RevBrasAnestesiol.2015;65(6):466---469
REVISTA
BRASILEIRA
DE
ANESTESIOLOGIA
OfficialPublicationoftheBrazilianSocietyofAnesthesiologywww.sba.com.br
SCIENTIFIC
ARTICLE
To
study
the
effect
of
injection
dexmedetomidine
for
prevention
of
pain
due
to
propofol
injection
and
to
compare
it
with
injection
lignocaine
Manisha
Sapate
∗,
Ujjwala
Andurkar,
Mugdha
Markandeya,
Rajesh
Gore,
Widya
Thatte
DepartmentofAnaesthesiology,YCMHospital,Pimpri,Pune,India
Received10July2013;accepted17October2013 Availableonline11November2013
KEYWORDS
Pain; Phenol; Propofol;
Dexmedetomidine; Lignocaine
Abstract
Background: Painduetoinjectionpropofolisacommonproblem.Differentmethodsareusedto decreasethepainbutwithlimitedsuccess.Theobjectiveofthisstudywastoassesstheeffect ofinjectiondexmedetomidine0.2mcg/kgforpreventionofpainduetopropofolinjectionand compareitwithinjectionlignocaine0.2mg/kg.
Method: AftertakingpermissionoftheInstitutionalEthicalCommittee,writteninformed con-sentwasobtainedfromallpatients,inarandomizedprospectivestudy.60AmericanSociety ofAnesthesiology IandII patients ofage range20---60 years ofeither sex postedfor elec-tivesurgeries undergeneralanaesthesiawere randomlyallocated intotwo groups. GroupI (dexmedetomidinegroup):Inj.dexmedetomidine0.2mcg/kgdilutedin5mLnormalsalineand Group II (lignocainegroup): Inj.lignocaine0.2mg/kgdiluted in 5mL normalsaline.IV line was secured with20Gcannula andvenousocclusion wasapplied to forearmusinga pneu-matic tourniquet and inflated to70mm Hgfor 1min. Study drug was injected, tourniquet releasedandthen25%ofthecalculateddoseofpropofolwasgivenintravenouslyover10s. After10sofinjection,severityofpainwasevaluatedusingMcCrirrickandHunterscaleand thenremainingpropofolandneuromuscularblockingagentwasgiven.Endotrachealintubation wasdoneandanaesthesiawasmaintainedonO2,N2Oandisofluraneonintermittentpositive pressureventilationwithBain’scircuitandinj.vecuroniumwasusedasmusclerelaxant.
Results:Demographic data showed that there was no statistically significant difference betweenthe2groups.Therewas nostatisticallysignificantdifferencebetween2groupsin respecttoinj.propofolpain.Noadverseeffectslikeoedema,pain,whealresponseatthesite ofinjectionwereobservedinthetwogroups.
©2013SociedadeBrasileiradeAnestesiologia.PublishedbyElsevier EditoraLtda.Allrights reserved.
∗Correspondingauthor.
E-mail:manisha.sapate@gmail.com(M.Sapate).
Dexmedetomidineforpropofolpainandcomparisonwithlignocaine 467
PALAVRAS-CHAVE
Dor; Fenol; Propofol;
Dexmedetomidina; Lidocaína
Avaliac¸ãodoefeitodedexmedetomidinanaprevenc¸ãodadorrelacionadaàinjec¸ão depropofolecomparac¸ãocomoefeitodainjec¸ãodelidocaína
Resumo
Justificativaeobjetivo: Adorrelacionadaàinjec¸ãodepropofoléumproblemacomum. Méto-dosdiferentessãousadosparadiminuí-la,mascomsucessolimitado.Oobjetivodesteestudofoi avaliaroefeitodadexmedetomidina(0,2mcgkg−1)naprevenc¸ãodadorrelacionadaàinjec¸ão depropofolecompará-locomlidocaína(0,2mgkg−1).
