Multimodal Analgesia to Prevent Propofol-Induced Pain: Pretreatment with Remifentanil and Lidocaine Versus Remifentanil or Lidocaine Alone

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.

Effect of 6% hydroxyethyl starch pre-administration for reduction of pain on propofol injection: A placebo-controlled randomised study

Background and Aims:

Colloids modify the vascular endothelium and prevent contact activation of various substances. Pre-administration of colloids may prevent contact activation of vascular endothelium by propofol. The objective of this study was to evaluate the effect of 6% hydroxyethyl starch (HES) 130/0.4 pre-administration on propofol injection pain.

Methods:

Adult patients of the American Society of Anesthesiologists physical status I and II patients, 18-65 years old, of either gender and undergoing elective surgery were randomised into two groups. 100 mL bolus of HES or 0.9% normal saline (NS) was administered over three to five minutes through an 18 G cannula placed in the hand or forearm vein, followed by induction with 1% propofol premixed with 2% lidocaine. Pain during propofol injection was assessed every 10 seconds before the loss of verbal contact as 0- no pain; 1- mild pain evident only on questioning after 10 seconds without any obvious discomfort; 2-moderate pain self-reported by patients within 10 seconds with some discomfort; and 3- severe pain accompanied by withdrawing of hand, and behavioural signs.

Results:

126 patients completed the study. Overall incidence of pain was significantly higher in the NS group vs HES group (53% vs 28%; P = 0.004; relative risk 1.54, 95% confidence interval 1.13-2.09). Incidence of severe (8% vs 0%) and moderate pain (16% vs 5%) was higher in the NS group, while the incidence of mild pain was comparable (29% vs 23%; NS vs HES). A significant difference was seen in the severity of pain between the groups (P = 0.002).

Conclusion:

Pre-administration of 100 mL bolus of 6% HES 130/0.4 significantly reduced propofol injection pain.

Comparison of Analgesic Effects between Nalbuphine and Sufentanil in First-Trimester Surgical Abortion: A Randomized, Double-Blind, Controlled Trial

Introduction

Surgical abortion is one of the commonly conducted procedures worldwide. Nevertheless, pregnant women still complain of procedural and postoperative pain despite the use of advanced anesthesia. It is vital to women’s reproductive healthcare to improve postsurgical pain management to achieve the lowest level of pain.

Methods

This randomized, double-blind, parallel-controlled clinical trial compared the analgesic effects between nalbuphine and sufentanil in patients who underwent first-trimester surgical abortion. In total, 224 patients were allocated randomly into (a) the sufentanil group that received sufentanil (0.1 ug/kg) combined propofol, and (b) the nalbuphine group that received nalbuphine (0.1 mg/kg) combined propofol. Postoperative pain scores, propofol injection pain, intraoperative analgesic effect, adverse events, and degree of satisfaction were recorded as outcome measures.

Results

The pain scores in the nalbuphine group were lower than those in the sufentanil group at 15 min, 30 min, 1 h, and 6 h after surgical abortion. In addition, the incidence and intensity of propofol injection pain were lower in the nalbuphine group. The degree of satisfaction of the patients in the nalbuphine group was higher than that in the sufentanil group. The intraoperative analgesic effect, hemodynamic fluctuation, and adverse events were comparable between the two groups.

Conclusions

Nalbuphine combined with propofol is superior to sufentanil combined with propofol for first-trimester abortion surgeries.

Clinical Trial Registration

The trial was registered at www.chictr.org.cn, identifier ChiCTR2000040243.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40122-021-00334-0.

Pain on propofol injection: Causes and remedies

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.

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.

Comparison of the potency of different propofol formulations: a randomized, double-blind trial using closed-loop administration

BACKGROUND

Several commercial formulations of propofol are available. The primary outcome of this study was the required dose of propofol alone or combined with lidocaine to achieve induction of general anesthesia.

METHODS

This multicenter, double-blinded trial randomized patients (American Society of Anesthesiologists physical status I-III) just before elective surgery with the use of a computer-generated list. Three different propofol 1% formulations-Diprivan (Astra-Zeneca, Cheshire, United Kingdom), Propoven (Fresenius-Kabi AG, Bad Homburg, Germany), and Lipuro (B-Braun, Melshungen AG, Germany)-were compared with either placebo (saline solution) or lidocaine 1% mixed to the propofol solution. Depth of anesthesia was automatically guided by bispectral index and by a computerized closed-loop system for induction, thus avoiding dosing bias. The authors recorded the total dose of propofol and duration of induction and the patient's discomfort through a behavioral scale (facial expression, verbal response, and arm withdrawal) ranging from 0 to 6. The authors further evaluated postoperative recall of pain using a Visual Analog Scale.

