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Pain on Injection of Propofol: Efficacy of Paracetamol and Lidocaine  [PDF]
H. Khouadja, H. Arnous, K. Tarmiz, D. Beletaifa, A. Brahim, W. Brahem, J. Sakhri, K. Ben Jazia
Open Journal of Anesthesiology (OJAnes) , 2014, DOI: 10.4236/ojanes.2014.44013

Background and Objectives: Propofol remains the most common drug for induction of general anaesthesia, although it causes considerable pain on injection. None of the commonly used methods completely attenuate this discomfort. We aimed to investigate the effect of i.v. paracetamol pretreatment on the propofol injection pain. Materials and Methods: A prospective randomized double-blind study was conducted on 180 patients, ASA I or II status, scheduled to undergo elective surgery. They were randomly assigned to one of the three groups of 60 each. Groups I, II, III were pretreated with 40 mg of lidocaine in saline, 100 mg of paracetamol and 10 ml of saline, respectively. All patients had an 18-gauge catheter inserted into a superficial radial vein. After 2 min of venous occlusion, one-fourth of the total propofol dose was injected into the vein over a period of 20 seconds. During the injection of both pretreatment solution and propofol, a blinded researcher assessed the patient’s pain level using a four-point verbal rating scale (VRS) (none = 0, mild = 1, moderate = 2, and severe = 3). X2 test and Kruskal-Wallis tests were used for the statistical analysis. For all analyses, differences were considered to be significant at P < 0.05. Results: The three groups were comparable in respect to patient’s characteristics. The incidence of pain on injection of propofol in placebo, i.v. paracetamol and lidocaine groups were 85%, 36%, 21% respectively (p < 0.05). Intensity and severity of propofol induced pain were comparable between paracetamol and lidocaine groups. Conclusion: Pretreatment using i.v. paracetamol was found to be effective in reducing propofol injection-induced pain.

Propofol injection pain reduction: ephedrine versus lidocaine and Normal saline
Hoseinkhan Z,Taghizadeh Imani A,Abedini GH,Naghibi T
Tehran University Medical Journal , 2009,
Abstract: "nBackground: Pain associated with IV injection of propofol is seen in 28 to 90% of patients. A number of techniques have been tried to minimize propofol-induced pain, with variable results. We compared the efficacy of pretreatment with ephedrine and lidocaine for the prevention of propofol-induced pain. "nMethods: One hundred and twenty adult patients, ASA physical status I-II, undergoing elective surgery were randomly assigned into six groups (20 each). Normal saline group received normal saline, lidocaine group received lidocaine 2% (40 mg), and ephedrine (E 30) group received 30 μg/kg ephedrine, ephedrine (E 70) group received 70 μg/kg ephedrine, ephedrine (E 100) group received 100 μg/kg ephedrine, ephedrine (E 150) group received 150 μg/kg ephedrine. All pretreatment drugs were made in two mL. Pain was assessed by a 100-point scale of visual analogue (VAS) (0= no pain, 100= the most severe pain) and (VRS) verbal rating scale at the time of propofol injection. Noninvasive mean arterial blood pressure (MAP) and HR were recorded before induction, just before intubation, and 1, 2, and 3 min after intubation, respectively. "nResults: The mean of pain scorel during propofol injection was significantly more in Normal Saline group compared to lidocaine and ephedrine (E30, E70, E100, E150) groups but there was no significant difference between lidocaine and ephedrine (E30, E70, E100, E150) groups (80.9vs 59.6 and 56.2, 51.05, 52.8, 57.45) Kruskal- wallis P=0.009. The incidence of pain was also significantly more in Normal Saline group compared to lidocaine group and ephedrine's groups but there was no significant difference between lidocaine and different dose levels of ephedrine. A small dose of ephedrine (30 and 70 μg/kg) could prevent propofol induced pain before intubation and did not produce significant hemodynamic changes compared with the other groups after intubation. "nConclusions: Pretreatment with ephedrine (specially low dose) effectively attenuated pain intensity, and frequency with propofol injection without undesired complications.
Prevention of Propofol Injection Pain in Children: A Comparison of Pretreatment with Tramadol and Propofol-Lidocaine Mixture
Hale Borazan, Osman Sahin, Ahmet Kececioglu, M.Selcuk Uluer, Tayfun Et, Seref Otelcioglu
International Journal of Medical Sciences , 2012,
Abstract: 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-1and 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.
