patients to help reduce the risk of POPI.
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Affiliation(s)
- Phillip J Leff
- Department of Internal Medicine, Creighton University Phoenix, 350 W Thomas Rd, Phoenix, AZ, 85013, USA.
| | - Brett A Dinner
- Department of Internal Medicine, Creighton University Phoenix, 350 W Thomas Rd, Phoenix, AZ, 85013, USA
| | - Keng-Yu Chuang
- Department of Gastroenterology, Creighton University Phoenix, 350 W Thomas Rd, Phoenix, AZ, 85013, USA
| | - David B Leff
- Central Arizona Medical Associates, 3638 E Southern Ave, Ste C108, Mesa, AZ, USA
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Karki Y, Sarna R, Singh N, Chauhan R, Meena SC, Luthra A, Thappa P. Prevention of pain on injection of propofol using ice gel pack versus pre-treatment with lignocaine: a randomized controlled trial. J Anesth 2023:10.1007/s00540-023-03216-1. [PMID: 37314584 DOI: 10.1007/s00540-023-03216-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 06/05/2023] [Indexed: 06/15/2023]
Abstract
PURPOSE Regardless of the positive attributes of propofol, it is frequently associated with pain on injection. We compared the efficacy of topical cold thermotherapy using an ice gel pack with intravenous lignocaine pre-treatment for reducing pain on propofol injection. METHODS This single-blinded randomized controlled trial was conducted in 200 American Society of Anesthesiologists physical status I, II, and III patients scheduled for elective/emergency surgery under general anesthesia. The patients were randomized into two groups: the Thermotherapy group- receiving an ice gel pack proximal to the intravenous cannula for 1 min, or the Lignocaine group-receiving 0.5 mg/kg of lignocaine administered intravenously, with occlusion proximal to the site of the intravenous cannula for 30 s. The primary objective was to compare the overall incidence of pain after propofol injection. The secondary objectives included the incidence of discomfort on the application of an ice gel pack, comparison of dose of propofol needed for induction, and hemodynamic changes at induction, between the two groups. RESULTS Fourteen patients in the lignocaine group and 15 patients in the thermotherapy group reported pain. The incidence of pain and the distribution of pain scores were comparable among groups (p = 1.00). Patients of the lignocaine group required significantly less amount of propofol for induction as compared to the thermotherapy group (p = 0.001). CONCLUSION Topical thermotherapy using an ice gel pack was not found superior to lignocaine pre-treatment in alleviating pain on injection of propofol injection. However, topical cold therapy using an ice pack remains a non-pharmacological technique that is easily available, reproducible, and cost-effective. Further studies are required to prove its equivalence to lignocaine pre-treatment. TRIAL REGISTRATION CTRI (CTRI/2021/04/032950).
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Affiliation(s)
| | - Rashi Sarna
- Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Nidhi Singh
- Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Rajeev Chauhan
- Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India.
| | - Shayam Charan Meena
- Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Ankur Luthra
- Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
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Tian S, Zhang D, Zhou W, Tan C, Shan Q, Ma R, Xing Z, Sui W, Zhang Z. 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. PAIN MEDICINE 2021; 22:1246-1252. [PMID: 33094312 DOI: 10.1093/pm/pnaa316] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
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.
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Affiliation(s)
- Shunping Tian
- School of Medicine, Yangzhou University, Yangzhou, China
| | - Dongsheng Zhang
- Department of Anesthesiology, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China
| | - Wei Zhou
- Department of Anesthesiology, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China
| | - Chao Tan
- School of Medicine, Yangzhou University, Yangzhou, China
| | - Qing Shan
- Department of Geriatrics, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China
| | - Rongrong Ma
- Department of Anesthesiology, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China
| | - Zhi Xing
- Department of Anesthesiology, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China
| | - Wei Sui
- Department of Anesthesiology, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China
| | - Zhuan Zhang
- Department of Anesthesiology, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China
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Bodnar J. The Use of Propofol for Continuous Deep Sedation at the End of Life: A Definitive Guide. J Pain Palliat Care Pharmacother 2019; 33:63-81. [DOI: 10.1080/15360288.2019.1667941] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- John Bodnar
- John Bodnar, Penn Hospice at Chester County, West Chester, Pennsylvania, USA
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Xing J, Liang L, Zhou S, Luo C, Cai J, Hei Z. Intravenous Lidocaine Alleviates the Pain of Propofol Injection by Local Anesthetic and Central Analgesic Effects. PAIN MEDICINE 2019; 19:598-607. [PMID: 28525614 DOI: 10.1093/pm/pnx070] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
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.
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Affiliation(s)
- Jibin Xing
- Department of Anesthesiology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ling Liang
- Department of Anesthesiology, People's Hospital of Gaoming, Foshan, China
| | - Shaoli Zhou
- Department of Anesthesiology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Chenfang Luo
- Department of Anesthesiology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jun Cai
- Department of Anesthesiology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ziqing Hei
- Department of Anesthesiology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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Abstract
Pain on propofol injection (POPI) is a minor problem that all anesthetists face every day. Introduction of several new formulations and hundreds of clinical trials have failed to find its remedy with just one intervention in all patients. This article highlights the causes of POPI and interventions that are used to eliminate this pain in current practice. Relevant articles from Medline and Embase databases were searched and included in this descriptive review with the following conclusions: (1) POPI is due to irritation of venous adventitia leading to release of mediators such as kininogen from kinin cascade. (2) When two or more drugs or measures are used, the incidence of POPI decreases considerably. Hence, the approach to eliminating POPI should be multimodal. (3) Any regimen that includes a drug having local anesthetic effect combined with central sedative/analgesic and rapid injection into a large vein should definitely reduce the risk of POPI to negligible levels.