RESULTS

Of the 227 patients enrolled, 217 were available for analysis. Demographic characteristics were similar in each group. Propoven required a higher dose for induction (2.2 ± 0.1 mg/kg) than Diprivan (1.8 ± 0.1 mg/kg) or Lipuro (1.7 ± 0.1 mg/kg; P = 0.02). However, induction doses were similar when propofol formulations were mixed with lidocaine. Patient discomfort during injection was significantly reduced with lidocaine for every formulation: Diprivan (0.5 ± 0.3 vs. 2.3 ± 0.3), Propoven (0.4 ± 0.3 vs. 2.4 ± 0.3), and Lipuro (1.1 ± 0.3 vs. 1.4 ± 0.3), all differences significant, with P < 0.0001. No adverse effect was reported.

CONCLUSION

Plain propofol formulations are not equipotent, but comparable doses were required when lidocaine was concomitantly administered.

The optimal effect-site concentration of remifentanil to attenuate the pain caused by propofol

Background

The injection pain of propofol is a frequent and well-known adverse effect. This study was designed to determine the optimal effect-site concentration of remifentanil for minimizing injection pain during induction with propofol.

Methods

A total intravenous anesthetic technique was used for patients undergoing general anesthesia and remifentanil was pretreated to reach a certain target concentration before propofol injection. Using Dixon's up-and-down method, the degree of pain described by the patient was used to adjust the target concentration of remifentanil for the next patient. Ten success-failure curves (crossovers) were sought to find the effect-site concentration (EC) of remifentanil for minimizing injection pain of propofol.

Results

The EC of remifentanil in 50% and 95% of adult female population (EC₅₀ and EC₉₅) for minimizing injection pain of propofol were 3.09 ng/ml (95% confidence limits [CI] 2.92-3.30 ng/ml) and 3.78 ng/ml (95% CI 3.45-3.95 ng/ml), respectively. Clinically significant hemodynamic compromise or respiratory complications were not found during remifentanil infusion.

Conclusions

Maintaining 3.78 ng/ml EC of remifentanil during induction with propofol attenuate propofol injection pain without serious adverse events in female patients undergoing general anesthesia and this method may provide the patient's comfort without preparing other drugs for pain relief.

Reduction of propofol injection pain by utilizing the gate control theory

Background

Propofol is the most commonly using intravenous hypnotic for the induction and maintenance of general anesthesia. However, pain on propofol injection is a well known adverse event. Currently, acute and chronic pain can be controlled by utilizing the "gate control" theory.

Methods

Patients were randomized to receive lidocaine (0.5 mg/kg; Group L), touch on IV injection site (Group T), combination lidocaine (0.5 mg/kg) and touch on IV injection site (Group B), or normal saline (Group S) with venous occlusion for 1 minute, followed by administration of propofol (0.5 mg/kg) into the largest dorsal vein of the hand. Immediately after administering propofol, an investigator blinded to the group assignments asked the patient about pain at the injection site and assessed pain intensity using a 4-point verbal rating scale (0 = none, 1 = mild, 2 = moderate, 3 = severe).

Results

A significant decrease in the incidence of pain on propofol injection was achieved in group L (37%) and group B (23%) compared to either group T (80%) and group S (83%) (P < 0.001). But, the incidence of moderate and severe pain was significantly lower in group L (7%), group T (20%) and group B (0%) when compared to group S (53%) (P < 0.05).

Conclusions

Light touch and rubbing reduced pain, although while, they did not reduce the incidence of pain, they reduced the intensity of pain. This method might be considered as an alternative to other treatments but may be contraindicated for use with other drugs.

The effect of priming injection of different doses of remifentanil on injection pain of microemulsion propofol premixed with lidocaine

Background

The injection pain of microemulsion propofol is frequent and difficult to prevent. This study examined the prevention of pain during microemulsion propofol injection by pretreatment with different doses of remifentanil or saline, and premixing of lidocaine.

Methods

One hundred sixty ASA physical status 1-2 adult patients scheduled for elective surgery were enrolled into one of four groups (n = 40, in each). The patients received saline (group LS), remifentanil 0.3 µg/kg (group LR 0.3), remifentanil 0.5 µg/kg (group LR 0.5), or remifentanil 1.0 µg/kg (group LR 1.0), and after 90 seconds received an injection of 2 mg/kg microemulsion propofol premixed with lidocaine 40 mg. Pain was assessed on a four-point scale during microemulsion propofol injection.

Results

The incidence of microemulsion propofol-induced pain was significantly lower in the LR 0.3, LR 0.5 and LR 1.0 groups than in the LS group (37.5%, 12.5% and 10% vs 65%, respectively). The LR 0.5 and LR 1.0 groups showed significantly less frequent and intense pain than the LR 0.3 group. However, both incidence and severity of pain were not different between LR 0.5 and LR 1.0 groups.

