Prevention of pain with the injection of microemulsion propofol: a comparison of a combination of lidocaine and ketamine with lidocaine or ketamine alone

Effect of ketamine combined with lidocaine in pediatric anesthesia

Background

We conducted a randomized clinical trial to determine whether adjunctive lidocaine diminishes the incidence of adverse effects in pediatric patients sedated with ketamine.

Methods

This case‐control study involved 586 consecutive pediatric patients necessitating anesthesia. Then systolic blood pressure, heart rate, respiratory rate, and blood oxygen saturation were observed. Alanine aminotransferase (ALT), aspartate aminotransferase (AST), urea nitrogen (BUN), and creatinine (Cr) levels were tested. General dose of ketamine, the time of onset and duration of anesthesia and postoperative recovery, anesthesia effect, and adverse reaction were subsequently compared. High‐performance liquid chromatography was employed to detect ketamine concentration at different time points after administration, and the postoperative cognition function was further evaluated.

Results

Intra‐ and post‐operation, the rising degree of ALT, AST, BUN, and Cr in patients treated with ketamine was higher than those in patients treated with the ketamine‐lidocaine complex. General dose of ketamine, the time of onset and duration of anesthesia, postoperative recovery time, and the incidence rate of adverse reaction in patients treated with ketamine‐lidocaine complex were lower, but the concentration of ketamine was higher compared to the patients treated with ketamine. In patients treated with the ketamine‐lidocaine complex, elimination half‐life of ketamine was prolonged, the area under curve was increased, and the plasma clearance rate was decreased relative to those with ketamine alone.

Conclusions

Ketamine combined with lidocaine may be beneficial in shortening the onset of anesthesia, promoting postoperative awake, prolonging elimination half‐life, increasing area under curve, and decreasing plasma clearance rate and incidence of adverse reactions.

Comparison of intradermal Dexmedmotidine and subcutaneous Ketamine for post-surgical pain management in patients with abdominal hysterectomy

Hysterectomy after cesarean section is the second most commonly used surgery for women in the United States. One of the most common problem after hysterectomy is pain. We decided to compare the effects of dexmedmotidine or ketamine on pain in patients by a double blind randomized clinical trial on 126 female candidates for abdominal hysterectomy in three groups of 42 persons referred to Taleghani hospital in Arak. For the first group, 50 micrograms of intradermal dexmedmotidine were injected, while in the second group, patients were injected with 100 mg of subcutaneous ketamine and the third group received 5 cc normal saline. Data were next analyzed by SPSS version 19. The mean age and body mass index of the patients were not significantly different in the three groups. The mean scores of pain during recovery of patients in ketamine, dexmedmotidine and placebo groups were 4.2±0.77, 2.6±0.89 and 1.3±0.87, respectively (p = 0.001). Scores of pain in patients at 4 and 8 hours after surgery showed also significant differences. In conclusion, ketamine and dexmedmotidine significantly reduce the severity of pain, but ketamine has a lower effect.

The effect of rectus muscle re-approximation at cesarean delivery on pain perceived after operation: a randomized control trial

Background: Cesarean section rate has increased dramatically worldwide but there is still debate about the optimum operative technique of cesarean section. Objective: The purpose of this study was to assess the effect of rectus muscle reapproximation at cesarean delivery on the postoperative pain. Methods: This study was a prospective, double-blind, randomized controlled trial. It included 280 primigravidas, with a singleton pregnancy, who underwent elective lower segment cesarean section at term. The patients were randomly allocated into two equal groups; Group (A): undergoing rectus muscle reapproximation, and Group (B): not undergoing rectus muscle reapproximation. Postoperative pain was assessed by visual analogue scale (VAS) from 0 (no pain) to 100 (maximum pain). Postoperative analgesia, operative time, changes in hemoglobin level, length of hospital stay, and occurrence of postoperative complication were also assessed. Results: Postoperative pain score at the end of the first 24 hours and at the end of the next 24 hours were significantly higher among the group of rectus muscle reapproximation (a difference in VAS pain score of: 5, 95% confidence interval: 0.1-11, p value: .02) and (a difference of 1, 95% confidence interval: 0.1-2.9, p value: .01), respectively. As regards the narcotic use in the first 24 hours after cesarean section, in the form of injections of meperidine 50 mg, it was significantly higher among the group of rectus muscle closure (a difference of 10 mg, 95% confidence interval 3-21.7 mg, p value: .02). While in the next 24 hours, the NSAIDs use, in the form of diclofenac sodium injection, was significantly higher among the group of rectus muscle reapproximation (a difference of 10 mg, 95% confidence interval 3.7-31.7 mg, p value: .02). Conclusions: Rectus muscle reapproximation among women undergoing primary caesarian section is associated with significant increase in the postoperative pain and analgesic requirements.

