As many as 60% of patients report significant pain with the injection of IV propofol. Once a patient experiences pain, it's too late to reverse it. Often all you can do is to tell them that the pain will subside in a few seconds.
What can you do preemptively to minimize the pain of propofol injection?
Tricks of the Trade:
- Place the IV in an antecubital vein (vs the hand).
- Pretreat with IV opioids.
- If the IV is in the hand, place a tourniquet proximally and pretreat with lidocaine.
For the IV is in the hand, you should pre-treat with lidocaine. First, apply a tourniquet. Intravenously inject 0.5 mg/kg of lidocaine. For a 70 kg person, that's 35 mg. This equals 3.5 mL of 1% lidocaine. Release the tourniquet after 30-120 seconds, and inject the propofol. The number-needed-to-treat to prevent pain in one person, who would have had pain had they received placebo, is 1.6!
Thanks to Dr. Andy Neill (of Emergency Medicine Ireland blog fame) for the tip from the Life in the Fast Lane's Research and Reviews series.
Reference
Jalota L, et al. Perioperative Clinical Research Core. Prevention of pain on injection of propofol: systematic review and meta-analysis. BMJ. 2011 Mar 15;342:d1110. PMID: 21406529.
Free PDF
Picard P, Tramèr MR. Prevention of pain on injection with propofol: a quantitative systematic review. Anesth Analg. 2000 Apr;90(4):963-9. PMID: 10735808.
Just as an aside, if doing an antecubital just be aware of the amount of fluid which can go interstitial here before being noticed. I have seen propofol go interstitial in an antecubital and the patient went off the wall in pain. Fortunately we had inhalational agents around but this isn't always the case.
ReplyDeleteYouch! That sounds painful indeed. Yes, a large FUNCTIONAL IV is key. If in doubt, establish a different IV. Good point.
ReplyDeleteYes, but the pain is transient at best, and the patient will most likely never remember the incident.
ReplyDeleteAll the gas docs I know never use lidocaine pre-induction.
Just because it's not mentioned, does not mean it's not remembered. Personally, I have had 3 GA in the last year and I remember every frightening second of the crippling pain before I went under.
DeleteBut a very nice outlook you have there...Let's hope the scope that you apply that logic to is small.
Since propofol has no analgesic properties, I can't think of a single ED use of propofol for which I don't give an opioid prior to administration. So the bigger issue beyond the location of the IV is whose pushing boluses of MoM without pain control....
ReplyDelete@jstgeorge: good point. I don't know of anyone who wouldn't give IV opioids upon arrival either. Sounds like this does occur though, based on the meta-analysis report. Thanks for commenting!
ReplyDeleteother things you can do.... cold propofol stings less, as does running a bag of fluid in relatively rapidly at the same time to dilute the propofol. Some other techniques I've seen have been adding a small amount of lignocaine into the propofol. I have used the tourniquet technique too with some success usually with a combination of lignocaine + short acting opioid. In Europe, there are formulations of propofol that contain greater proportion of lipid which are popular because they don't sting as much. That said, there are some people you can do everything for and it still stings.
ReplyDeleteI think your tip about warm propofol is falling into my belief that "all things warm are less painful" (i.e. lidocaine). Interesting that you can get propofol with more lipids. So that's the "regular propofol" and there is a "low-fat/diet propofol"? Awesome.
ReplyDelete