Services on Demand
Journal
Article
Indicators
- Cited by SciELO
- Access statistics
Related links
- Similars in SciELO
Share
Acta Médica Costarricense
On-line version ISSN 0001-6002Print version ISSN 0001-6012
Acta méd. costarric vol.55 n.1 San José Jan./Mar. 2013
Original
Propofol
injection pain during sedation for colonoscopy: the role of venous
catheterization site
Roberto Rodríguez-Miranda,
Roy Rojas-Zeledón y Sandra Trisnoski-Suárez
Department of Anesthesiology. San Juan de Dios
Hospital.
Author’s
membership:
Abstract
Background:
The use of
propofol has seen its greatest growth in
the operating
room and diagnostic centers. Pain associated with propofol
injection is a common clinical issue. There have been many attempts to
reduce pain, however, complete inhibition
has not been achieved.
Methods: Data was colected from patients sedated with propofol
in the Endoscopy room at San Juan de Dios Hospital. The data obtained
included
the McCrirrick pain on propofol
injection scale, demographic variables, caliber and location of venous
catheters, as well as concomitant medications. The data was recorded by
the
treating anesthesiologist and reviewed by the researcher.
Results: 58% of
patients did not experience pain on propofol
injection; 24,8% experienced mild pain,
12,8% moderate
pain, and 1,7% severe pain. Statistically, the group of patients that
received propofol through a venous
catheter in the antecubital fossa, experienced
less pain than those with a venous catheter placed in the hand, wrist,
or
anterior forearm. (p=0,006).
Conclusion:
The best
way to reduce pain on propofol injection
is to place
the venous catheter in the antecubital fossa.
Keywords: Pain, propofol, sedation, colonoscopy.
In recent
years, sedation with propofol
has increased significantly for gastrointestinal endoscopy.4 Several
studies had established the propofol is
superior to
traditional sedation systems, because its offers a rapid onset and a
short
recovery time, with an excellent satisfaction level for the patient and
the
endoscopist.5 Propofol is
especially
appropriate for the outpatient setting, since it markedly decreases the
need
for vigilance after the procedure.4
Propofol
injection pain is a common clinical problem, presented in 28-90% of
patients.6,7 Moderate to intense
pain has been reported in
32-67% of patients that received a bolus of standard dose.8
Propofol
is directly irritating on venous intima;9
also, it activates the kinin-kallikrein
system,
resulting in bradykinin production (a
potent
endogenous algesic) and provoked pain.10
With the
decrease of postoperative adverse events, the
patient satisfaction is assuming great importance. Pain, and
particularly pain
caused by anesthetic, is a major important cause of dissatisfaction for
the
patient, which is particularly true during sedation for colonoscopy;
therefore,
it is necessary to have studies designed to identify factors associated
with
the onset of pain. In
This study
evaluated the factors associated with the
onset of pain during the administration of propofol,
and compared the relative efficacy of different analgesic techniques to
prevent
pain caused by injecting propofol.
Materials
and methodology
After the
Bioethics Local Committee’s (Comité Local
de Bioética
(CLOBI)) approval, an observational analytical cohort study was made.
The
outpatient population admitted to the Endoscopy Room of San Juan de
Variables
taken into account were: age, genre, weight,
co-administered medications, gauge and location of the employed venous
catheter
and the verbal or corporal manifestation of pain during propofol
injection, according to MacCrirrick Scale.11
The study
included all outpatients with ASA physical
status 1 and 2, capable of giving informed consent. Pregnant women,
patients
with neurological diseases and those expose to sedatives and
painkillers 24
hours prior were excluded.
The
attending anesthesiologist daily assigned to the
Endoscopy Room performed sedation without the researcher’s
intervention.
Since it is an observational study, no action was made to interfere
with the
sedation technique.
The data
was processed in a SPSS version 13
statistical package, and Excel to create the graphics. All frequencies
were
distributed for all variables.
A
comparison between groups was made, according to the
level of pain reported (no pain, mild, moderate or intense pain). The
results
were put on a Chi-square (χ2) test,
under a null hypothesis of
independence.
The
average for quantitative variables (age,
channelization attempts and doses/weight) was compare between the
levels of
pain reported; the results were analyzed through ANOVA. The correlation
between
the pain manifested in the I.V. route and the intensity of the pain
from the propofol injection was analyzed,
through Spearman’s
rank correlation coefficient. In all the analysis, it was considered
significant when p<0.05 (Figure 1).