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.

Lidocaine for reducing propofol-induced pain on induction of anaesthesia in adults

BACKGROUND

Pain on propofol injection is an untoward effect and this condition can reduce patient satisfaction. Intravenous lidocaine injection has been commonly used to attenuate pain on propofol injection. Although many studies have reported that lidocaine was effective in reducing the incidence and severity of pain, nevertheless, no systematic review focusing on lidocaine for preventing high-intensity pain has been published.

OBJECTIVES

The objective of this review was to determine the efficacy and adverse effects of lidocaine in preventing high-intensity pain on propofol injection.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 10), Ovid MEDLINE (1950 To October 2014), Ovid EMBASE (1988 to October 2014), LILACS (1992 to October 2014) and searched reference lists of articles.We reran the search in November 2015. We found 11potential studies of interest, those studies were added to the list of 'Studies awaiting classification' and will be fully incorporated into the formal review findings when we update the review.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) using intravenous lidocaine injection as an intervention to decrease pain on propofol injection in adults. We excluded studies without a placebo or control group.

DATA COLLECTION AND ANALYSIS

We collected selected studies with relevant criteria. We identified risk of bias in five domains according to the following criteria: random sequence generation, allocation concealment, adequacy of blinding, completeness of outcome data and selective reporting. We performed meta-analysis by direct comparisons of intervention versus control. We estimated the summary odds ratios (ORs) and 95% confidence intervals using the random-effects Mantel-Haenszel method in RevMan 5.3. We used the I(2) statistic to assess statistical heterogeneity. We assessed overall quality of evidence using the GRADE approach.

MAIN RESULTS

We included 87 studies, 84 of which (10,460 participants) were eligible for quantitative analysis in the review. All participants, aged 13 years to 89 years, were American Society of Anesthesiologists (ASA) I-III patients undergoing elective surgery. Each study was conducted in a single centre in high- , middle- and low-income countries worldwide. According to the risk of bias assessment, all except five studies were identified as being of satisfactory methodological quality, allowing 84 studies to be combined in the meta-analysis. Five of the 84 studies were assessed as high risk of bias: one for participant and personnel blinding, one for incomplete outcome data, and three for other potential sources of bias.The overall incidence of pain and high-intensity pain following propofol injection in the control group were 64% (95% CI 60% to 67.9%) and 38.1% (95% CI 33.4% to 43.1%), respectively while those in the lidocaine group were 30.2% (95% CI 26.7% to 33.7%) and 11.8% (95% CI 9.7% to 13.8%). Both lidocaine admixture and pretreatment were effective in reducing pain on propofol injection (lidocaine admixture OR 0.19, 95% CI 0.15 to 0.25, 31 studies, 4927 participants, high-quality evidence; lidocaine pretreatment OR 0.13, 95% CI 0.10 to 0.18, 43 RCTs, 4028 participants, high-quality evidence). Similarly, lidocaine administration could considerably decrease the incidence of pain when premixed with the propofol (OR 0.19, 95% CI 0.15 to 0.24, 36 studies, 5628 participants, high-quality evidence) or pretreated prior to propofol injection (OR 0.14, 95% CI 0.11 to 0.18, 52 studies, 4832 participants, high-quality evidence). Adverse effects of lidocaine administration were rare. Thrombophlebitis was reported in only two studies (OR not estimated, low-quality evidence). No studies reported patient satisfaction.

AUTHORS' CONCLUSIONS

Overall, the quality of the evidence was high. Currently available data from RCTs are sufficient to confirm that both lidocaine admixture and pretreatment were effective in reducing pain on propofol injection. Furthermore, there were no significant differences of effect between the two techniques.

Analgesic Efficacy of Nephrostomy Tract inFiltration of Bupivacaine and Ketamine after Tubeless Percutaneous Nephrolithotomy: A Prospective Randomized Trial

BACKGROUND

Recently, the use of ketamine as a systemic and local analgesic drug in reducing post-operative pain is studied more frequently.