The Professional Medical Journal , 2008,
Abstract: Introduction: Propofol causes pain on injection in 28% - 90% ofpatients. A number of techniques have been tried for minimizing propofol-induced pain with variable results. Objectives:To compare the use of premixed lidocaine-propofol with metoclopramide pretreatment for the reduction of pain duringinjection of propofol in adult patients. Design: A prospective, double blind, randomized, placebo-controlled study.Setting: Shiraz University Hospital, Department of Anesthesiology, Shiraz, Iran. Period: From Jan 2007 to Dec 2007.Materials & Methods: 202 subjects (ASA I-II) scheduled for elective operations under general anesthesia wereallocated into three groups and treated as follows: Group A: 20 ml propofol mixed with 20mg lidocaine %1 following 2mlnormal saline; Group B: 20 ml propofol mixed with 2ml normal saline following 5 mg metoclopramide; Group C (controlgroup): 20 ml propofol mixed with 2 ml normal saline following 2 ml normal saline. Pain intensity was graded by a single,blinded observer and recorded as either severe, moderate, mild or no pain according to the response of the patientsto the injection. Results: The incidence of pain was 72% in placebo group compared to 58.7% in the metoclopramideand 28.8% in the lidocaine group. Conclusion: Propofol-lidocaine admixture is more effective than metoclopramidepre treatment in decreasing the pain of propofol injection.
A. Movafegh,F.A. Gharehdaghi,G. Shoeibi,Z.N. Hatmi
Acta Medica Iranica , 2005,
Abstract: Intravenous administration of dexamethasone before diazepam injection seems "0 reduce the incidence or pain on injection. We conducted a randomized. prospective, double-blind. placebocontrolled clinical trial to compare effect or dexamethasone, mctoclopramidc ami placebo in reducing the injection pain.:" total of 120 ASA class I and ll mcn aged 20-45 years that needed more than one intravenous access were enrolled in the study and were randomly allocated to one of the three groups: group 1, :2 ml intravenous normal saline and 2 1111 dexamethasone (X mgj: group 2. 2 1111 intravenous normal saline and 2 1111 mctoclopramidc l10 mg), and group 3.:2 ml intravenous dexamethasone (X mg) and 2 ml ructoclopramidc (10 mg). After 30 seconds. I ml diazepam (5 mg) was injected simultaneously into each of patients' hand veins and a maximal visual analog scale (VAS) for pain of each venous discomfort was assessed separately. In group I. the mean of VAS for pain was significantly less in dexamethasone pretreatment than saline pretreatment. In group 2. the mean of VAS for pain was significantly less in mctoclopramidc pretreatment than saline pretreatment. In group 3, the mean of VAS for pain was significantly less in dexamethasone pretreatment than mctocloprauudc pretreatment. There were no significant differences in incidence of pain between pretreatment and placebo in three groups. Dexamethasone or mctoclopramidc pretreatments arc effective in reducing the severity of pain on injection of diazepam and dexamethasone pretreatment has greater efficacy in reducing the intensity of pain.
Comparison of Effects of Ephedrine, Lidocaine and Ketamine with Placebo on Injection Pain, Hypotension and Bradycardia Due to Propofol Injection: A Randomized Placebo Controlled Clinical Trial
Vida Ayatollahi,Shekoufeh Behdad,Saeed Kargar,Tayebe Yavari
Acta Medica Iranica , 2012,
Abstract: Propofol is a widely used anesthetic drug because of its minor complication and also its fast effect. One of most popular complication in using this drug is pain during injection that is more sever in new generation of its components (lipid-free microemulsion). Other complications of propofol are bradycardia and hypotension. This study compares 3 drugs with placebo in control of these complications of propofol. In this double blinded randomized placebo controlled trial 140 patient who were candidates for elective surgery were divided in 4 groups (35 patients in each groups) and drugs (ephedrine, lidocaine, ketamine and NaCl solution (as placebo) were tried on each group by a blinded technician and responses to drugs were evaluated under supervision of a blinded anesthesiologist. Pain after injection, systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP) and heart rate (HR) were measured 5 times during anesthesia process of each patient. All gathered data were analyzed using t-test and Chi-square under SPSS software. Our data shows that in pain management all tested drugs can decrease pain significantly comparing with placebo (P=0.017). In control of hemodynamic parameters ephedrine could efficiently control SBP, DBP, MAP at the time 1 min after intubation. Based on our study ephedrine can be an appropriate suggestion for control of both pain and hemodynamic changes induced by propofol, although because of inconsistent result in other studies it is recommended to design a systematic review to draw a broader view on this issue.