Results
We worked
with all the patients admitted in the
Endoscopy Room that met the inclusion criteria in the period studied, a
total
of 117; it was found that 58.1% of patients did not have pain with propofol injection. Among those who did present
pain, the
majority (24.8%) was mild, 12.8% was moderate and 1.7% was intense
(Table 1).
The most
common site for venous catheterization was
the antecubital fassa
(34.5%), and less used were the back of the hand, the forearm and the
wrist. A
significant statistical difference was found (p=0.006), since pain on
the antecubital fossa
was of lower
intensity to propofol injection respect
the other
groups.
Discussion
Since
there is no national statistics, or data that
could be use for comparison, it was decided to use the numbers reported
on
international literature.
Of a total
of studied patients, 58.1% didn’t
have pain with propofol injection, on 2.6%
the data
was not recollected, because the data collection sheet was illegible or
incomplete; which means that about 40% of patients did have some degree
of pain
with propofol injection, quantify on McCrirrick scale. Comparing this information
with the one
reported worldwide, the numbers found were similar.
Namely,
multiple studies agreed that pain with propofol
injection is a common adverse effect of this
anesthetic and even, that is of high incidence. However, the exact
percentage varies
immensely among diverse related studies. For example, Stark et al study
establish that up to 30% of patients presented pain when administered propofol intravenously.12 Nathason
et al establish the incidence of pain of discomfort with propofol injection in 45-75% of cases.13
Meanwhile,
previous studies have reported that pain
incidence goes from 40 to 86% in Cheong et al article,14 up to
frequencies
between 28-90% according to Agarwal et al.15
This
is consistent with the current study, placing the incidence of pain
with propofol injection in a 42% in our
area, which is
consistent with what Doenicke et al say,
who argue
that using propofol for anesthesia,
without a
previous dose of fentanyl or lidocaine,
30 to 70% of patients reported pain on the injection site. Similarly,
the
percentage found in our area is within the range indicated by Tan and Onsiong, who place the pain in 5 to 48% of cases.16
No
differences were found in terms of demographic
characteristics, which is consistent with the literature, in relation
to pain
onset.17 The incidence and intensity of propofol
injection pain was similar in different age groups, genre, ASA physical
states
and weight.
When
comparing different intravenous catheter gauges
used to obtain vascular access, it was noted that there were no
differences
between groups. In the current study, the attending anesthesiologist
was not
limited to a choice of venous catheter gauge, which provided an
opportunity to
compare sizes. Consistent with the current study, Picard and Tramer’s meta-analysis, found no evidence of a
relation between the size of the catheter or the injection rate, with
the
probability of pain with propofol
administration.18
Considering
that many studies have limited to one site
of venous catheterization, in this study the door was left open for the
attending anesthesiologist, with the purpose of using this variable for
the
review and the statistical analysis. A significant statistical
difference was
found between groups (p=0.006).
When
injecting propofol to the
back of the hand, pain was present in 18 of 31 patients, for an
incidence of
58%; on the wrist veins the pain incidence was present in 9 of 14
patients,
corresponding to 64% of cases. This is perfectly consistent with what
was
stipulated in Dubey and Kumar article, who
say that propofol injection pain is still
a problem, when presenting
in 32-67% of patients to whom, propofol
injection was
give through small veins of the hand.18
On
contrast, propofol
injection pain at the antecubital fossa
was documented in only 7 of 39 patients neither of them referred
moderate or
intense pain. Thus, it coincides with what was reported by Iyilikci
et al, who cite that one method to reduce propofol
injection pain is to administered it into an antecubital
large vein.19 Even Ohmizo et
al referred
that the use of a larger vein is one of the most effective methods to
prevent
this pain.20 An article by Doenicke
et al,
established that with the injection on proximal large veins, the
probability of
a painful reaction was of 0-30%.21
Patients
data were tabulated according to the
incidence and level of pain with propofol
injection,
which were compared in relation to the administered dose of propofol,
considering, of course, the weight of the patient and therefore, it was
ordered
according to dose by weight, through the following ranges: less than 1
mg/kg, 1
to 2mg/kg, and from 2 to 3 mg/kg for sedation. No relationship was
found
between the various infused doses of propofol
and the
degree of pain presented by patients.
