Substitute for IV Lidocaine Prior to Propofol

[Aether2000]

IV lidocaine is no longer available in my hospital due to national shortages. We frequently used this prior to propofol (I do it as a mini-Bier block over 60 seconds) to reduce the incidence of severe propofol-injection pain. We also have shortages of ketamine and remifentanil so those are not available. We have developed a list of alternatives as below- do you have others?
1. Increase fentanyl dosage pre induction 2-4 min prior to the propofol
2. Use 50% nitrous oxide for a minute before propofol
3. Use a larger vein esp. an antecubital vein
4. Use higher dosage of midazolam so the screams will not be remembered
5. Chloroprocaine prior to propofol
6. Etomidate instead of propofol

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[Ronin786]

Etomidate burns just as bad as propofol.

Seems like way too much trouble for something that isn't always remembered. If you're that concerned, just dilute 30mg of propofol in a 20cc syringe and push that upfront as an amnestic.

 

[dchz]

I am in the school that IV lido prior to propofol is BS. So just don't use it anymore.

Also 50 mcg of fent before monitors hook up is way more effective than lidocaine at attenuating the burning.

 

[deleted171991]

I am in the school that IV lido prior to propofol is BS. So just don't use it anymore.

You must have not been my patient then. More than 90% of them would disagree.

 

[cockblockandrun]

I haven't used lidocaine with propofol in over 5 years.

I tell the patients the burn will go away in 10 seconds and let the prop do its job. Plus I also crank up some sevo which also doubly serves as a distraction!

 

[deleted162650]

8% Sevo

 

[drmwvr]

bupivicaine

 

[Psai]

Iv bupi

 

[deleted59964]

toughen up buttercup

sux, tube, prop

givem something to cry about

 

[siliso]

Propofol infusion with no lido (and no other pre/concurrent med either) is one of my top 2 agonizing/traumatic painful experiences of life...and I have experienced unmedicated 48h labor and childbirth. In fact I was in active labor (different kid) at the time of the propofol infusion and the sensation of having my arm set on fire and dying was far worse and more memorable than any other pain going on at the time, Do something, for mercy’s sake.

 

[nimbus]

Propofol infusion with no lido (and no other pre/concurrent med either) is one of my top 2 agonizing/traumatic painful experiences of life...and I have experienced unmedicated 48h labor and childbirth. In fact I was in active labor (different kid) at the time of the propofol infusion and the sensation of having my arm set on fire and dying was far worse and more memorable than any other pain going on at the time, Do something, for mercy’s sake.

Why in the world did they give you a propofol infusion during active labor?

 

[Psai]

Propofol infusion with no lido (and no other pre/concurrent med either) is one of my top 2 agonizing/traumatic painful experiences of life...and I have experienced unmedicated 48h labor and childbirth. In fact I was in active labor (different kid) at the time of the propofol infusion and the sensation of having my arm set on fire and dying was far worse and more memorable than any other pain going on at the time, Do something, for mercy’s sake.

None of this makes sense

 

[pgg]

Propofol infusion with no lido (and no other pre/concurrent med either) is one of my top 2 agonizing/traumatic painful experiences of life...and I have experienced unmedicated 48h labor and childbirth. In fact I was in active labor (different kid) at the time of the propofol infusion and the sensation of having my arm set on fire and dying was far worse and more memorable than any other pain going on at the time, Do something, for mercy’s sake.

That's a very odd story. Never in my life have I ever seen or heard of someone getting a propofol infusion during labor.

 

[Robotic Wis-Hipple]

IV lidocaine is no longer available in my hospital due to national shortages. We frequently used this prior to propofol (I do it as a mini-Bier block over 60 seconds) to reduce the incidence of severe propofol-injection pain. We also have shortages of ketamine and remifentanil so those are not available. We have developed a list of alternatives as below- do you have others?
1. Increase fentanyl dosage pre induction 2-4 min prior to the propofol
2. Use 50% nitrous oxide for a minute before propofol
3. Use a larger vein esp. an antecubital vein
4. Use higher dosage of midazolam so the screams will not be remembered
5. Chloroprocaine prior to propofol
6. Etomidate instead of propofol

1. At my shop, and I’m assuming many others will move that way in the near future, there’s a huge push, bordering on mandate to remove fentanyl from our anesthetic completely (reactionary imo but it is what it is). So increasing or giving the evil fentanyl for reduction in propofol pain just isn’t in the cards.