Método: DepoisdapermissãodoComitêdeÉticaInstitucional,aassinaturadotermode consen-timentoinformadofoiobtidadetodososparticipantesdesteestudoprospectivoerandomizado. SessentapacientescomestadofísicoASAI-II,idadesentre20-60anos,deambosossexose programadospara cirurgiaseletivassobanestesia geralforamrandomicamentealocadosem doisgrupos:GrupoI(dexmedetomidina)recebeuinjec¸ãodedexmedetomidina(0,2mcgkg−1) diluídaem5mLdesoluc¸ãosalinanormaleGrupoII(lidocaína)recebeuinjec¸ãodelidocaína (0,2mgkg−1)diluídaem5mLdesoluc¸ãosalinanormal.OacessoIVfoiobtidocomumacânulade calibre20Geaoclusãovenosaaplicadanoantebrac¸ocomousodeumtorniquetepneumático einfladoa70mmHgduranteumminuto.Osmedicamentosemestudoforaminjetados,o torni-quetefoiliberadoe,emseguida,25%dadosecalculadadepropofolfoiadministradaporvia intravenosadurante10segundos.Após10segundosdeinjec¸ão,aintensidadedadorfoi avali-adacomousodaescaladeMcCrirrickeHuntere,emseguida,orestantedopropofoleum agentebloqueadorneuromuscularforamadministrados.Aintubac¸ãoendotraquealfoifeitaea anestesiamantidacomO2,N2Oeisofluranoemventilac¸ãocompressãopositivaintermitente, comocircuitodeBaineusodevecurôniocomorelaxantemuscular.
Resultados: Osdadosdemográficosmostraramquenãohouvediferenc¸aestatisticamente sig-nificanteentreosdoisgrupos.Nãohouvediferenc¸aestatisticamentesignificanteentreosdois gruposemrelac¸ãoàdorrelacionadaàinjec¸ãodepropofol.Nãohouveefeitosadversos,como edema,dorepápulanolocaldainjec¸ãonosdoisgrupos.
©2013SociedadeBrasileira deAnestesiologia.PublicadoporElsevierEditoraLtda.Todosos direitosreservados.
Introduction
Painisanunpleasantsubjectivesensationwhichisvery
dis-tressingtothe patient.Pain oninjection withpropofolis
a common problem.1,2 It is due to phenol group present
in propofol. Phenol group is irritating to skin, mucous
membrane and venous intima. In the absence of
treat-mentregimens,28---90%ofpatientsexperiencemoderateto
severepainwhenpropofolisinjectedintoperipheralvein.1
Variousmethodshavebeenusedtodecreasetheseverityof
painlikeNitroglycerineointmentattheinjectionsite,
dilut-ingpropofolwith5%dextroseorintralipid,inj.ondensetron
oropioidssuchasfentanyl,NSAIDs.IntravenousLignocaine
isthemostcommonlyusedpre-treatmenttoreducethepain
causedbyinj.propofol.Itisdefinitelyeffectivebutitalso
hasafailurerateof13---32%.3,4
Dexmedetomidine is a highly selective, specific and
potentalpha-2adrenoreceptoragonist.Itisapotent
anal-gesic,sedative,alongwithsympatholyticeffect.Inaddition,
it has supraspinal, spinal and peripheral action. Alpha
2-adrenoreceptors located on blood vessels inhibit
nor-epinephrinerelease,resultinginreleaseof prostaglandins
andcausevasodilationthatantagonizethevenoconstrictor
response.5 Dexmedetomidine has been shown to promote
peripheral antinociception.6 Therefore dexmedetomidine
can also be used for relief of propofol pain. Lignocaine
is a time tested local anaesthetic belonging to the ester
group.
Inthepresentstudy,weplantoinvestigatetheeffectof
inj.dexmedetomidineforpreventionof propofolinjection
painandcompareitwithinj.Lignocaine.
Methods
Thestudywasconductedafterobtainingtheapprovalfrom
institutional ethical committee. A written and informed
consentwasobtained fromall patients. 60patients were
includedinourstudy.Allthesepatientsbelongedto
Amer-icanSocietyofAnesthesiology(ASA)gradeIorII andwere
posted for elective surgery under General Anaesthesia.