OBJECTIVES

The aim of the present study was to assess the analgesic efficacy of IV ketamine injection inaddition to nephrostomy tract infiltration of ketamine-bupivacaine on postoperative pain relief after tubeless percutaneous nephrolithotomy (PCNL).

PATIENTS AND METHODS

Patients (n = 100), with renal stone who were candidates for PCNL were randomized to five groups with 20 cases in each: Group C, 10 mL of saline solution was infiltrated into the nephrostomy tract; Group B, 10 mL of 0.25% bupivacaine was infiltrated into the nephrostomy tract; Group BK1, 10 mL of 0.25% bupivacaine plus 0.5 mg/kg ketamine was infiltrated into the nephrostomy tract; Group BK2, 10 mL of 0.25% bupivacaine plus 1.5 mg/kg ketamine was infiltrated into the nephrostomy tract; Group K, 10 mL of saline solution containing 0.5 mg/kg ketamine was intravenously administered. Post-operative pain scores were compared between groups as the primary objective. Comparison of Sedation Scores, rescue analgesic consumption, time to the first rescue analgesics administration, hemodynamic and SpO2 values were regarded as the secondary objective.

RESULTS

Mean VAS scores in the first 30 min and total analgesic consumption in the first 24 h of post-operative period were significantly lower in groups BK1 and BK2 in comparison with the other groups (P < 0.05). Also, time to first rescue analgesics administration was longer in the same groups (P < 0.05).

CONCLUSIONS

Infiltration of ketamine plus bupivacaine provides superior analgesic effects in PCNL surgery compared with other methods.

Change in Musculoskeletal Pain in Patients With Work-Related Musculoskeletal Disorder After Tailored Rehabilitation Education: A One-Year Follow-Up Survey

OBJECTIVE

To apply tailored rehabilitation education to video display terminal (VDT) workers with musculoskeletal pain and to assess changes in musculoskeletal pain after rehabilitation education.

METHODS

A total of 8,828 VDT workers were screened for musculoskeletal disorders using a self-report questionnaire. Six hundred twenty-six VDT workers selected based on their questionnaires were enrolled in musculoskeletal rehabilitation education, which consisted of education on VDT syndrome and confirmed diseases, exercise therapy including self-stretching and strengthening, and posture correction. One year later, a follow-up screening survey was performed on 316 VDT workers, and the results were compared with the previous data.

RESULTS

Compared with the initial survey, pain intensity was significantly decreased in the neck area; pain duration and frequency were significantly decreased in the low back area; and pain duration, intensity, and frequency were significantly decreased in the shoulder and wrist after tailored rehabilitation education. In addition, pain duration, intensity, and frequency showed a greater significant decrease after tailored rehabilitation education in the mild pain group than in the severe pain group.

CONCLUSIONS

This study found that work-related musculoskeletal pain was reduced after tailored rehabilitation education, especially in the shoulder, wrist, and low back.

Effects of lidocaine, ketamine, and remifentanil on withdrawal response of rocuronium

BACKGROUND

Rocuronium has been well known to produce withdrawal response in 50-80% patients when administered intravenously. Several drugs are administered prior injection of rocuronium to prevent the withdrawal response. We compared the preventive effect of lidocaine, ketamine, and remifentanil on the withdrawal response of rocuronium.

METHODS

A total of 120 patients undergoing various elective surgeries were enrolled. Patients were allocated into 4 groups according to the pretreatment drugs (Group N, normal saline; Groups L, lidocaine 40 mg; Group K, ketamine 0.5 mg/kg; Group R, remifentanil 1 µg/kg). Patients received drugs prepared by dilution to 3 ml volume before injection of rocuronium. Withdrawal responses after injection of rocuronium were graded on a 4-point scale. Hemodynamic changes were observed before and after administration of pretreatment drugs and after endotracheal intubation.

RESULTS

Incidence of withdrawal response was significantly lower in group L (20%), group K (30%), and group R (0%), than group N (87%). Severe withdrawal response was observed in 5 of the 30 patients (17%) in group L, and in 9 of the 30 patients (30%) in group K. There was no severe withdrawal response in group R. Mean blood pressure and heart rate were significantly decreased in group R compared to other groups.