2. Nitrous? Sure, I guess. Not sure I think the propofol pain has a high enough incidence to make me nitrous everyone.

3. I hate AC PIVs, and this just isn’t a reliable requirement to place on my preop nurses.

4. Versed? See #1

5. Sure. Though I’ve never heard of it for this. And the lidocaine is only minimally effective anyway (though it serves another purpose during induction) But I’d listen to those that had tried this.

6. There’s not many reasons I’d give etomidate to anyone, this is not one of those reasons by a long shot. Plus, as mentioned, it burns too.

I find, a little verbal Anesthesia in preop, especially in the patients that find it abhorrent you have to put in an IV while they’re awake, is pretty good. We’re talking about adults here.

But this brings up an annoying daily trend for us these days in the drug shortages. If I’m told to avoid fentanyl and versed, remi imo is probably the most likely to cause hyperalgesia postop so I rarely use it, and then ketamine and lidocaine are on such shortage I can’t use 5cc’s of lidocaine with induction, wtf am I supposed to do? Blocks of course, but those aren’t logistically feasible or possible for all cases, and Mg and Tylenol will only get you so far. I’ll be shocked if Mag doesn’t join this shortage list this year.

 

[Robotic Wis-Hipple]

None of this makes sense

Active labor = emergent crash section without neuraxial in place
Infusion = induction?

Otherwise, agree.

 

[bcat85]

“Alright. This one burns but you’ll be asleep in 10 seconds.”

 

[Hoya11]

IV lidocaine is no longer available in my hospital due to national shortages. We frequently used this prior to propofol (I do it as a mini-Bier block over 60 seconds) to reduce the incidence of severe propofol-injection pain. We also have shortages of ketamine and remifentanil so those are not available. We have developed a list of alternatives as below- do you have others?
1. Increase fentanyl dosage pre induction 2-4 min prior to the propofol
2. Use 50% nitrous oxide for a minute before propofol
3. Use a larger vein esp. an antecubital vein
4. Use higher dosage of midazolam so the screams will not be remembered
5. Chloroprocaine prior to propofol
6. Etomidate instead of propofol

Lots of docs that I trained with give nothing, I personally have found that I do see less complaints when I give the lido. If im in a hurry to do an induction do I stop and draw it up if its not already? No.

The bier block thing I find a little strange, just waiting and delaying induction, sure its not that long of a time, but probably not necessary may be viewed by your peers/surgeons as an odd technique and unnecessary delay.... do others do this?

1. 50 fent on induction should help, 100 for a painful case
2. No Nitrous as im not going to drop my FIO2 on induction to worry about their propofol burning
3. Yes if possible, but lots of hand IVs and Im not going to put the IV in the AC just to reduce propofol burning and it kinks after positioning
4. Yes midaz is always good IMO, but im not going to give a whopping dose and delay discharge for the burning either, im only giving 2-4 of midaz max for induction if im trying to get them to go home somewhat soon
5. Hard NO
6. No, as said etomidate burns also, and Im not going to give my patients an inferior induction agent (for healthy ppl) just to avoid the burning. I dont want the SBP 215 after intubation but hey possibly less burning on induction.

One additional thing that I think helps is to rub a little bit over the IV site.

And try to push the bolus fast by pulling back on the empty syringe after giving the ppfl and filling the syringe with saline from the bag and then pushing that saline bolus rapidly to flush the ppfl in.

I think the burning comes from the SLOW administration (infusion, or cuff is up, or small IV/vein) and the ppfl sits in the vein...

 

[deleted171991]

@algosdoc, I remember some legends that Zofran helps with propofol burn, too, just like lido.

Efficacy of ondansetron for the prevention of propofol injection pain: | JPR
Ondansetron Pretreatment to Alleviate Pain on Propofol... : Anesthesia & Analgesia

It seems that ondansetron has some LA activity.

Hat tip @Coastie.

 

[Aether2000]

Here is the URL of the venous occlusion study using lidocaine prior to propofol: Lidocaine for prevention of propofol injection-induced pain: A prospective, randomized, double-blind, controlled study of the effect of duration of... - PubMed - NCBI

It appears there are a number of other ways noted in the literature to decrease burning including cooling the site, heating the site, using a 5% lidocaine patch over the site, using Mg IV prior to lidocaine, etc.

 

[BLADEMDA]

@algosdoc, I remember some legends that Zofran helps with propofol burn, too, just like lido.

Efficacy of ondansetron for the prevention of propofol injection pain: | JPR
Ondansetron Pretreatment to Alleviate Pain on Propofol... : Anesthesia & Analgesia

It seems that ondansetron has some LA activity.

