Substitute for IV Lidocaine Prior to Propofol

[Temeraire]

I use the patient’s response to my induction dose of propofol to estimate how dramatic and pain-intolerant they will be in the postop period. Anecdotally, those who wince and grunt a little, or use coping mechanisms like deep breathing (without being told to), seem to handle postop pain better than those who scream and cry. The chronic opioid users with opioid induced hyperalgesia definitely make the biggest scene when getting propofol...

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[propadope]

I use the patient’s response to my induction dose of propofol to estimate how dramatic and pain-intolerant they will be in the postop period. Anecdotally, those who wince and grunt a little, or use coping mechanisms like deep breathing (without being told to), seem to handle postop pain better than those who scream and cry. The chronic opioid users with opioid induced hyperalgesia definitely make the biggest scene when getting propofol...

+1.
The patients I see who have a history of opioid abuse and are on methadone are definitely the ones that complain the most about the propofol, taking the electrodes off, taking the IV tape off. And they definitely scream and cry.

 

[nimbus]

+1.
The patients I see who have a history of opioid abuse and are on methadone are definitely the ones that complain the most about the propofol, taking the electrodes off, taking the IV tape off. And they definitely scream and cry.

The paradox is that they are also covered in tattoos.

 

[propadope]

The paradox is that they are also covered in tattoos.

Always. And needlephobic

 

[Temeraire]

The paradox is that they are also covered in tattoos.

It’s a control issue. Case in point.

 

[abolt18]

I use the patient’s response to my induction dose of propofol to estimate how dramatic and pain-intolerant they will be in the postop period. Anecdotally, those who wince and grunt a little, or use coping mechanisms like deep breathing (without being told to), seem to handle postop pain better than those who scream and cry. The chronic opioid users with opioid induced hyperalgesia definitely make the biggest scene when getting propofol...

Just last week, had a 20something guy going back for work on his leg after multiple recent failed surgeries (severe injuries a few months ago). Now on chronic high dose opioids.

Freaked out about the IV, including when the nurse smacked his hand to get the veins to pop up. Winced and whined when LR went in his nicely flowing IV on the dorsum of his hand. Grunting and writhing on the OR table as the fentanyl and lidocaine went in. Then as the propofol goes in, he starts screaming like he's literally dying, followed by "F*** YOUUUUUU!" Under the mask as loud as he can... And .... Asleep.

He reportedly was cursing and was aggressive after his previous anesthetic as well, so he had a nice smooth wakeup with some precedex worked in near the end and a bit of propofol as he blew off the gas.

 

[dchz]

Pudendal vein IV + awake decadron

That ought to learn em

How do you get to the pudendal vein? insert an extra long cath in the dorsal vein of the pee pee?

 

[Psai]

How do you get to the pudendal vein? insert an extra long cath in the dorsal vein of the pee pee?

There is no body cavity that cannot be reached with a number fourteen needle and a good strong arm.

 

[amyl]

i use ketamine routinely before propofol..... no one complains of burning. if ketamine isn't an option ill titrate the fentanyl until they are quiet... i suspect the iv benadryl just knocks them out enough they don't recognize the burning... same reason it works for nausea? I didn't know about reglan... will have to try that!

 

[dchz]

There is no body cavity that cannot be reached with a number fourteen needle and a good strong arm.

Rule #6 FATMAN!

 

[propadope]

i use ketamine routinely before propofol..... no one complains of burning. if ketamine isn't an option ill titrate the fentanyl until they are quiet... i suspect the iv benadryl just knocks them out enough they don't recognize the burning... same reason it works for nausea? I didn't know about reglan... will have to try that!

Benadryl has LA properties

 

[dchz]

Benadryl has LA properties

So does meperidine, but much better at creating work hour restrictions.

 

[propadope]

So does meperidine, but much better at creating work hour restrictions.

Didn’t know that. Also has anticholinergic properties as well if I’m not mistaken

 

[psychbender]

So does meperidine, but much better at creating work hour restrictions.

Sent from my SM-G930V using SDN mobile

 

[fakin' the funk]

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

Tickle (mechanodistract) the general area where the venous end of the IV ends and the drug first hits endothelium. It works. Bonus points if you don't blow the IV (not possible if you do this right).