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Lee M, Kwon T, Kim S, Kim S, Park K, Jeon Y. Comparative evaluation of the effect of remifentanil and 2 different doses of esmolol on pain during propofol injection: A double-blind, randomized clinical consort study. Medicine (Baltimore) 2017; 96:e6288. [PMID: 28272252 PMCID: PMC5348200 DOI: 10.1097/md.0000000000006288] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Propofol is associated with pain during injection, which is stressful to patients. The present study was designed to investigate the analgesic effect of pretreatment with remifentanil and esmolol in minimizing propofol injection pain, compared with placebo. METHODS In a randomized, double-blind, prospective trial, 120 patients, scheduled for elective dental surgery under general anesthesia, were randomized to 1 of the 4 treatment arms (n = 30 each) receiving normal saline, remifentanil 0.35 μg/kg, esmolol 0.5 mg/kg, and 1 mg/kg before administration of propofol. During injection of 1% propofol 0.5 mg/kg, pain was evaluated by a 4-point score (0 = none, 1 = mild, 2 = moderate, 3 = severe). Any adverse effects such as hypotension and bradycardia were recorded during the perioperative periods. RESULTS In all, 120 patients completed this study. There were no significant differences in terms of demographic data. The incidence of pain on injection of propofol was 11 (36.7%) with remifentanil 0.35 μg/kg, 12 (40%) with esmolol 0.5 mg/kg, and 11 (36.7%) with esmolol 1 mg/kg, compared with 25 (83.3%) with normal saline (respectively, P < 0.05). There were no significant differences in the incidence of pain between groups with remifentanil 0.35 μg/kg, and esmolol 0.5 mg/kg and 1 mg/kg. There were no emergence reactions such as hypotension and bradycardia in all groups. CONCLUSIONS Pretreatment with esmolol 0.5 mg/kg and 1 mg/kg and remifentanil 0.35 μg/kg equally decreased pain during propofol injection.
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Affiliation(s)
- Myunghwan Lee
- Department of Oral and Maxillofacial surgery, School of Dentistry
| | - Taegeon Kwon
- Department of Oral and Maxillofacial surgery, School of Dentistry
| | - Sujin Kim
- Department of Anesthesiology and Pain Medicine, Kyungpook National University Hospital
| | - Saeyoung Kim
- Department of Anesthesiology and Pain Medicine, Kyungpook National University Hospital
| | - Kibum Park
- Department of Anesthesiology and Pain Medicine, Keimyung University Dongsan Hospital, Daegu, Republic of Korea
| | - Younghoon Jeon
- Department of Oral and Maxillofacial surgery, School of Dentistry
- Department of Anesthesiology and Pain Medicine, Kyungpook National University Hospital
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Euasobhon P, Dej‐arkom S, Siriussawakul A, Muangman S, Sriraj W, Pattanittum P, Lumbiganon P. Lidocaine for reducing propofol-induced pain on induction of anaesthesia in adults. Cochrane Database Syst Rev 2016; 2:CD007874. [PMID: 26888026 PMCID: PMC6463799 DOI: 10.1002/14651858.cd007874.pub2] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
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.
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Affiliation(s)
- Pramote Euasobhon
- Faculty of Medicine, Siriraj Hospital, Mahidol UniversityDepartment of Anaesthesiology2 Prannok RoadSiriraj, Bangkok‐noiBangkokThailand10700
| | - Sukanya Dej‐arkom
- Faculty of Medicine, Siriraj Hospital, Mahidol UniversityDepartment of Anaesthesiology2 Prannok RoadSiriraj, Bangkok‐noiBangkokThailand10700
| | - Arunotai Siriussawakul
- Faculty of Medicine, Siriraj Hospital, Mahidol UniversityDepartment of Anaesthesiology2 Prannok RoadSiriraj, Bangkok‐noiBangkokThailand10700
| | - Saipin Muangman
- Faculty of Medicine, Siriraj Hospital, Mahidol UniversityDepartment of Anaesthesiology2 Prannok RoadSiriraj, Bangkok‐noiBangkokThailand10700
| | - Wimonrat Sriraj
- Khon Kaen UniversityDepartment of AnaesthesiologyFaculty of MedicineKhon KaenThailand40002
| | - Porjai Pattanittum
- Khon Kaen UniversityDepartment of Biostatistics and Demography, Faculty of Public HealthMitraparp RoadMueng DistrictKhon KaenKhon KaenThailand40002
| | - Pisake Lumbiganon
- Khon Kaen UniversityDepartment of Obstetrics and Gynaecology, Faculty of Medicine123 Mitraparb RoadAmphur MuangKhon KaenThailand40002
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Sun J, Zhou R, Lin W, Zhou J, Wang W. Magnesium Sulfate Plus Lidocaine Reduces Propofol Injection Pain: A Double-blind, Randomized Study. Clin Ther 2016; 38:31-8. [DOI: 10.1016/j.clinthera.2015.10.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Revised: 09/24/2015] [Accepted: 10/07/2015] [Indexed: 11/30/2022]
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