Zusammenfassung
Injektionsschmerzen bei Einleitung einer Narkose oder Sedierung beeinträchtigen den Patientenkomfort. In der Kinderanästhesie kann dies die Anwendung Propofol-gestützter Verfahren verhindern. Auf der Suche nach Strategien, den Propofol-induzierten Venenschmerz zu mildern oder auszuschalten, ist inzwischen eine große Datensammlung entstanden. Zur Reduktion des Injektionsschmerzes werden Pharmaka, physikalisch-technische Maßnahmen sowie die Kombination verschiedener Methoden eingesetzt. Insgesamt scheint das Schmerzproblem mit Einzelmethoden bisher nicht gelöst, eine Kombination verschiedener Maßnahmen ist effektiver wirksam. So führt die zusätzliche Anwendung eines venösen Tourniquet bei präventivem Einsatz von Pharmaka mit peripherem Wirkungsmechanismus zu einer deutlicheren Schmerzreduktion. Als effektivste Präventionsmaßnahme gilt die intravenöse Vorinjektion von Lidocain mit kurzzeitigem Venenstau.
Prinzipiell ist die Verwendung einer Propofol-MCT/LCT-Emulsion empfehlenswert. Zudem erscheint ein multimodales Vorgehen, das den Anforderungen im klinischen Alltag gerecht wird, sinnvoll. So kann im Rahmen einer Allgemeinanästhesie durch Vorinjektion von Opioidanalgetika oder Ketamin, bei Propofoleinsatz zur Sedierung durch Vorgabe einer subanästhetischen Thiopentaldosis eine wirksame Schmerzreduktion erreicht werden. Ist eine medikamentöse Prophylaxe von Übelkeit und Erbrechen indiziert, sollten zur Injektionsschmerzprävention geeignete Antiemetika eingesetzt werden. Für die Kinderanästhesie bietet sich die Verwendung von EMLA-Creme an, da hierdurch gleichzeitig die Toleranz der Venenpunktion ermöglicht wird.
Obwohl das Nonplusultra für die schmerzfreie Propofolinjektion bisher noch nicht gefunden ist, existiert bereits eine breite Palette effektiv wirksamer Präventionsmöglichkeiten. Die hierzu vorliegenden Daten sind Gegenstand des Beitrags.
Abstract
Injection-induced pain during induction of anaesthesia can result in patient's discomfort. This can prevent the use of propofol-anaesthesia in paediatric patients. Because of the high incidence of pain on injection with propofol numerous interventions have been tested to prevent this pain including the use of different drugs and physical measures as well as the combination of methods. The use of a single intervention is not as effective as the combination of different preventive measures. Thus the additional application of a venous tourniquet improves the pain reducing effect if drugs with peripheral mechanism of action are used for prevention of pain. Injection of lidocaine with a rubber tourniquet before the propofol injection is recommended as best effective method.
In any case a propofol-MCT/LCT-Emulsion should be used for propofol-anaesthesia. Additionally a multimodal strategy that is adapted to the daily clinical practice seems to be convenient. That means, for general anaesthesia opioids or ketamine and for sedation a subanaesthetic dose of thiopental can be used for effective prevention of pain. If the prevention of nausea and emesis is intended, antiemetics that are appropriate for prevention of injection pain should be given. For paediatric anaesthesia the application of EMLA-cream seems to be suitable, because it alleviates the pain during venous cannulation at the same time.
Although a painfree propofol injection is not possible with every prevention strategy there exist a wide range of effective interventions to prevent pain on injection with propofol. This article reviews methods that have been investigated and established to minimise the incidence of pain.
Schlüsselwörter
Propofol - Injektionsschmerz - Kinderanästhesie
Key words
Propofol - pain on injection - paediatric anaesthesia
Literatur
-
1
Kretz F J.
The future of paediatric anaesthesia is total intravenous anaesthesia.
Curr Opin Anaesthesiol.
2002;
15
305-307
-
2
Strauß J M, Giest J.
Total intravenöse Anästhesie. Auf dem Weg zum Standardverfahren bei Kindern.
Anaesthesist.
2003;
52
763-777
-
3
Westphal K, Strouhal U, Kessler P, Schneider J.
Arbeitsplatzbelastung durch Sevofluran - Konzentrationsmessungen während Bronchoskopien bei Kindern.
Anaesthesist.
1997;
46
677-682
-
4
Picard V, Dumont L, Pellegrini M.
Quality of recovery in children: sevoflurane versus propofol.
Acta Anaesthesiol Scand.
2000;
44
307-310
-
5
Smith I, Terhoeve P A, Hennart D, Feiss P, Harmer M, Pourriat J L, Johnson I AT.
A multicentre comparison of the costs of anesthesia with sevoflurane or propofol.
Br J Anaesth.
1999;
83
564-570
-
6
Jobalia N, Mathieu A.
A meta-analysis of published studies confirms decreased postoperative nausea/vomiting with propofol.
Anesthesiology.
1994;
81
Suppl 3A
-
7
Veyckemans F.
Excitation phenomena during sevoflurane anaesthesia in children.
Curr Opin Anaesthesiol.
2001;
14
339-343
-
8
Jöhr M.
Postanaesthesia excitation.
Paediatr Anaesth.
2002;
12
293-295
-
9
Holzki J.
Maskennarkoseeinleitung in der Kinderanästhesie: Kontra.
Anaesthesiol Intensivmed Notfallmed Schmerzth.