Conclusions

The combination of remifentanil and lidocaine is effective in alleviating pain associated with a microemulsion propofol injection compared with just lidocaine. Remifentanil 0.5 µg/kg had a similar analgesic effect compared to the 1.0 µg/kg dose.

Preclusion of pain on injection with propofol: Evaluating the effects of lignocaine or fentanyl pretreatment

BACKGROUND

Propofol (2,6-di-isopropylphenol) used for the induction of anesthesia often causes mild to severe pain or discomfort on injection, for which various methods have been tried, but with conflicting results.

OBJECTIVE

The present study involved pretreatment with lignocaine, fentanyl and placebo for prevention of pain on propofol injection to determine the difference in efficacy of fentanyl 100 μg compared with lignocaine 40 mg.

MATERIALS AND METHODS

Sixty-three participants of either sex, between 18 and 60 years of age, belonging to ASA physical status 1 and 2, undergoing elective surgery under general anesthesia, were randomized into three equal groups of 21 participants. They received, intravenously, either lignocaine (20 mg/mL) or fentanyl (50 μg/mL) or placebo (normal saline 2 mL) pretreatment before the propofol injection.

RESULTS

The three groups were comparable with respect to age, height, weight, sex and ASA physical status. The incidences of pain on pretreatment drug injection was higher in the fentanyl group (33.3%) compared with lignocaine and normal saline (P<0.05). The lowest incidence of pain on propofol injection was observed in the lignocaine pretreatment group (14.3%) compared with fentanyl (42.9%) and normal saline (71.4%) (P<0.05). There was no significant difference in adverse skin reaction within groups. In the normal saline pretreatment group, 38.1% of the participants experienced severe pain, compared with 9.5% in the fentanyl (P<0.05) group; none with lignocaine. The number needed to treat was 2 in the lignocaine pretreatment group compared with 4 in the fentanyl pretreatment group.

CONCLUSION

Compared with fentanyl, lignocaine pretreatment was more effective in preventing pain on propofol injection.

Efficacy of the combination of cold propofol and pretreatment with remifentail on propofol injection pain

Background

Pain upon the injection of propofol is a common adverse effect. This study was conducted to evaluate the analgesic effect of remifentanil and cold propofol during propofol injection for the induction of anesthesia and to determine if a combination of cold propofol and remifentanil produced additional analgesic efficacy.

Methods

A total of 160 patients aged 20-65 years old were randomly allocated into one of four groups (n = 40, in each). Control and remifentanil group patients received 2 mg/kg propofol that had been stored at room temperature (20-23℃), while the cold and combination group received cold (4℃) propofol. The patients received remifentanil 0.5 µg/kg IV in the remifentanil and combination groups or saline in the control and cold groups. Ninety seconds after administration the patients were administered propofol over a 30 second period. The pain intensity and incidence were then evaluated using a 4-point verbal rating scale.

Results

The incidence of pain was significantly reduced in groups that received remifentanil in the cold and combination groups when compared with the control group (27.5%, 30%, and 2.5% vs. 70%, respectively). Moreover, the severity of pain was significantly lower in groups that received remifentanil in the cold and combination groups when compared with the control group. The incidence and severity of pain from the propofol injection in the combination group was significantly lower than that in the remifentanil and cold groups.

Conclusions

The combination of cold propofol and pretreatment with remifentanil more effectively reduced the incidence of pain upon the injection of propofol than either treatment alone.

Pain reduction on injection of microemulsion propofol via combination of remifentanil and lidocaine

BACKGROUND

Microemulsion propofol produces more frequent and severe pain upon injection than lipid emulsion propofol. This study examined the analgesic effect of lidocaine-premixed microemulsion propofol in patients pretreated with remifentanil. The induction of anesthesia with this combination was compared with microemulsion propofol accompanied with either remifentanil or lidocaine.

METHODS

One hundred twenty patients aged between 20-65 years old were allocated randomly into one of three groups (n = 40, in each). The patients in the remifentanil group received remifentanil 0.5 microg/kg IV for 30 seconds before a microemulsion propofol injection. The patients in the lidocaine group received propofol 2 mg/kg premixed with 40 mg lidocaine over a 60 second period. The patients in the combination group received both remifentanil and lidocaine.

RESULTS

There was a significantly lower incidence of microemulsion propofol injection pain (severity 2 or more) in the combination group (12.5%) than in the remifentanil and lidocaine groups (90% and 65%, respectively, P < 0.05). The incidence of moderate pain disappeared completely in the combination group (0%) compared to that in the remifentanil and lidocaine group (32.5% and 20%, respectively, P < 0.05). Severe pain did not appear in any of the three groups. There were no complications on the injection site in the lidocaine alone and combination groups.

