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

Avoiding pain during propofol injection in pediatric anesthesia: Hypnoanalgesia of the hand versus intravenous lidocaine

INTRODUCTION

Pain related to injection of propofol during induction of anesthesia decreases from 66.8% without prevention, to 22-31% of cases when lidocaine is associated. Hypnoanalgesia of the hand is currently used for painful procedures in children but has never been evaluated in this indication. The primary aim of this prospective randomized single-blind study was to evaluate the efficacy of hypnoanalgesia of the hand for the prevention of moderate to severe pain during intravenous injection of propofol alone in comparison to lidocaine admixture. The secondary aim was to compare the global satisfaction of children in both methods.

PATIENTS AND METHODS

One hundred patients aged 7-14 years, ASA 1-2, admitted for scheduled surgery under general anesthesia were randomized into two groups. Group L received a mixture of 1% propofol (3 mg/kg) and 1% Lidocaine (0.3 mg/kg). Group H received 1% propofol (3 mg/kg) after hypnoanalgesia of the hand realized by a single experimented operator. A video was made in order to evaluate the pain related to propofol injection by a blinded observer using the 4-point score of Cameron (painful ≥ 2). The global satisfaction of children was evaluated in postanesthesia care unit and documented if visual analog score was <7/10.

RESULTS

Ninety-six patients were analyzed. The rate of painful patients did not differ significantly between groups (8.5% in group H [n = 47] vs 6.1% in group L [n = 49], OR= 0.70; 95% CI [0.13-3.35], p = 0.65), nor did the rate of nonsatisfied patients (10.6 in group H vs. 12.2% in group L, OR = 0.85; 95% CI [0.19-3.65], p = 1).

CONCLUSIONS

Our results suggest that hypnoanalgesia of the hand alone is effective to prevent the pain related to propofol injection in children. No significant difference was found in comparison with lidocaine admixture nor for pain or satisfaction.

Analgesic Effects of Ketamine, Magnesium Sulfate, and Sodium-Thiopental on Propofol Injection Pain: A Single-Blind Randomized Clinical Trial

BACKGROUND

Propofol is one of the most frequently used medications for inducing and maintaining anesthesia. However, propofol injection causes pain and discomfort in more than 70% of patients. This study was performed to determine the comparative effects of ketamine, sodium-thiopental, and magnesium sulfate on reducing pain at the onset of anesthesia induced by propofol injection.

MATERIALS AND METHODS

This single-blind randomized clinical trial was conducted on a population of patients, requiring nonemergency surgeries. The sample size was determined as 25 patients per group. The eligible samples were randomly divided into three groups. An 18-gauge intravenous catheter was inserted in the dorsum of the hand for all patients. Three groups received 0.5 ml/kg of ketamine, 30 mg/kg of magnesium sulfate, and 0.5 ml/kg of sodium-thiopental, respectively. Next, 2.5 mg/kg of propofol 2% was administered at a rate of 1 ml/s. The verbal rating scale (VRS) was applied to assess the severity of pain during injection.

RESULTS

According to the results, the prevalence of pain was 36% in the magnesium sulfate group, 16% in the sodium-thiopental group, and 4% in the ketamine group. The ordinal logistic regression test showed that patients from the ketamine group experienced less pain, compared to the magnesium sulfate group (OR, 0.045; P= 0.008). However, no significant difference was observed between the ketamine and sodium-thiopental groups (OR, 0.253; P= 0.283).

CONCLUSION

Ketamine and sodium-thiopental can be effective medications in reducing pain caused by propofol injection. According to the results, magnesium sulfate is not recommended for reducing pain due to propofol injection.

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.

Efficacy of tramadol and butorphanol pretreatment in reducing pain on propofol injection: A placebo-controlled randomized study

BACKGROUND AND AIMS

Pain of propofol injection has been recalled by many patients as the most painful part of the induction of anesthesia. Tramadol and butorphanol are commonly used analgesics for perioperative analgesia in anesthesia practice. However, their potential to relieve propofol injection pain still needs to be explored.

MATERIAL AND METHODS

A randomized, double-blind, placebo-controlled study was conducted on 90 American Society of Anesthesiologists I and II adult patients undergoing elective surgery under general anesthesia with propofol as an induction agent. Consecutive sampling technique with random assignment was used to allocate three groups of 30 patients each. Group I patients received an injection of normal saline 3 ml intravenously (placebo) while Group II and Group III patients received injection of tramadol 50 mg and butorphanol 1 mg intravenously, respectively. Before induction of anesthesia patients were asked about the intensity of pain on propofol injection by using visual analog scale (VAS) before the loss of consciousness. Descriptive statistics and analysis of variance with Chi-square test were used to analyze the data. The value of P < 0.05 was considered as a significant and P < 0.0001 as highly significant.

RESULTS

The incidence of pain in Group I was observed in 80% of the patients, while it was observed in 23.33% and 20% of patients in Group II and III, respectively. Mean VAS scores were 2.27 ± 1.51, 1.14 ± 1.74, and 1.03 ± 1.72 in Group I, II, and Group III patients, respectively. The incidence of pruritus was 10% and 6.7% and erythema in 13.2% and 6.7% in Group II and III, respectively.

CONCLUSION

Pretreatment with both butorphanol and tramadol significantly reduced pain on propofol injection; however, they exhibited comparable efficacy among each other. Thus, either of these two drugs can be considered for pretreatment to reduce propofol injection pain.

Efficacy of ephedrine in the prevention of vascular pain associated with different infusion rates of propofol

Context:

Vascular pain is a frequent and hypotension is most important complications of propofol administration.