CONCLUSIONS

It seems that remifentanil (1 µg/kg intravenously) was the strongest and most effective in prevention of withdrawal response after rocuronium injection among the 3 drugs.

Analgesic effect of low dose subcutaneous ketamine administration before and after cesarean section

BACKGROUND

Pain is considered as an importantissue after cesarean section. Multimodal approach to post cesarean pain management may not only enhance analgesia but also reduce side effects after the surgery.

OBJECTIVES

This study was aimed to evaluate the clinical efficacy of subcutaneous injection of low dose ketamine at the incision site to reduce cesarean section pain.

PATIENTS AND METHODS

Sixty patients, aged between 18 and 25 years old, scheduled for elective cesarean section, were enrolled to this double-blind randomized controlled trial study. Patients were divided into three groups of 20 patients each group one (k-pre) received 0.5 mg/kg ketamine before skin incision and normal saline after skin closure, group two (k-post) received normal saline before skin incision and 0.5 mg/kg ketamine after skin closure and group three (C) received normal saline before skin incision and after skin closure; subcutaneously at the incision site. The first analgesic request, the amount of analgesic and the pain intensity were evaluated for 24 hours.

RESULTS

The first time analgesic requested was longer and the amount of analgesic used during the first 24 hours was significantly lower in groups K-pre and K-post compared with group C (P < 0.05). Pain intensity was significantly lower at 2, 4, 6 and 12 hours in groups K-pre and K-post compared with group C (P < 0.05). Nevertheless, pain intensity was not significantly different at 18 and 24 hours in group C (P > 0.05). The first requested time, total used amount of analgesicand pain intensity were not meaningfully different in K-pre and K-post groups (P > 0.05).

CONCLUSIONS

Patients who were given ketamine before or after cesarean section subcutaneously at incision site had lower pain intensity and less analgesic consumption than patients who were given placebo.

Intravenous lidocaine pretreatment with venous occlusion for reducing microemulsion propofol induced pain: Comparison of three doses of lidocaine

Objective

Pretreatment with intravenous 40 mg or 0.5 mg/kg lidocaine with venous occlusion is recommended to prevent pain following injection of lipid emulsion propofol. This approach is not sufficient to prevent pain from the injection of microemulsion propofol. The present study investigated whether a higher dose of lidocaine pretreatment with venous occlusion would be more effective for reducing pain following injection of microemulsion propofol compared with 40 mg lidocaine.

Methods

Patients undergoing elective surgery were randomly assigned to one of three groups: pretreatment with 40 mg (group L40), 60 mg (group L60) or 80 mg (group L80) lidocaine intravenously with venous occlusion, followed by injection with microemulsion propofol 1 min later. Pain was assessed on a four-point scale (severe, moderate, mild, none) based on physical responses to the injection.

Results

A total of 68 patients were included in the final analysis. Pain severity and incidence were significantly lower in patients in group L60 and L80 compared with patients in group L40. There were no statistically significant differences in pain incidence or severity between group L60 and group L80.

Conclusions

Pretreatment with 60 mg lidocaine intravenously with venous occlusion may be the most effective minimum dose for reducing injection pain following microemulsion propofol administration for induction of anaesthesia.

A prospective, randomized, double-blind study to compare the efficacy of lidocaine + metoclopramide and lidocaine + ketamine combinations in preventing pain on propofol injection

PURPOSE

Propofol injection is known to cause distressing pain, and various methods have been used to decrease this pain. We investigated the efficacy of the lidocaine + metoclopramide and lidocaine + ketamine combinations on modulating propofol injection pain.

METHODS

Ninety ASA I/II patients aged 20-60 years were randomly assigned to three groups to receive lidocaine 20 mg (group L), lidocaine 20 mg + metoclopramide 10 mg (group LM), or lidocaine 20 mg + ketamine 5 mg (group LK), respectively, with venous occlusion for 1 min using a forearm tourniquet. Propofol 0.5 mg/kg was subsequently administered into a dorsal hand vein, and pain was assessed during its injection using a verbal rating score. The results were analyzed statistically with analysis of variance, the chi-square test, and the Wilcoxon rank sum test, where appropriate. The significance level was set at p < 0.05.