Thoroughpreoperativeevaluationwasdone.Patientswere
keptfastingfor6h.Randomizationwasdoneinto2groups
bydoubleblindmethod.GroupI(dexmedetomidinegroup)
inwhichinj.dexmedetomidine0.2mcg/kgdilutedin5mL
normalsalineandGroupII(lignocainegroup)inwhichinj.
Lignocaine 0.2mg/kg diluted in 5mL normal saline were
given.
Exclusioncriteriafor thisstudywerepatientsunwilling
forthetrial, thoserequiringrapidsequenceinductionand
thosewithanticipateddifficultyinvenousaccess.
On arrival of patient to the operation theatre, a 20G
intravenous cannula was inserted in a prominent vein on
dorsum of non-dominant hand. All monitors like
electro-cardiogram,non-invasivebloodpressureandpulseoximeter
468 M.Sapateetal.
Table1 McCrirrickandHunterScaleforevaluationofpain.
Degreeofpain Response
None(0) Noresponsetoquestioning Mild(1) Painreportedinresponseto
questioningonlywithoutany behaviouralsigns
Moderate(2) Painreportedinresponseto questioningandaccompanied bybehaviouralsignsorpain reportedspontaneously withoutquestioning Severe(3) Strongvocalresponseor
responseaccompaniedby facialgrimacing,arm withdrawalortears
sameupperarmwithpressureinflatedto70mmHgto
pro-ducevenousocclusion.
The study drugs were preservative free and kept at
room temperature. Each of the study drug was prepared
by independent Anaesthesiologists into 5mL volume. The
tourniquetwasinflatedfor1minandstudydrugweregiven
intravenouslyover5sandthentourniquetwasreleased.25%
ofthecalculateddoseofpropofolwasgivenintravenously
over 10s. After 10s severityof painwas evaluated using
McCrirrickand Hunter Scale2 (Table 1)which wasalready
explained to the patient. Then remaining propofol and
neuromuscularblockingagent(inj.vecuronium0.08mg/kg)
weregiven&endotrachealintubationweredonewith
appro-priatesizetube.AnaesthesiawasmaintainedwithO2,N2O
andIsofluraneonintermittentpositivepressurewithBain’s
circuitandInjVecuroniumwasusedasmusclerelaxant.
Statisticalanalysis
AnalysiswasperformedusingtheprogramSPSS(Statistical
PackageForSocialServices)versionforwindows.Thedata
werereportedasamean±SD,medianandnumbers(%)as
0 10 20 30 40 50 60 70
Group I Group II
Age Sex Weight
Figure1 Demographicdata.Table2showsoverallincidence and severity of pain after injection of propofol in the two groups.
foundsuitable.Relationshipsbetweencategoricalvariables
were tested usingthe ChiSquare Test. Two sample t-test
wasusedforcomparisonofnormallydistributedcontinuous
variablesbetweenthetwogroups.pValuemorethan0.05
wasconsideredasstatisticallysignificant(Fig.1,Table2).
Results
Fifteenpatients(50%)inGroupIandeighteenpatients(60%)
inGroupIIhadnopainoninj.propofol.Ninepatients(30%)
indexmedetomidinegroupandeightpatients(27%)in
ligno-cainegrouphadmildpain.Sixpatients(20%)inGroupIand
fourpatients(13%)inGroupIIhadmoderatepain(Table3,
Fig.2).Thestudyshowedthattherewasnodifferenceinthe
painscorewhichwasstatisticallysignificant.Nopatientin
thisstudyhadseverepain.Noadverseeffectslikeoedema,
pain,whealresponseatthesiteofinjectionwereobserved
inthestudy.
Discussion
Propofolinduced painisconsideredtobeoneof themost
importantproblemsofcurrentclinicalpractice.Itwasrated
Table2 Demographicdata.Thedemographicdatawerecomparedamongthetwogroups.
