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ORIGINAL ARTICLE
Year : 2011  |  Volume : 14  |  Issue : 1  |  Page : 60-64

The effect of propofol lipuro with and without lidocaine on injection pain in children


1 Departmant of Anesthesia and Reanimation, Pain medicine, Sevgi Women's and Children's Hospital, Ordu, Turkey
2 Dicle University Faculty of Medicine, Department of Anesthesia and Reanimation, Diyarbakir, Turkey
3 Department of Anesthesia and Reanimation, Diyarbakir State Hospital, Diyarbakir, Turkey

Date of Acceptance28-Jan-2011
Date of Web Publication11-Apr-2011

Correspondence Address:
S Gökhan Beyaz
Sevgi Women's and Children's Hospital, Anesthesia and Intensive care specialist, Karsiyaka Neighborhood, 906, street number:5, zip code 52100, Center, Ordu
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1119-3077.79252

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   Abstract 

Objective: Despite advantages of propofol use such as providing a good anesthesia and rapid recovery; pain due to intravenous propofol injection continues to be a problem. The aim of this study was to compare the effects of generic propofol and propofol lipuro with and without lidocaine on injection pain in children.
Materials and Methods:
This study performed between 01 December 2009 and 16 May 2010. A total of 120 children, who planned to undergo elective surgery under general anesthesia, were included in four groups of 30 in a prospectively, randomized and double-blind study. Generic propofol was given to first and second groups and propofol lipuro was given to third and fourth groups. In addition to propofol, lidocaine was given to second and fourth groups. Injection pain was assessed using Ontario Children's Hospital Pain Scale (mCHEOPS).
Results:
No differences were found in the mean age, weight and given dose of propofol administered between all groups (P>0.05). Double comparison of groups revealed no significant difference in pain scores between Group 1 and 2 (mean pain scores, 1.34 ± 1.42 vs. 1.22 ± 1.31 points, respectively; P>0.05). However, significant difference was found between propofol lipuro groups with or without lidocaine (3.20 ± 2.10 vs. 0.95 ± 1.21 points, respectively; P<0.001).
Conclusion:
The highest pain scores were found in the propofol lipuro without lidocaine use while propofol lipuro plus lidocaine had the lowest pain scores. Because adding lidocaine to propofol lipuro decreased injection pain scores to minimum levels, this practice seems to be the most appropriate alternative in order to diminish propofol injection pain during anesthesia in children.

Keywords: Children, propofol, lipuro, injection pain, lidocaine


How to cite this article:
Beyaz S G, Tüfek A, Tokgöz O. The effect of propofol lipuro with and without lidocaine on injection pain in children. Niger J Clin Pract 2011;14:60-4

How to cite this URL:
Beyaz S G, Tüfek A, Tokgöz O. The effect of propofol lipuro with and without lidocaine on injection pain in children. Niger J Clin Pract [serial online] 2011 [cited 2019 Nov 15];14:60-4. Available from: http://www.njcponline.com/text.asp?2011/14/1/60/79252


   Introduction Top


Propofol provides pleasant and smooth anesthetic induction with rapid recovery. Although it is a popular intravenous agent, its injection is painful. Frequency and importance of injection pain was ranked 7th among 33 clinical problems of anesthesia practice. [1] Therefore, several drugs and techniques are being used in order to relieve injection pain. Topical lidocaine, fentanyl, alfentanyl, ketamin, ondansetron, tramadol, metoclopramide are all drugs that have been tried for the prevention of propofol injection pain. Drug injection at different rates and concentrations, tourniquets at arm of injection, injection of drugs at different temperatures (4°C and 37°C), utilizing larger veins for injection are examples of various techniques that have been studied. [1],[2],[3],[4],[5]

As a widely used intravenous anesthetic, Propofol has different formulations in many solutions. Standard propofol today, has a formulation with long chain trigliseride (LCT). [6] Middle chain trigliseride (MCT) and LCT are mixed together in an emulsion which is called Propofol Lipuro (B.Braun Melsungen AG, Germany). Propofol Lipuro is different from standard Propofol LCT. Liquid phase free propofol is decreased; it is believed that injection pain would also decrease. In addition to these techniques of decreasing injection pain, some of the most used methods in clinical practice include lidocaine administration with or without tourniquets, and addition of 10-40 mg lidocaine inside propofol injection just before administration. [1],[7]

The aim of this study was to compare the extent of Propofol Lipuro (MCT/LCT) versus standard (generic) Propofol (LCT) on injection pain in children. Randomized four patient groups were compared according to their Propofol Lipuro and standard Propofol with or without lidocaine; pain level of each children was evaluated with a standard pain scale.