Zofran IV on backorder in many locations

 

[siliso]

Active labor = emergent crash section without neuraxial in place
Infusion = induction?

Otherwise, agree.

Yes, this is correct. Sorry for lapses in terminology, I’m nothing but a lowly internist who long ago had an emergent cesarean under general. While conscious and as yet without anesthesia or analgesia of any kind, received IV propofol, and the pain level in the arm was right about my personal 10 despite several other experiences acknowledged to be quite painful indeed. Was it so crash that nothing else could reasonably have been done, it was not: plenty other preparations were made despite urgency, it wasn’t some coding hysterotomy. Happily it all came out well in the end. My main point: it really ****ing hurts in an extremely memorable 13 yrs later kind of way, if you haven’t had the pleasure to experience yourself, and it would be kind if at all possible to mitigate.

 

[Gern Blansten]

With regards to nitrous, it seems that at a time when you are trying to maximally preoxygenate the patient, giving 60-70% nitrous would have the exact opposite effect. Very little gain but quite a bit lost in preoxygenation. I would not choose that method to treat a minor problem.
With regard to siliso's strange account, I would guess that she got propofol through a small IV on the same side as the BP cuff while it was cycling. People really tend to dislike that.
With regards to algo's technique, if you give it prior to applying all of the monitors, then it will be 30-60 seconds by the time you are ready for it, so no real slow down if you plan ahead. I don't do it, but I recall the study he posted and have long believed that this technique is likely the best for prevention of pain with injection.
It is purely anecdotal, but I would think diluting it with saline with 5 ml of propofol in a 20 cc syringe and injecting that prior to the undiluted one would ease the pain and stun them enough to not recall the rest.

 

[coffeebythelake]

Yes, nothing makes a grownass man scream like a little girl than propofol through a small hand IV while the blood pressure cuff is going up on that arm. I remember making that mistake as a resident. I' sure everyone has made that mistake at least once before

 

[anbuitachi]

It's a lot of money used for a 10 second potential pain relief

 

[Depakote]

“Alright. This one burns but you’ll be asleep in 10 seconds.”

I tell my patients "This one might burn a little. If it bothers you, take a really deep breath and blow it away." It gives them something to focus on until the propofol hits the brain and encourages a good vital capacity breath on 100% FiO2.

 

[dannyboy1]

There is a lot of anecdotal evidence that giving an induction dose of propofol reliably treats this pain within 10 seconds. Almost 100% efficacy...

 

[Planktonmd]

Give the induction dose over 10 seconds, that's all you need to do. Occasionally they might still hurt and if it happens int's not the end of the world!

 

[Planktonmd]

There is a lot of anecdotal evidence that giving an induction dose of propofol reliably treats this pain within 10 seconds. Almost 100% efficacy...

 

[Drangue]

Yes, nothing makes a grownass man scream like a little girl than propofol through a small hand IV while the blood pressure cuff is going up on that arm. I remember making that mistake as a resident. I' sure everyone has made that mistake at least once before

I did that as a medical student on one of my rotations.

Lets just say I did not ask that attending for an LOR.

 

[Aether2000]

I agree it is only 10-20 seconds but with some patients screaming out of control under the mask, it is very concerning to the surgeon and OR staff, and this is the one thing patients may remember about their anesthetic (unless there is enough midazolam on board). However a recent Chinese author study shows that only 8.5% actually remember the pain. (Is propofol injection pain really important to patients? - PubMed - NCBI)

 

[pgg]

It's a shame thiopental isn't available any more.

 

[propadope]

I wonder if benadryl would work. Its supposed to have local anesthetic properties

 

[Twiggidy]

Inadequate IV or hand IV. This tends to be the culprit.

I tend to not beg and choose when thr nurses are starting IVs but usually if the IV is in the wrist or antecubital they dont feel a thing. Im in an area whwre patients complain about everything so i dilute with lido and also with a little Ringers.

(I should say functional but not great IV. This is where the versed comes in handy)

 

[MirrorTodd]

Inadequate IV or hand IV. This tends to be the culprit.

I tend to not beg and choose when thr nurses are starting IVs but usually if the IV is in the wrist or antecubital they dont feel a thing. Im in an area whwre patients complain about everything so i dilute with lido and also with a little Ringers.

(I should say functional but not great IV. This is where the versed comes in handy)

Are there any areas where pt's don't complain?

 

[deleted162650]

Are there any areas where pt's don't complain?