Aims:

The goal of this study is to evaluate frequency of vascular pain during rapid and slow injection of propofol and also effect of ephedrine for decreasing of vascular pain.

Materials and Methods:

After approval of local ethical committee, 120 patients with American Society of Anesthesiologists status I (ASA I), who were candidates for cataract surgery, were divided randomly into three groups. The first group received 20 mg of lidocaine, and propofol 1% at 1 ml per 5 seconds (slow injection). The second and third groups received propofol at 10 ml per 5 seconds without lidocaine (rapid injection) and also in the third group, 10 mg of ephedrine were injected at first and vascular pain were evaluated with 5-point scale.

Statistical analysis:

Data were analyzed with Statistical Package for the Social Sciences (SPSS) v16, Chi-square test, one-way analysis of variance (ANOVA), Kruskel-Wallis. P <0.05 was considered statistically significant.

Results:

Demographic characteristics of the three groups were similar. The vascular pain was 52.5%, 40%, and 27.5% in first, second, and third group, respectively. The injection pain was more severe in the slow injection (P = 0.025), but was the same between two rapid groups (P = 0.76). Heart rate and blood pressure changes were similar between all groups (P = 0.45 and P = 0.58, respectively).

Conclusion:

Rapid propofol injection induced less vascular pain compared with slow injection, but 10 mg ephedrine was not more effective.

Tramadol for postoperative pain treatment in children

BACKGROUND

According to current recommendations a multimodal approach is believed to be the gold standard for postoperative pain treatment in children. However, several surveys in the last few years demonstrated that postoperative pain in children is still a serious problem, mainly because opioids are avoided. One of the reasons for this is the fear of severe adverse events following opioid administration. Tramadol is a weak mu-opioid agonist and inhibits reuptake of noradrenaline and serotonin (5HT). Because of a relatively wide therapeutic window and a ceiling effect with a lower risk for severe adverse events (for example respiratory depression) tramadol is a widely used opioid in children. However, the exact efficacy and occurrence of adverse events following tramadol (in comparison with placebo or other opioids) for postoperative pain treatment in children and adolescents are currently not clear.

OBJECTIVES

To assess the effectiveness and side effect profile of tramadol for postoperative pain relief in children and adolescents undergoing different surgical procedures.

SEARCH METHODS

We searched the following electronic databases: the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2014, Issue 6), MEDLINE via PubMed (January 1966 to July 2014) and EMBASE via Ovid (January 1947 to July 2014). There were no restrictions regarding language or date of publication. The reference lists of all included trials were checked for additional studies.

SELECTION CRITERIA

All randomised controlled clinical trials investigating the perioperative administration of tramadol compared to placebo or other opioids for postoperative pain treatment in children and adolescents were included.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed the study eligibility, performed the data extraction and assessed the risk of bias of included trials.

MAIN RESULTS

Twenty randomised controlled trials involving 1170 patients were included in this systematic review. The overall risk of bias in included trials was assessed as unclear, because concealment of allocation processes and blinding of outcome assessors were poorly described. Due to inconsistent outcome reporting, data from 17 included trials could be pooled for some endpoints only. Eight trials compared tramadol administration with placebo and five trials found that the need for rescue analgesia in the postoperative care unit (PACU) was reduced in children receiving tramadol (RR 0.40; 95% CI 0.20 to 0.78; low quality evidence). Only one trial investigated the number of patients with moderate to severe pain, but a non-validated pain scale was used (very low quality evidence). Four trials compared morphine with tramadol administration. There was no clear evidence of difference in the need for rescue analgesia in the PACU (RR 1.25; 95% CI 0.83 to 1.89; low quality evidence) with tramadol compared with morphine. No trials could be pooled for the outcome 'number of patients with moderate to severe pain'. Three trials were included for the comparison of tramadol with nalbuphine. There was no clear evidence for the need for rescue analgesia in the PACU (RR 0,63; 95% CI 0.16 to 2.45; low quality evidence). Only one trial reported the number of patients with moderate to severe pain, but used a non-validated pain scale (very low quality evidence). Two out of six included trials, which compared pethidine with tramadol, reported the number of children with a need for rescue analgesia within the PACU and showed no clear evidence (RR 0.93; 95% CI 0.43 to 2.02; very low quality evidence). Two trials reported the number of patients with moderate to severe pain and showed a lower RR in patients treated with tramadol (RR 0.64; 95% CI 0.36 to 1.16; low quality evidence). Only one trial was included, which compared tramadol with fentanyl, reporting the number of patients with the need for rescue analgesia (very low quality evidence). Generally, adverse events were poorly reported. Most data could be pooled for the comparison with placebo focusing on the RR for postoperative nausea and vomiting (PONV) in the postoperative care unit and 24 h postoperation. Children treated with tramadol, compared to placebo, did not show clear evidence of benefit for PONV in the postoperative care unit (RR 0.84; 95% CI 0.28 to 2.52; moderate quality evidence) and 24 h postoperation (RR 0.78; 95% CI 0.54 to 1.12; moderate quality evidence).

AUTHORS' CONCLUSIONS

The overall evidence regarding tramadol for postoperative pain in children is currently low or very low and should be interpreted with caution due to small studies and methodological problems (different validated and non-validated pain scales with different pain triggers, missing sample size calculations and missing intention-to-treat analysis). Nevertheless, we demonstrated that tramadol administration might provide appropriate analgesia when compared to placebo; this is based on results showing reduced rescue analgesia in children treated with tramadol compared to placebo. In contrast, the evidence regarding the comparison with other opioids (for example morphine) was uncertain. Adverse events were only poorly reported, so an accurate risk-benefit analysis was not possible.