The Professional Medical Journal , 2007,
Abstract: Objective: To assess the potential of oral Clonidine premedication indecreasing patient discomfort during the injection of Propofol. Design: This was a comparative study of 80 ASA class1 and II. Place and Duration of study: This study was carried out at Combined Military Hospital, Kharian. Patients andMethods: This was a study of 80 ASA class 1 and 2 patients of similar age group. Patients selected were from amongstthose undergoing elective gynaecological surgery, specifically Diagnostic Dilatation and Curettage. These patients wereselected by non-probability convenience sampling. The patients were randomly assigned, by means of a random table,to one of the two groups of 40 patients each. Group ‘A’ patients were given oral Clonidine, 300mg two hours beforeinduction of anaesthesia by Propofol injection. Group B’ patients were given 0.01 to 0.02mg/kg plain Lidocaine justbefore Propofol induced anaesthesia. Non-invasive systolic arterial blood pressure (ni-SBP), non-invasive diastolicarterial blood pressure (ni-DBP) and heart rate were recorded in the ward about 120 min [before administration of oralClonidine in group-A] in both groups. Measurements were repeated in the operating theatre before induction ofanaesthesia. Patients in Group-A were given one tablet Catapres [Clonidine, 300mg] with a sip of water, two hoursbefore induction of anaesthesia and they were observed in the Post Anaesthesia Care Unit during this period, whiletheir pulse and blood pressure were monitored. Patients in group-B were not premedicated with Clonidine. They wereinjected 0.01 to 0.02mg/kg injection plain lidocaine, through the injection port of an 18-gauge cannula, as premedicationjust before propofol monitoring was done as for group-A. Before administration of propofol, the patient was requestedto rate immediately any sensation of pain during injection as none (0), mild (1), moderate (2) or severe (3), also calledthe Verbal Rating Scale (VRS). Results: The results showed both groups to have similar pain score, and differenceswere deemed statistically not significant by the analysis. Conclusion: Our results imply that Clonidine makes anexcellent premedication with Propofol for short gynaecological procedures.
The effect of Magnesium sulfate on reducing Propofol injection pain in elective surgeries
Shoaybi G,Soltanimohammadi S,Rajabi M
Tehran University Medical Journal , 2007,
Abstract: Background: Propofol, an anesthetic noted to give rapid recovery, causes discomfort at the site of injection. A number of methods to reduce propofol-induced pain have been tried, including pretreatment with lidocaine, with varying results. Here, we evaluate the efficacy of magnesium sulfate compared to that of lidocaine and normal saline in mitigating propofol-induced pain. Methods: One hundred ASA I and II adults, aged 20-50 years, scheduled for elective surgery requiring two IV lines with 20-gauge cannulae in the dorsum of each hand, were enrolled in this study. The patients were randomly placed into two groups of 50 patients. In each patient, one hand was the case study and other hand was the control. Group A received 10% magnesium sulfate in one hand and normal saline in the other hand. Group B received 10% magnesium sulfate in one hand and 1% lidocaine in the other hand. All injections had a volume of 2 ml. After 30 seconds, 2 cc of 1% propofol was injected simultaneously into each hand. Pain was assessed according to the VAS rating system, ranging from 0 (no pain) to 10 (the most severe pain), with a minimum interval of 3 as significant pain. Data were analyzed by chi-square and independent t tests. A P value <0.05 was considered significant. Results: In Group A, the mean pain in the hand premedicated with magnesium was 1.46±1.07, compared to 4.54±2.15 for that of the other hand that had received normal saline (P=0.001). In group B, the mean pain in the hand that had received magnesium was 0.82±1.34, compared to 0.78±1.07 for that of the other hand, which had received lidocaine (P=0.86). Conclusion: Intravenous magnesium and lidocaine pretreatments are equally effective in attenuating propofol-induced pain, and were better than normal saline in attenuating propofol-induced pain.