In
relation to the studied medication used prior to propofol
injection, precisely to reduce pain associated
with it, the literature is plenty. Although many strategies has been
described
to relief propofol injection pain, the
complete inhibition
has not been achieved.22 The most common method in clinical
practice
is mixing 10 to 40mg of lidocaine into a
syringe with
propofol prior to inyection.16 However,
lidocaine administration prior to the
injection of propofol and the lidocaine mixture
directly with propofol, are less effective
than
intravenous application with a tourniquet, emulating a Bier blockage.18
Fujii
and Shiga study demonstrated that 40mg of lidocaine
in young patients and 20mg for older ones were enough to minimize the
pain associated
with propofol.23 Since lidocaine
is
absorbed by oil droplets, a mixture of lidocaine
and propofol must be used quickly so the
anesthetic effect is
present in the vein.21 In the research, nine patients
received lidocaine alone concomitantly
with propofol,
doses ranging from 10 to 80mg. In addition 5 pacients
received lidocaine and midazolam,
prior to propofol. None of them presented
moderate or
intense pain to propofol injection,
however despite
the strong correlation, this finding did not reach statistical
significance
(p=0.06).
The use of
opioids –
especially those of short action like alfentanyl
or fentanyl – and derivatives has been
described to
prevent effectively the pain of propofol
injection.24
With the use of fentanyl, it is determined
that it is
required to administrate in 3 or 4 patients to prevent propofol
injection pain (NNT=3-4).18
Pang et
al and Mok et
al, has demonstrated that 40mg of meperidine
is
equally effective as 60mg of lidocaine to
reduce pain
associated to propofol.25,26 This is similar to an Egyptian
study,
which documented equal efficacy of premedicating
with
0.5mg/kg of Meperidine as with 1mg/kg of
lidocaine.22
This phenomenon can be attributed to meperidine’s
anesthetic effect, that could be related to an structure similarity to
cocaine
and tetracaine.27 Also, butorfanol
(an opioid agonist-antagonist) had
demonstrated to reduce propofol injection
pain as well. Two milligrams were
equivalent to 40mg of lidocaine to
attenuate this
adverse effect, according to Agarwal et al.15
The only opioid used was fentanyl.
This was applied alone or with midazolam
in 36 patients, without documenting a significant
pain reduction when injecting propofol.
Interestingly, none of the attending anesthesiologists combined fentanyl with lidocaine,
during
the research period.
According
to the collected data during the observation
period of the study, there are no benefits in the prior administration
of lidocaine, fentanyl
or midazolam to reduce the incidence or
the intensity of pain
with propofol injection. Nor pain
reduction with the
combination of these drugs.
Therefore,
there is no significant statistical
difference between studies patient groups, according to co-administered
drugs,
and the level of pain with propofol in
sedation for
colonoscopy on the Endoscopy Room at San Juan de Dios Hospital
(p=0,062). (Table 2).
In conclusión, 40% of
patients presented pain with propofol
injection. 25%
presented a mild pain; 13% presented moderate pain, and only 2%
presented
intense pain when administering propofol.
There was
not a significant statistical reduction on pain with propofol
injection when using lidocaine or fentanyl
concomitantly. A significant pain reduction was significant when
placing the
venous catheter on the antecubital fossa, but the used gauge of the venous catheter
was not
affected.