   Materials and Methods Top


We obtained Institutional Ethics Committee approval and informed written consent from parents. We performed between 01 December 2009 and 16 May 2010. One hundred and twenty children were prospectively included in this study. Their ages were betweeen 3 and 15 years, they were ASA I and scheduled for elective surgery under general anesthesia. Exclusion criteria include inability to establish and IV access, emergency cases, presence of liver/or renal dysfunction problems, musculoskeletal system disorders, a neurological deficit in the nondominant hand, or know allergies to propofol, egg lecithin, soybean oil.

According to the admission order, children were randomized into 4 groups. No premedication was given. Angiocath 22-24 gauge was placed into an antecubital vein and isodex (3.3% dextrose + 0.3% NaCl, Eczacıbası/Baxter, Istanbul, Turkey) solution (3-5 ml/kg/h) was given intravenously. Three-way stop cock was attached to the venous cannula distally. Via this three-way stop cock, an infusor (Braun perfusor compact type-8714827) placed. Electrocardioogram, systolic (SBP), diastolic (DBP), mean blood pressure (MBP), heart rate (HR) and peripheral oxygen saturations (SpO 2 ) were monitorized (Datex-Engstrom AS/3 monitor). Tourniquet pressure was set to 70 mmHg on the upper arm, groups 1 and 3 received saline, groups 3 and 4 received intravenous 1 mg/kg lidocaine. After waiting 60 seconds, tourniquet was removed. Via infusor, 600 mL/hour Propofol LCT %1 (Propofol %1 Fresenius, Fresenius Kabi, Sweden) and/or Propofol-MCT/LCT %1 (Lipuro®, B.Braun, Germany) with lidocaine (Jetokain® %2, Adeka ŏlaç Sanayi ve Ticaret A.Ş., Türkiye) and without lidocaine were administered.

Group 1 received 2 ml saline and propofol LCT %1 10 mg/ml (Fresenius) for induction, Group 2 received 1 mg/kg + propofol LCT %1 10 mg/ml (Fresenius), Group 3 received 2 ml saline + Propofol Lipuro %1 10 mg/ml and Group 4 received Lidocaine 1mg/kg + Propofol Lipuro %1 10 mg/ml. Anesthesia induction was conducted via infusion at 600 ml/hour. On commencing the infusion, Modified Eastern Ontario Children's Hospital pain scale (mCHEOPS) was used to evaluate the injection pain [Table 1].
Table 1: Modified Eastern Ontario Children's Hospital pain scale

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Propofol infusion was terminated after the loss of eyelash reflex. Infused propofol amount (ml) was recorded. With a facemask, patient was ventilated with inhalational agents; %50 O 2 and %50 N 2 O, 3 MAC sevoflurane. Intravenous fentanyl 2 μg/ kg was also administered. When deep anesthesia was judged to have been reached, age-weight appropriate Proseal laryngeal mask was inserted. At the end of the operation, patient was awakened and sent to the ward.

Statistical analysis

Data was presented as mean ± standard deviation. SPSS vs. 12.0 program was used for statistical analysis. Single-sample Kolmogorov-Smirnov test was used to investigated whether data of each group fits normal distribution. In order to compare measured data between groups; Kruskal-Wallis variance analysis was used while χ2 test was used to compare counted data between groups. For statistical significance, P<0.05 was accepted as significant.


   Results Top


Demographic data (age, sex, weight, ASA physical status) and (consumed propofol amounts) total dose of propofol administered revealed no significant different (P> 0.05) [Table 2] and [Table 3].
Table 2: Distribution of age, weight and consumed propofol amount (mg) among groups

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Table 3: Distribution of sex and ASA scores among groups

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Pain scale (mCHEOPS) points revealed that there was significant difference between all groups (P<0.001). On comparison of groups two at a time, pain scale (mCHEOPS) points revealed that there was no significant difference between standard (generic) propofol group without lidocaine (Group 1, 1.34±1.12 points) and standard (generic) propofol group with lidocaine (Group 2, 1.22±1.16 points) (P>0.05).

However, there was significant difference between group 1 (standard -generic propofol group without lidocaine) and group 3 (propofol lipuro group without lidocaine) in terms of pain scale scores. Also, there was significant difference between groups 1 and 4 (propofol lipuro group with lidocaine) in terms of pain scale scores (P<0.05) [Figure 1]. Average pain points of group 1 was significantly lower than Group 3 (respectively, 1.34±1.12 points and 3.20±1.7 points, P=0.003), but Group 1 was significantly higher than Group 4 (respectively, 1.34±1.12 points and 0.95±0.81 points, P=0.025).
Figure 1 : Average mCHEOPS pain points mean values (Group 1: standard-generic propofol without lidocaine; Group 2: standard -generic propofol with lidocaine; Group 3: propofol lipuro without lidocaine; Group 4: propofol lipuro with lidocaine). [Groups compared two at a time with Mann-Whitney U-test; Group 1-2 (P>0.05); Group 1-3 (P=0.003); Group 1-4 (P=0.025); Group 2-3 (P<0.001); Group 2-4 (P>0.05) and Group 3-4 (P<0.0001)]