RESULTS

The incidence of pain was rated to be significantly less in patients in groups LM (40 %) and LK (6.7 %) than in those in group L (83.3 %) (p = 0.001 and p < 0.001, respectively). The pain score [median (range)] was also significantly less in patients in groups LM [0 (0-3)] and LK [0 (0-2)] than in those in group L [2 (0-3)] (p = 0.001 for both groups).

CONCLUSION

The lidocaine-ketamine combination is most effective for decreasing the pain on propofol injection.

Single pretreatment of remifentanil may reduce pain after propofol and rocuronium injection in rapid sequence induction

Background

We designed this double-blind, placebo-controlled study to compare the efficacy of remifentanil in reducing the pain of both propofol and rocuronium injection during rapid-sequence induction.

Methods

Ninety-five patients, scheduled for elective surgery under general anesthesia, were divided into 3 groups: saline (Group S, n = 31), remifentanil 1 µg/kg (Group R, n = 32), and lidocaine 1.5 mg/kg (Group L, n = 32) were administered after tourniquet application. The occlusion was released after 1 min and 5 ml of 1% propofol was injected over 10 s. Pain on propofol injection was evaluated by a 10-point verbal numeric rating scale (VNRS). The rest of the induction dose of propofol and 1 mg/kg of rocuronium, were injected. Pain on rocuronium injection was evaluated by a four-point score (FPS).

Results

The VNRS of propofol injection was as follows: R (0.78) = L (1.34) < S (4.26). The incidence of withdrawal response due to rocuronium was as follows: R (6.3%) < L (53.1%) < S (83.9%). The FPS of rocuronium injection was as follows: R (0.81) < L (1.78) < S (2.93).

Conclusions

Pretreatment with a bolus of remifentanil was effective in simultaneously reducing injection pain of propofol and rocuronium. In addition, remifentanil pretreatment was more effective in suppression of withdrawal response by rocuronium than lidocaine.

Reduction of microemulsion propofol-induced injection pain via target-controlled remifentanil infusion

The intravenous injection of microemulsion propofol to induce anaesthesia causes more intense and frequent pain than lipid emulsion propofol. This study investigated whether different target effect-site concentrations of remifentanil could prevent pain due to microemulsion propofol injection. In total, 96 patients were randomly assigned to one of three groups receiving target effect-site concentrations of remifentanil 0 (control group), 4 or 6 ng/ml, followed by injection with microemulsion propofol. Remifentanil pretreatment significantly reduced the incidence and severity of injection pain compared with the control group. Although no difference in pain reduction between the two remifentanil-treated groups was observed, those receiving a target effect-site concentration of 6 ng/ml exhibited an increased rate of complications, compared with those receiving 4 ng/ml. In conclusion, prior administration of remifentanil at a target effect-site concentration of 4 ng/ml is a useful strategy to decrease the injection pain of microemulsion propofol.

Preincisional administration of intravenous or subcutaneous infiltration of low-dose ketamine suppresses postoperative pain after appendectomy

BACKGROUND

Ketamine, an N-methyl-D-aspartate receptor antagonist, can suppress hyperalgesia and allodynia. The purpose of the present study was to evaluate the clinical efficacy of preincisional intravenous or subcutaneous infiltration of ketamine for postoperative pain relief after appendectomy.

METHODS

Ninety patients, aged 18-60 years, scheduled for appendectomy was enrolled in this study. Patients were divided into three groups of 30 each and received subcutaneous infiltration of ketamine 0.5 mg/kg (KS), intravenous ketamine 0.5 mg/kg (KI), or subcutaneous infiltration of normal saline 3 mL (C) before surgery. Visual analog scale (VAS) values and analgesic consumption were evaluated for 24 hours after surgery.

RESULTS

VAS scores were significantly lower at the time of arrival in the recovery room, and at 10, 20, and 30 minutes thereafter in group KI and group KS compared with group C (P < 0.05). VAS scores were not significantly different between group KI and group KS at these intervals. Postoperative VAS scores were significantly lower at 6, 12, 18, and 24 hours in group KI compared with group C (P < 0.05). In group KS, the postoperative VAS score was significantly lower at 6 hours (P < 0.05). VAS scores were significantly lower at 12, 18, and 24 hours after surgery in group KI compared with group KS (P < 0.05).

CONCLUSION

A 0.5 mg/kg dose of ketamine given at approximately 15 minutes before surgery by the intravenous route provided analgesia for 24 hours after surgery in patients undergoing appendectomy.