CONCLUSIONS

The combination of microemulsion propofol premixed with lidocaine after a pretreatment with remifentanil was more effective in reducing the incidence of pain upon the injection of microemulsion propofol than either treatment alone.

Pain on injection from propofol may be avoided by changing its formulation

BACKGROUND

After using propofol for a decade, pain on injection had been considered routine by patients and medical personnel. When given propofol from a different manufacturer, patients did not complain. Two preparations of propofol were compared.

METHODS

A comparative, double-blind, randomized study was conducted in 22 adult patients undergoing pain relief procedures; they received sedation by an intravenous injection of 1.7 mg/kg of propofol and then were treated with paravertebral injections. Pain on injection was assessed by verbal complaint, movement of the extremity, of the whole body and recollection of pain at induction, when discharged. Propofol from Baxter Laboratories, mixed with either 5 ml of 2% lidocaine or 5 ml of NaCl 0.9%, was compared with propofol Laboratorios Gray, which was similarly mixed. Injections were randomly administered four times, blindly, to each of 22 patients. Statistical analysis was conducted using the analysis of variance method.

RESULTS

A total of 352 propofol injections were given. Each of the four propofol solutions was administered 88 times; of patients receiving Baxter propofol+saline, 74 (84%) had pain; when mixed with 2% lidocaine 45 (50.2%) complained. After propofol Gray with NaCl 0.9% was given, two patients (2.2%) experienced pain. Propofol Gray with 2% lidocaine produced no pain. None of the latter group remembered having pain, whereas, those given propofol Baxter 54 (61.3%) and 26 (29.5%) remembered experiencing pain at injection. Pain on injection was prevented and statistically reduced (<0.01) with the propofol from Laboratorios Gray.

CONCLUSIONS

By changing the formulation (size of molecules and their dispersion) of propofol, pain on injection was avoided.

The effect of pretreatment with two different concentrations of remifentanil on propofol injection pain

BACKGROUND

Propofol produces anesthesia with rapid recovery but also causes pain on injection. This study was designed to evaluate the effects of two different concentrations of remifentanil for minimizing the pain caused by propofol and to compare the hemodynamic changes during propofol-remifentanil infusion.

METHODS

In a randomized, double-blind study of 80 patients, we compared the severity of the injection pain of propofol between two groups of patients. The initial effect-site target concentration of remifentanil was set at 4 ng/ml (the R4 group, n = 40) or 8 ng/ml (the R8 group, n = 40). After the effect-site concentration of remifentanil was achieved, the infusion of propofol was started with the concentration of 4 microgram/ml. The remifentanil-related complications were evaluated and the severity of the pain caused by propofol was compared by using a four-point scale during the propofol infusion. The heart rate and arterial blood pressure were measured at pre-induction, just before intubation and at 1 minute after intubation.

RESULTS

The severity of injection pain of propofol was significantly lower in the R8 group than in the R4. There was no significant difference in the incidence of remifentanil-related complications between the two groups. Compared with the pre-induction values, the heart rate and arterial blood pressure were significantly lower at pre-intubation and at 1 minute after intubation in the R4 and R8 groups.

CONCLUSIONS

Pretreatment with an effect-site concentration of 8 ng/ml remifentanil may be useful for minimizing the propofol injection pain compared with 4 ng/ml remifentanil.

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

BACKGROUND

Pain from a propofol injection is a common side-effect in paediatric patients. This prospective, randomized, double-blind study evaluated the efficacy of a combined pretreatment of alfentanil with lidocaine on the incidence and severity of propofol injection pain in children.

METHODS

After obtaining parental consent, 120 paediatric patients were allocated randomly into one of the three groups (n=40, in each). The patients in the alfentanil group received alfentanil 15 microg kg(-1) 90 s before the propofol injection. The patients in the lidocaine group received propofol 3 mg kg(-1) premixed with lidocaine 0.1% over a 15 s period. The patients in the combination group received both alfentanil and lidocaine.

RESULTS

The incidence of propofol injection pain (severity 2 or more) in the combination group (2.6%) was significantly lower than that in the alfentanil and lidocaine groups (30% and 38.5%, respectively) (P=0.001 and <0.001, respectively). No patient in the combination group complained of moderate or severe pain from propofol injection.

CONCLUSIONS

Our study demonstrated that the combination treatment of two different analgesic modalities, alfentanil and lidocaine, could prevent the moderate and severe pain on propofol injection, and reduce the incidence of mild pain compared with each drug alone.