Teaching Points: Propofol and Lidocaine

[epidural man]

Draw up 40mg lido in 200mg PPF. I tell the pt you might feel a warm feeling in your IV, it may even sting. If it hurts, I push and flush faster.

I tell them "you'll feel some sunshine in your arm..."

I imagine with the little versed, that might be a cool mental picture

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[turkeyjerky]

I tell them "you'll feel some sunshine in your arm..."

I imagine with the little versed, that might be a cool mental picture

it'd be a lot cooler w/ ketamine

 

[Gasser1]

this works well in my practice.....however no mention about "shaking well before using"...most of my peers are not doing this (can't read maybe)...is the unshaken drug more or less irritating ?

 

[Gasser1]

I had one attending (very ANA L) tell me that she mixed 50 mg (5 ml) of 1% lidocaine and 50 mg (5 ml) of propofol ina 10 cc syringe. She first injected this and then the remaining does of propofol(plain). She said that she heard it in a meeting .... somewhere....

Initially I thought that it was bogus because it just did not make sense. Still tried it about a year ago and sice then have never had any patient complain. It does not matter how small the vein is etc etc.... no pain during injection or recall of pain in PACU.

Again, I do not have answers regarding pH etc.... but this has really worked for me.

Let me know what you guys think

I have been using this method for over a year, it's very effective. However, smokers seem to be more sensitive to the discomfort of propofol. I am one of a few anesthetists that actually SHAKE WELL BEFORE USING the propofol , as printed in red on the bottle.

 

[anes]

At my home institution there seems to be some debate regarding the use of Lidocaine before or combined with Propofol during induction. There seems to be general agreement that lidocaine (as well as Fentanyl) is used for blunting the sympathetic response and maintaining more steady pulse and blood pressures. The debate is whether to give Lidocaine mixed with Propofol or Lidocaine then propofol.

I am interested in hearing people's experiences and thoughts but particularly anything evidenced based. The article below was mentioned by a faculty member as one of the few pieces of evidence they were aware of and is for your enjoyment and discussion.

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Anaesth Intensive Care. 2004 Aug;32(4):482-4.
Preventing pain on injection of propofol: a comparison between lignocaine pre-treatment and lignocaine added to propofol.

A randomized double-blind study compared two methods of preventing the pain from injection of propofol, lignocaine pre-treatment followed by propofol and lignocaine added to propofol. One hundred patients received a 4 ml solution intravenously with a venous tourniquet for 1 minute, followed by propofol mixed with 2 ml of solution. Patients were divided into two treatment groups of 50 patients each: 4 ml 1% lignocaine pre-treatment followed by propofol and 2 ml saline, or 4 ml saline followed by propofol and 2 ml 2% lignocaine. Pain was assessed with a 100 mm visual analogue scale after induction and in recovery. The incidence of injection pain was 8% in the propofol mixed with lignocaine group, and 28% in the lignocaine pre-treatment group. This difference is statistically significant (P=0.017). For those patients who had pain, the mean pain score was 26.5 on induction for the propofol with lignocaine group (n =4), while the mean score was 44.4 for the pre-treatment group (n=13). The difference was not statistically significant (P=0.25). None of the propofol mixed with lignocaine group recalled pain, while 13 of the pre-treatment group did so. Lignocaine pre-treatment does not improve the immediate or the recalled comfort of patients during propofol induction when compared to lignocaine added to propofol. It is recommended that lignocaine should be added to propofol for induction rather than given before induction.

I give lidocaine before ppf. There is some theoretical concern of mixing the two in the same syringe which may result in pulmonary embolism. May not be a.real threat, but I see no benefit.to giving them in same syringe.

 

[narcusprince]

A couple of things I have noticed from my practice. I used to give 2-3ml of IV propofol in patients once wheeling them from the preop room into the OR. I would routinely mix the lidocaine 20mg of lidociane with the propofol the patients never complained of burning. Interestingly it worked well for semi-anxious people. What it did make uncomfortable are the OR nurses seeing that patients were given IV propofol while coming to the OR. The rare time I see burning from the Propofol was when using smaller IV's 20,22 guage IV's in distal veins patients usually complained of burning even when lidociane was given before in a semi bier block fashion. AC veins with IV propofol patients rarely complain of burning.