 

[DocVapor]

Tickle (mechanodistract) the general area where the venous end of the IV ends and the drug first hits endothelium. It works. Bonus points if you don't blow the IV (not possible if you do this right).

Does saying "Goochy-goo! Goochy-gooo!" Also help?

 

[propadope]

Does saying "Goochy-goo! Goochy-gooo!" Also help?

Perhaps a feather as well?

 

[propadope]

Perhaps a feather as well?

But not a French tickler. Thats probably too far

 

[deleted697535]

Give more propofol.

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

 

[Aether2000]

Reporting back on IV diphenhydramine 20-25mg in 3cc saline injected into port 7cm from the IV with occlusion of the vein for 60 seconds during injection: 100% success rate in 40 patients. No complaint of pain, no withdrawal, no complaint of burning, no vocalization. Patients were noted to have less oral secretions and wake up smoothly. Slightly more sleepy on wakeup from short cases <30 min.

 

[propadope]

Reporting back on IV diphenhydramine 20-25mg in 3cc saline injected into port 7cm from the IV with occlusion of the vein for 60 seconds during injection: 100% success rate in 40 patients. No complaint of pain, no withdrawal, no complaint of burning, no vocalization. Patients were noted to have less oral secretions and wake up smoothly. Slightly more sleepy on wakeup from short cases <30 min.

Thanks for the report! Impressive results so far

Any narcs on board? If so how much? Are we going to have a benadryl shortage now?

 

[Aether2000]

No opioids on board. Indeed, benadryl could be in shortage if enough people begin using it ;-)

 

[deleted162650]

I don’t doubt that Benadryl works. The problem for me though is the potential for sedation. Benadryl really kicks the crap outta some people, and I don’t want my patients groggy all day after an outpatient or other shorter case.

Meperidine intrigues me for this though.

 

[propadope]

I don’t doubt that Benadryl works. The problem for me though is the potential for sedation. Benadryl really kicks the crap outta some people, and I don’t want my patients groggy all day after an outpatient or other shorter case.

Meperidine intrigues me for this though.

Fair point about oversedation. Probably good antiemesis though. I wonder if a smaller dose would be effective. Maybe 10mg in conjunction with narcs?

 

[dannyboy1]

If they start screaming I just push the roc faster. Seems to help.

 

[sigrhoillusion]

I find that performing infraclavicular blocks pre-op helps with propofol burn. I tend to give 20cc of 0.5% bupivacaine with decadron. I also ask the nurses to try and put 14g IVs in everyone which increases flow, and gets the brain doused in the propofol quicker.

 

[MaximusD]

Anecdotally, when I give precedex as a premed I rarely note discomfort with propofol. Try it sometime.

 

[Psai]

Reporting back on IV diphenhydramine 20-25mg in 3cc saline injected into port 7cm from the IV with occlusion of the vein for 60 seconds during injection: 100% success rate in 40 patients. No complaint of pain, no withdrawal, no complaint of burning, no vocalization. Patients were noted to have less oral secretions and wake up smoothly. Slightly more sleepy on wakeup from short cases <30 min.

The problem with iv benadryl is that when you give it with iv opioids, patients will start demanding it with every administration. Apparently it contributes to the high.

 

[CopaceticOne]

The problem with iv benadryl is that when you give it with iv opioids, patients will start demanding it with every administration. Apparently it contributes to the high.

This. The number of patients I had to deal with, during intern year, about their desire for IV benadryl was ungodly. My answer was always the same... No.

 

[propadope]

The problem with iv benadryl is that when you give it with iv opioids, patients will start demanding it with every administration. Apparently it contributes to the high.

They don’t have to necessarily know you have given it. Also propofol, midazolam ketamine, remi, fent etc.. will all make the patient feel high. Not necessarily a bad thing...

 

[chocomorsel]

The problem with iv benadryl is that when you give it with iv opioids, patients will start demanding it with every administration. Apparently it contributes to the high.

And how do they know what you are giving? Are you telling all your patients everything you are giving them?
Edit- someone already stated this.

 

[chocomorsel]

Anecdotally, when I give precedex as a premed I rarely note discomfort with propofol. Try it sometime.

Way too expensive to be all willy nilly with it.