The VA

 

[Psai]

Inadequate IV or hand IV. This tends to be the culprit.

I tend to not beg and choose when thr nurses are starting IVs but usually if the IV is in the wrist or antecubital they dont feel a thing. Im in an area whwre patients complain about everything so i dilute with lido and also with a little Ringers.

(I should say functional but not great IV. This is where the versed comes in handy)

Pudendal vein IV + awake decadron

That ought to learn em

 

[propadope]

Benadryl
Comparison of diphenhydramine and lidocaine for prevention of pain after injection of propofol: a double-blind, placebo-controlled, randomized study. - PubMed - NCBI

Metoclopramide
The effects of remifentanil, lidocaine, metoclopramide, or ketamine pretreatment on propofol injection pain. - PubMed - NCBI

 

[siliso]

Would you sign up to have your fingernails ripped off or your testicles crushed for just 10 or 20 seconds? When there are alternatives and no cash prizes or other benefits to be gained? And so I will end my posting career in patient advocacy on behalf of the unfortunate 8.5%

 

[MoMoGesiologist]

To the people saying "oh it's just ten seconds of pain," we do so many unnecessary and elective things to make patients comfortable or happy. Why not give them lidocaine to make the propofol more comfortable... the risk/benefit ratio greatly seems to favor the lidocaine.

 

[Twiggidy]

Pudendal vein IV + awake decadron

That ought to learn em

 

[deleted171991]

The VA

+1. Which proves once again that we are a society of pampered whiners.

Veterans are mostly older men, so one would expect them to be more sensitive to discomfort (like their non-veteran brethren). And yet, because those people have seen much-much worse in life, everything else is just minor inconvenience. This is one of the reasons why I am all for compulsory peacetime civilian or military service (inside the U.S.), for all the youngsters, male and female. Like the French have just reintroduced. To make whiners into citizens.

 

[DocVapor]

To make whiners into citizens.

 

[jwk]

Would you sign up to have your fingernails ripped off or your testicles crushed for just 10 or 20 seconds? When there are alternatives and no cash prizes or other benefits to be gained? And so I will end my posting career in patient advocacy on behalf of the unfortunate 8.5%

We do a lot of things that aren't pleasant. Have you had an NG tube placed? Male cysto with local only? Chest tube placement?

I've had IV propofol a number of times. Just wasn't a big deal. The other things I just mentioned suck - somehow relating the pain of IV propofol as one of the most painful experiences in my life just doesn't make sense.

 

[pgg]

I'd like to know more

 

[deleted875186]

Anyone ever try elevating the arm to increase venous drainage?

 

[nimbus]

+1. Which proves once again that we are a society of pampered whiners.

Veterans are mostly older men, so one would expect them to be more sensitive to discomfort (like their non-veteran brethren). And yet, because those people have seen much-much worse in life, everything else is just minor inconvenience. This is one of the reasons why I am all for compulsory peacetime civilian or military service (inside the U.S.), for all the youngsters, male and female. Like the French have just reintroduced. To make whiners into citizens.

Will compulsory military service reduce whining on SDN? If so I support it.

 

[deleted171991]

Will compulsory military service reduce whining on SDN? If so I support it.

I haven't served in the military, but I've been through tough times in my life. Hence little chance that military service would change my whining.

 

[Orin]

The competing theories on why propofol burns was of interest to me back in the day. I came from an IV Lidocaine +/- BP cuff for the mini-Bier block, but folks still had that burn. We had faculty that worried about the lidocaine bolus increasing the post-induction hypotension.

If you don't have medication options, I would lean on mechanical things such as prophylactic rubbing upstream of the IV while injecting or using something like they do on pediatric sticks. Buzzy helps control needle pain & fear from shots IVs injections

The nice thing about this is it's easy to try something and see an effect in your own hands, with the high incidence of pain (20-90%) with propofol induction and ease of measuring it. Pick something for a week and try it out.

 

[dhb]

From the little i've read, ketamine looks a good alternative.

 

[pgg]

Will compulsory military service reduce whining on SDN? If so I support it.

We've got enough whiners in the all-volunteer military already. Stop trying to unload more on us!

More seriously, I'm not opposed to some kind of mandatory national service but military service can't be the only option. A draft creates lots of issues. There was a time during Vietnam when it was physically dangerous for leaders to enter barracks ... granted there was a lot going on there, an unpopular war, widespread drug use, racism, but the draft was a huge part of it. An all-volunteer military is a far better situation.