 

[Gas you down]

I read on this forum several years ago, to mix 5cc propofol with 5 cc 2% lido, then push rest of propofol.
in 3 years since, I have had exactly 2 pts complain, both of which had the tiniest veins imaginable. my nurses are now believers as well....

 

[chfo]

I believe it's the desensitization of veins to a very small amount of propofol.

My usual is 5cc lido 1% followed by 1cc 1% propofol. Let that run in for 30 seconds. Then bolus rest of propofol at whatever rate you want.

Zero complaints.

 

[chocomorsel]

Well, gonna try this pre treatment with propofol tomorrow. See how it works.

 

[dhb]

20mg of lidocaine is enough mixed in with the propofol

 

[Sublimazing]

On adult patients this was never an issue...but on pediatric patients it was very problematic...the patient would be sedated on a ketamine cocktail IM injection during which time I would start the IV (and i will admit just about all of my IVs were 22-24g in the hand since these kids were mostly 1.5-2.5 yo and that was my most reliable combo for me)...the patient would be mostly compliant during the IV and positioning, but upon pushing the propofol it would burn the heck out of them, they would retract their arm (kinking my access preventing them from getting an induction dose) and simultaneously hold their breath as they tach'd up to 150+ from pain/ketamine/glyco causing a very very quick desat. I was always hesitant to use IV lidocaine since these were mostly dental cases where local was going to be administered by the surgeon.

My solution was...additional ketamine IV before the propofol to take them deeper. It worked very well since i always had ketamine left over from the dart, and they stayed spontaneous while i could continue to push meds and get my tube ready

On adults...18g in the ACF...versed/fentantyl/lido...then prop pushed slowly, rarely did i see any discomfort

 

[narcusprince]

I have also found that giving patients realistic expectations about that its quite possible you may feel some warmth or slight burning decreases their reaction to IV propofol. I have seen providers not tell the patient that it will burn and it scare the heck out of the patient. Probably contributing to a negative experiance with anesthesia. Incidentally I have found telling the patients that they are going to wake up with a tube in place and that after they follow "simple commands" the tube comes out smooths out my extubations. Some times we have to be part-psychiatrist too, but only for 5 minutes

 

[deleted162650]

In residency we would always give ~1-1.5mg/kg lido first followed by the propfol (sometimes with the pseudo bier-block depending on attending) and a significant proportion of pts still c/o burning with the prop. Somewhere towards he end of my training (maybe it was on this site) I saw an article which showed that lido mixed with prop causes less burning than when given separately. So when I started PP, I started adding Lido to my prop. I just draw up 18ish mL's of prop in a 20cc syringe and then max out the rest of the syringe with 2% lido (prob about 3-4mL's). I've done this for virtually every case over the last 1.5 yrs and I can think of only 1 pt that had any notable discomfort with the propofol.

I'm sure the whole pre-treatment with lido/baby dose prop works too but that's about 3 more steps than I want to add to my induction sequence. KISS.

 

[Spinach Dip]

I have also found that giving patients realistic expectations about that its quite possible you may feel some warmth or slight burning decreases their reaction to IV propofol. I have seen providers not tell the patient that it will burn and it scare the heck out of the patient.

As someone who has been under the knife more than my fair share in the past couple years, I can attest to this. Some patients are also more sensitive to propofol (I'm apparently one of these).

in 3 years since, I have had exactly 2 pts complain, both of which had the tiniest veins imaginable. my nurses are now believers as well....

I'm not doubting your expertise, but I wonder if these complaints were made during induction, or if you asked after the patient woke up?

 

[Spinach Dip]

Incidentally I have found telling the patients that they are going to wake up with a tube in place and that after they follow "simple commands" the tube comes out smooths out my extubations.

What? You find TALKING to your patients to be USEFUL? Bizarre.



Sarcasm aside, I can handle being intubated. Been there. Seriously. Words fail to describe how aggravating the experience is, but it is 100x preferable to aspiration pneumonia. Nothing can completely alleviate the experience (except, perhaps, a few mg of versed given during emergence (but that's counter-productive)), but some warning ahead of time can give the patient some time to prepare mentally for what is to come.

Of course, in a perfect world, the tube would always come out before the patient's memory-forming centers are completely operational, but you cannot always control what a patient will or will not remember.