Demographicdata GroupI(dexmedetomidine) GroupII(lignocaine) pvaluea
Age(yr) 45.4±16.11 40.72±13.96 >0.05
Male/female 16/14 15/15 <0.05
Weight 57.92±8.41 61.88±5.91 <0.05
Therewasnosignificantstatisticaldifferenceamongthe2groupsinrelationtotheweightandsexexcepttheageparameterwhichwas clinicallyinsignificant(Fig.1).
apvalue---probability/testofsignificance.
Table3 Severityofpainscore.
Painscore GroupI(dexmedetomidine) GroupII(lignocaine) pvaluea
None(0) 15(50%) 18(60%) <0.005
Mild(1) 9(30%) 8(27%) <0.005
Moderate(2) 6(20%) 4(13%) <0.005
Severe(3) 0 0
Dexmedetomidineforpropofolpainandcomparisonwithlignocaine 469
0 2 4 6 8 10 12 14 16 18 20
Number of patients
none mild moderate severe
Pain Score Distribution of severity of pain
Gr-I Gr-II
Figure2 Severityofpainscore.
astheseventhmostdisturbingexperiencetothepatientin
anaesthesiapracticebyagroupofexperts.7Natureofthe
vascularpainisexpressedbythepatientsasaching,
burn-ingandcrushing.Inj.propofolhasaphenolgroupwhichis
irritating toskin, mucous membrane and venous intima.8
Mechanismofimmediatepainis duetoirritationof
affer-entnerveendingswithinthevein.Scottetal.3speculated
that mechanism of the delayed pain is due toactivation
ofkallikrien---kinin systemby propofol,therebygenerating
kinin, probably bradykinin. It produces local vasodilation
andhyperpermeability.Itincreasescontactbetween
propo-foland freenerveendingsresultinginpainoninjection.9
Theuseofadjuvantmedication beforepropofoltoreduce
thepainofinjectionhasbecomeacommonpractice.
The 0.2mcg/kg dexmedetomidine dose was chosen
accordingtoastudyofMemisetal.10wheretheycompared
0.1mcg/kgand0.2mcg/kgdexmedetomidinefordecreasing
rocuroniuminjectionpainandtheyconcludedthatthelatter
dosewasmoreeffective.
Ayogluetal.11intheircomparativestudyof
dexmedeto-midinewithlignocainefortheireffectonreducingpropofol
androcuroniuminjectionpainconcludedthat
dexmedeto-midine failed to decrease propofol injection pain but
reducedrocuroniumwithdrawalmovement.
Comparison of 0.2mcg/kg of dexmedetomidine with
placeboforpropofolpainwasstudiedbyUzunetal.12who
concludedthatinjectionofdexmedetomidinebefore
propo-folwasfoundtobemoreeffectivethaninjectionofnormal
salineinalleviatingpropofolinjectionpain.
Alpha 1- and alpha 2-stimulation might be a
possi-ble mechanism involved in decreasing propofol injection
painandresultinginreleaseofprostaglandinswhichcause
vasodilationthatantagonizevenoconstrictorresponse.This
modulates the sympathetic response of venous smooth
muscle and may be important in endothelial dysfunction
caused by propofol.13 This might bethe basic mechanism
of action with dexmedetomidine as it is highly potent
alpha2adrenoreceptor agonist.Anothermechanism might
behyper-polarisationactivatedconductanceinperipherally
mediatedantinociception.
Mechanismofactioninlignocaineforpropofolpainrelief
isduetolocalanaestheticeffectwhichcausesaninhibitory
effectontheenzymaticcascadeleadingtoreleaseofkinin.
Conclusion
Inj.Dexmedetomidineisequallyeffectiveandcanbeusedas
analternativetotimetesteddruginj.Lignocaineforrelief
ofpainduetopropofolinjectionwithoutanysignificantside
effects.
Conflict
of
interest
Theauthorsdeclarenoconflictsofinterest.
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