The Effect of Intravenous Dexamethasone and Lidocaine on Propofol-Induced Vascular Pain: A Randomized Double-Blinded Placebo-Controlled Trial  [PDF]
Shireen Ahmad,Gildasio S. De Oliveira Jr.,Paul C. Fitzgerald,Robert J. McCarthy
Pain Research and Treatment , 2013, DOI: 10.1155/2013/734531
Abstract: Background. The mechanism for pain associated with intravenous administration of propofol is believed to be related to the release of nitric oxide. We hypothesized that pain following propofol injection would be reduced by pretreatment with dexamethasone. Methods. One hundred fourteen female subjects received 5?mL of preservative-free saline, 0.5?mg·kg?1 of lignocaine hydrochloride 10?mg·mL?1 or 0.25?mg·kg?1 of dexamethasone, intravenously, following exsanguination and occlusion of the veins of the arm. This was followed by a 0.5?mg·kg?1 injection of propofol. Pain scores, facial grimacing, arm withdrawal, and vocalization were recorded prior to and at 15 and 30 seconds following the injection of propofol. Results. The incidence of moderate to severe pain following the injection of propofol was significantly decreased with both lidocaine and dexamethasone. Hand withdrawal was also significantly decreased in comparison to saline. Conclusion. Low dose dexamethasone is commonly used as an antiemetic, and, in larger doses, it has been demonstrated to provide prolonged postoperative analgesia. At higher analgesic doses, dexamethasone may also reduce pain associated with the injection of propofol. This effect is probably related to the effect of the steroid on nitric oxide production associated with intravenous propofol injection. 1. Introduction Propofol (Diprivan, 2,6-di-isopropylphenol) was introduced into clinical use in 1986 and has now become the most widely used intravenous anaesthetic, despite the high incidence of localized pain on injection. In studies of propofol injection into an intravenous catheter in a forearm cephalic vein or vein on the back of the hand, the incidence of pain was 68%–72% [1, 2]. The pain is immediate and can be profound, and it has been ranked the seventh out of the 33 anesthesia outcomes deserving high priority for improvement, by a panel of anaesthesiologists from academic and community practices [3]. In addition, the hyperdynamic cardiovascular response to the pain can precipitate adverse events in high-risk patients with history of coronary artery disease and/or abnormal heart rhythm. Clinical strategies designed to alleviate propofol-related pain have been described in the literature including cooling the extremity, dilution of the propofol solution injecting propofol into a large antecubital vein, and the application of topical nitroglycerin on the skin overlying the tip of the intravenous catheter. Injection of lidocaine to prevent propofol injection pain is the most extensively studied technique and is commonly used
The Professional Medical Journal , 2010,
Abstract: Background: Propofol is wonderful drug for short duration procedures. However, pain on injection of propofol, which has been reported to occur in 28-90% of patients, is a major drawback to its use. Different methods have been used to decrease this pain but intravenouslignocaine is most commonly used pretreatment. Period:................... Methods: A comparative, randomized, double blind study was undertaken to compare the efficacy of three drugs for prevention of pain on propofol injection on induction of anaesthesia. 100 patients of ASA status 1 and 2 posted for General Surgery were allocated randomly in four groups of 25 each, using computer- generated table of random numbers. Venous occlusion was made with tourniquet for one minute. The study drug intravenous lignocaine 1% 2ml (group1), Ketamine 10mg (group2), Dexamethasone 4mg in 2ml (group 3) or normal saline 2ml (group 4) was administered over 10 seconds according to random number. There after occlusion was released and intravenous propofol was given. After the first 25% of propofol given, patients were asked for intensity of pain they experienced.Conclusion: It was concluded that Lignocaine, Ketamine and Dexamethasone significantly reduces the pain induced by Propofol injection pain as compared to Placebo but there is no difference in efficacy for prevention of pain among these three groupsKey words: Propofol, pain, intravenous injection. Results: Lignocaine, Ketamine and Dexamethasone significantly reduces the pain on propofol injection in comparison to placebo, but there was no significant difference in pain score among groups 1, 2, 3. There was no significant difference in recall of pain among groups 1, 2, and 3. Although there was significant difference between placebo group and other three groups.
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