Thanks: We thank
Mayra Cartín,
We thank
Dr. Franklin Dawkins Arce,
anesthesiologist and epidemiologist from
References
1. Communication from the ASGE Standards of Practice Committee. Guideline: Sedation and anesthesia in GI Endoscopy. Gastrointest Endosc 2008; 68:205-15. [ Links ]
2. Huang R, Eisen GM. Efficacy, safety, and limitations in current practice of sedation and analgesia. Gastrointest Endosc Clin N Am 2004; 14:269-88. [ Links ]
3. Lubarsky DA, Candiotti K, Harris E. Understanding modes of moderate sedation during gastrointestinal procedures: a current review of the literature. J Clin Anesth 2007; 19:397-404. [ Links ]
4. Külling D, Orlandi M, Inauen W. Propofol sedation during Endoscopic procedures: how much staff and monitoring are necessary? Gastro intest Endosc 2007; 66:443-449. [ Links ]
5. Cohen L, Wecsler J, Gaetano J, Benson A, et al. Endoscopic sedation in the
6. Yew W, Chong S, Tan K, Goh M. The Effects of Intravenous Lidocaine on Pain During Injection of Medium- and Long-Chain Triglyceride Propofol Emulsions. AnesthAnalg 2005; 100:1693-5. [ Links ]
7. Sun N, Wong A, Irwin M. A Comparison of Pain on Intravenous Injection Between Two Preparations of Propofol. AnesthAnalg 2005; 101:675-8. [ Links ]
8. Shao X, Li H, White P, Klein K, Kulstad C, Owens A. Bisulfite-Containing Propofol: Is it a Cost-Effective Alternative to DiprivanTM for Induction of Anesthesia? AnesthAnalg 2000; 91:871-5. [ Links ]
9. Dubey, PK, Kumar A. Pain on injection of lipid-free propofol and propofol emulsion containing medium-chain triglyceride: a comparative study. Anesth Analg 2005; 101:1060-1062. [ Links ]
10. Nakane M, Iwama H. A potential mechanism of propofol-induced pain on injection based on studies using nafamostatmesilate. Br J Anaesth 1999; 83: 397-404. [ Links ]
11. McCrirrick A, Hunter S. Pain on injection of propofol: the effect of injectate temperature. Anaesthesia 1990; 45:443-4. [ Links ]
13. Nathanson MH,
14. Cheong MA, Kim KS, Choi WJ. Ephedrine Reduces the Pain from Propofol Injection. Anesth Analg 2002; 95:1293-6. [ Links ]
15. Agarwal A, Raza M, Dhiraaj S, Pandey R, et al. Pain During Injection of Propofol: The Effect of Prior Administration of Butorphanol. Anesth Analg 2004; 99:117-9. [ Links ]
16. Tan CH, Onsiong MK. Pain on injection of propofol. Anaesthesia 1998; 53:468-76. [ Links ]
17. Agarwal A, Dhiraj S, Raza M, et al. Vein pretreatment with magnesium sulfate to prevent pain on injection of propofol is not justified. Can J Anesth 2004; 51:130-33. [ Links ]
18. Picard P, Tramèr MR. Prevention of Pain on Injection with Propofol: A Quantitative Systematic Review. AnesthAnalg 2000; 90:963-9. [ Links ]
19. Iyilikci L, Balkan BK, Gökel E, Günerli A, Ellidokuz H. The Effects of Alfentanil or Remifentanil Pretreatment on Propofol Injection Pain. J ClinAnesth 2004; 16:499-502. [ Links ]
20. Ohmizo H, Obara S, Iwama H. Mechanism of injection pain with long and long-medium chain triglyceride emulsivepropofol. Can J Anesth 2005; 52:595-599. [ Links ]
21. Doenicke AW, Roizen MF, Rau J, Kellermamm W, Babl J. Reducing pain during propofol injection: the role of the solvent. AnesthAnalg 1996; 82:472-4. [ Links ]
22. Saadawy I, Ertok E, Boker A. Painless Injection of Propofol: Pretreatment with Ketamine vs Thiopental, Meperidine, and Lidocaine. M.E.J. Anesth 2007; 19:631-44. [ Links ]
23. Fujii Y, Shiga Y. Influence of aging on lidocaine requirements for pain on injection of propofol. J ClinAnesth 2006; 18:526-9. [ Links ]
24. Al-Refai A, Al-Mujadi H, Ivanova M, Marzouk HM, Batra YK, Al-Qattan AR. Prevention of pain on injection of propofol: a comparison of remifentanil with alfentanil in children. Minerva Anestesiol 2007; 73:219-23. [ Links ]
25. Pang WW, Mok MS, Hauang S, Hwang MH. The analgesic effect of fentanyl, morphine, meperidine, and lidocaine in the peripheral veins: a comparative study. AnesthAnalg 1998; 86:382-6. [ Links ]
26. Mok MS, Pang WW, Hwang MH. The analgesic effect of tramadol, metoclopramide, meperidine, and lidocaine in ameliorating propofol injection pain: a comparative study. J Anesthesiology 1999; 15:37-42. [ Links ]
27. Armstrong PJ, Morton CPJ, Nimmo AF. Pethidine has a local anesthetic action on peripheral nerves in vivo. Anaesthesia 1993; 48:382-6. [ Links ]