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Average pain points of Group 3 (propofol lipuro group without lidocaine) was significantly higher than both groups 1 and 2, and also group 4 (P<0.05). Whereas average pain points of Group 4 was significantly lower than other three groups. However, the difference between group 4 versus groups 1 and 3 was statistically significant (P<0.05), but the difference between group 4 versus group 2 was not statistically significant (P>0.05). The lowest pain scores were acquired with propofol lipuro group with lidocaine, the highset scores were acquired in propofol lipuro group without lidocaine [Figure 1].


   Discussion Top


Propofol is the most used intravenous general anesthetic drug for anesthesia induction. [5] Smooth induction, pleasant sleep, faster recovery and lower incidence of nausea-vomit in postoperative period are the advantages. [8] Although propofol has these positive characteristics, it has some unwanted effects like injection pain which impairs patient comfort. This subject has generated various studies.

This study revealed that there is no benefit of adding lidocaine to standard (generic) propofol. In contrast, adding lidocaine into propofol lipuro resulted in the lowest pain scores of all groups. In addition, we also observed that propofol lipuro without lidocaine resulted in more injection pain than standard (generic) propofol.

Although mechanism of injection pain from propofol is impressed by various factors, it is still not fully apparent. The most emphasized mechanism is activation of plasma kinin-kallikrein system. [6] Site of injection, speed of injection, free propofol concentration at liquid phase, buffering effect of blood, temperature of propofol, injector material, some local anesthetics, opioids have been suggested to have role in injection pain. None of these agents or methods have been successful in relieving propofol injection pain. Lidocaine administration (either pretreatment or mixing with propofol) is the most used method. The application of tourniquet before lidocaine injection have been suggested to significantly decreases injection pain. [4],[9] In our study, we found that pretreatment of lidocaine in group 4 decreased injection pain significantly.[Figure 1]

Among other mechanisms of injection pain of propofol; lipid carrier [10],[11] and emulsion of propofol concentration at aqueous phase were reported have important role. [12],[13] Doenicke et al.[14] mixed propofol LCT emulsion with both saline and lipid emulsion. They indicated that lipid emulsion mixture group had lesser intensity and incidence of pain. They concluded that free concentration at aqueous phase was decreased by absorption of propofol by lipid particles. Song et al.[15] compared standard propofol with propofol formulation which contains 50% less soya oil and egg lesithin. They reported that standard propofol caused less pain. They concluded that free concentration of aqueous phase propofol was higher and causing more pain.

Propofol Lipuro (MCT-LCT) is a new emulsion and there are numerous reports that intravenous administration caused lesser pain than standard LCT propofol in adult patients. [7],[16],[17],[18] However, we observed that propofol lipuro without lidocaine caused more pain in children. This might be due to the difference of patient populations.

Propofol MCT/LCT has lesser aqueous phase than Propofol LCT; therefore leads to lesser injection pain. [6],[19] In previous studies conducted on children, propofol lipuro was found to have lesser pain scores. However, results of this presented study were not coherent with those limited numbered studies. [20],[21] In two different studies conducted on adults, addition of lidocaine in Propofol MCT/LCT significantly decreased injection pain. Whereas, addition of lidocaine in standard Propofol LCT had no beneficial effect on injection pain. [2],[22] Similarly in our study, pain scores of generic propofol with lidocaine were the same as pain scores of generic propofol without lidocaine. Thus, our results are consistent with previous results. Furthermore, we found that propofol lipuro without lidocaine was not superior to generic propofol. Pretreatment of lidocaine before both formulations were found to decrease injection pain.

In conclusion, we observed that the best formulation which decreases injection pain was propofol lipuro with lidocaine. Further studies are needed to explain how propofol lipuro without lidocaine caused more pain than generic propofol. In children, addition of lidocaine to propofol lipuro solution decreases injection pain to the lowest values. In order to clarify this subject more studies with different pain scales are needed.

 
   References Top

1.Bachmann-Mennenga B, Ohlmer A, Heesen M. Incidence of pain after intravenous injection of a medium-/long chain triglyceride emulsion of propofol. Arzneim Forsc Drug Res 2003; 53:621-6.  Back to cited text no. 1
    
2.Kam E, Abdul-Latif MS, McCluskey A. Comparison of Propofol-Lipuro with propofol mixed with lidocaine 10 mg on propofol injection pain. Anaesthesia 2004; 59:1167-9.  Back to cited text no. 2
    
3.Fletcher GC, Gillespie JA, Davidson JA. The effect of temperature upon pain during injection of propofol. Anaesthesia 1996; 51:498-9.   Back to cited text no. 3
    
4.Picard P. Tramer MR. Prevention of pain on injection with propofol: A quantitative systematic review. Anesth Analg 2000; 90:963-9.   Back to cited text no. 4
    
5.Öztürk ÇE, Beyaz SG, Tokgöz O, Sentürk Y. 1% and 2% injection pain of propofol in infusion rates and to intubation comparison of the effects on hemodynamic responses. Turkiye Klinikleri J Anest Reanim 2010;8:79-85.  Back to cited text no. 5
    
6.Nishiyama T. How to decrease pain at rapid injection of propofol: Effectiveness of flurbiprofen. J Anesth 2005; 19:273-6.  Back to cited text no. 6
    
7.Mallick A, Elliot SC, Krishnan K, Vucevic M. Lidocaine is more efficient than the choice of propofol formulations to reduce incidence of pain on induction. Eur J Anaesthesiol 2007; 24:403-7.  Back to cited text no. 7
    
8.Montanini S, Pratico C, Tufano R. Propofol for sedation in the intensive care unit: Comparative evaluation of 1% and 2% formulations. Br J Intensive Care 1999:9:110-4.   Back to cited text no. 8
    
9.Massad IM, Abu-Ali HM, Al-Ghanem SA, Badran IZ, Ammari BA, Daradkeh SS. Duration of venous occlusion with lidocaine for preventing propofol induced pain. Saudi Med J 2008;29:971-4.  Back to cited text no. 9
    
10.Ohmizo H, Obara S, Iwama H. Mechanism of injection pain with long and long-medium chain triglyceride emulsive propofol. Can J Anaesth 2005;52.595-9.  Back to cited text no. 10
    
11.Tan CH, Onsiong MK. Pain on injection of propofol. Anaesthesia 1998;53:468-76.  Back to cited text no. 11
    
12.Nakane M, Iwama H. A potantial mechanism of propofol-induced pain on injection based on studies using nafamostat mesylate. Br J Anaesth 1999;83:397-404.  Back to cited text no. 12
    
13.Doenicke AW, Raizen MF, Rau J, Kellermann W, Babl J. Reducing pain during propofol injection: The role the solvent. Anesth Analg 1996;82:472-4.  Back to cited text no. 13
    
14.Doenicke AW, Roizen MF, Rau J, O'Connor M, Kugler J, Klotz U, et al. Pharmacokinetics and pharmacodynamics of propofol in a new solwent. Anesth Analg 1997;85:1399-403.  Back to cited text no. 14
    
15.Song D, Hamza M, White PF, Klein K, Recart A. The pharmacodynamic effects of a lower-lipid emulsion of propofol: A comparison with the standard propofol emulsion. Anesth Analg 2004;98:687-91.  Back to cited text no. 15
    
16.Ayoðlu H, Altunkaya H, Özer Y, Yapakçi O, Cukdar G, Ozkoçak I, et al. Does dexmedetomidine reduce the injection pain due to propofol and rocuronium? Eur J Anaesthesiol 2007;24:541-5.  Back to cited text no. 16
    
17.Sun NC, Wong AY, Irwin MG. A comparison of pain on intravenous between two preparations of propofol. Anesth Analg 2005;101:675-8.  Back to cited text no. 17
    
18.Kunitz O, Lösing R, Schulz-Stübner S, Haaf-von-Below S, Rossaint R, Kuhlen R. Propofol-LCT Versus Propofol-MCT/LCT with or without Lidocaine: A comparison on pain on injection. Anästhesiol Intensivmed Notfallmed Schmerzther 2004;39:10-4.  Back to cited text no. 18
    
19.Liljeroth E, Akeson J. Less local pain on intravenous infusion of a new propofol emulsion. Acta Aneesthesiol Scand 2005;49:248-51.  Back to cited text no. 19
    
20.Nyman Y, Von Hofsten K, Georgiadi A, Eksborg S, Lönnqvist PA. Propofol injection pain in children: A prospective randomized double-blind trial of a new propofol formulation versus propofol with added lidocaine. Br J Anaesth 2005;95:222-5.  Back to cited text no. 20
    
21.Larsen R, Beerhalter U, Erdkönig R, Larsen B. Injection pain from propofol MCT-LCT in children: A comparison with propofol-LCT. Anaesthesist 2001;50:676-8.  Back to cited text no. 21
    
22.Yew WS, Chong SY, Tan KH, Goh MH. The effects of intravenous lidocaine on pain during injection of medium-and long-chain triglyseride propofol emulsions. Anesth Analg 2005;100:1693-5.  Back to cited text no. 22
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]


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