2001;
36
434-436
-
10
Doenicke A W, Roizen M F, Rau J, Kellermann W, Babl J.
Reducing pain during propofol injection: the role of the solvent.
Anesth Analg.
1996;
82
472-474
-
11
Iwama H, Nakane S, Ohmori S, Kaneko T, Kato M, Watanabe K, Okuaki A.
Nafamostat mesilate, a kallikrein inhibitor, prevents pain on injection with propofol.
Br J Anaesth.
1998;
81
963-964
-
12
Klement W, Arndt J O.
Pain on i. v. injection of some anaesthetic agents is evoked by the unphysiological osmolality or pH of their formulations.
Br J Anaesthesia.
1991;
66
189-195
-
13
Klement W, Arndt J O.
Pain on injection of propofol: effects of concentration and diluent.
Br J Anaesth.
1991;
67
281-284
-
14
Babl J, Doenicke A, Moench V.
Propofol LCT/MCT fat emulsions as solvent: approach to reducing pain on injection of propofol?.
Eur Hosp Pharm.
1995;
1
15-21
-
15
Rau J, Roizen M, Doenicke A W, O'Connor M F, Strohschneider U.
Propofol in an emulsion of long- and medium-chain triglycerides: The effect on pain.
Anesth Analg.
2001;
93
382-384
-
16
Picard P, Tramèr M R.
Prevention of pain on injection with propofol: a quantitative systematic review.
Anesth Analg.
2000;
90
963-969
-
17
Johnson R A, Harper N JN, Chadwick S, Vohra A.
Pain on injection of propofol. Methods of allevation.
Anaesthesia.
1990;
45
439-442
-
18
Hiller A, Saarnivaara L.
Injection pain, cardiovascular changes and recovery following induction of anaesthesia with propofol in combination with alfentanil or lignocaine in children.
Acta Anaesthesiol Scand.
1992;
36
564-568
-
19
Gajraj N M, Nathanson M H.
Preventing pain during injection of propofol: the optimal dose of lidocaine.
J Clin Anesth.
1996;
8
575-577
-
20
Nathanson M H, Gajraj N M, Russell J A.
Prevention of pain on injection of propofol: a comparison of lidocain with alfentanil.
Anesth Analg.
1996;
82
469-471
-
21
Goldmann R, Bornscheuer A, Kirchner E.
Einfluss der Applikationsart von Lidocain auf die Verminderung des Injektionsschmerzes durch Propofol.
Anästhesiol Intensivmed Notfallmed Schmerzther.
1997;
32
98-100
-
22
Tan C H, Onsiong M K.
Pain on injection of propofol.
Anaesthesia.
1998;
53
468-476
-
23
Madenoglu H, Yildiz K, Dogru K, Boyaci A.
Efficacy of different doses of lidocaine in the prevention of pain due to propofol injection: a randomized, open-label trial in 120 patients.
Curr Ther Res Clin Exp.
2003;
64
310-316
-
24
Kunitz O, Lösing R, Schulz-Stübner S, Haaf-von-Below S, Rossaint R, Kuhlen R.
Propofol-LCT versus Propofol-MCT/LCT mit oder ohne Lidocain - Vergleichende Untersuchung zum Injektionsschmerz.
Anästhesiol Intensivmed Notfallmed Schmerzther.
2004;
39
10-14
-
25
Scott R PF, Saunders D, Norman J.
Propofol: clinical strategies for preventing the pain of injection.
Anaesthesia.
1988;
53
492-494
-
26
Yokota S, Komatsu T, Komura Y, Nishiwaki K, Kimura T, Hosoda R, Shimada Y.
Pretreatment with topical 60 %-lidocaine tape reduces pain on injection of propofol.
Anesth Analg.
1997;
85
672-674
-
27
Uda R, Ohtsuka M, Doi Y. et al .
Sixty percent lidocain tape alleviates pain on injection of propofol after diminishing venepuncture pain.
Masui.
1998;
47
843-847
-
28
McCluskey A, Currer B A, Sayeed I.
The efficacy of 5 % lidocaine-prilocaine (EMLA) cream on pain during intravenous injection of propofol.
Anesth Analg.
2003;
97
713-714
-
29
Sadler P J, Thompson H M, Maslowski P, Liddle A, Rowbotham D J.
Iontophoretically applied lidocaine reduces pain on propofol injection.
Br J Anaesth.
1999;
82
432-434
-
30
Sharpe P, Asif M, Victoria A, Rowbotham D J.
Iontophoretically applied lidocaine and the prevention of pain associated with the injection of intravenous propofol: a acomparison wih inravenous lidocain.
Eur J Anaesthesiol.
2002;
19
170-172
-
31
Yoshikawa T, Wajima Z, Inoue T, Ogura A, Ogawa R.
Epidural anesthesia with lidocaine reduces propofol injection pain.
Can J Anesth.
2001;
48
538-544
-
32
Roehm K D, Piper S N, Maleck W H, Boldt J.
Prevention of propofol-induced injection pain by remifentanil: a placebo-controlled comparison with lidocaine.
Anaesthesia.
2003;
58
161-182
-
33
Agarwal A, Raza M, Dhiraaj S, Pandey R, Gupta D, Pandey C h, Singh P, Singh U.
Pain during injection of propofol: the effect of prior administration of butorphanol.
Anesth Analg.
2004;
99
117-119
-
34
Pang W W, Huang P Y, Chang D P, Huang M H.
The peripheral analgesic effect of tramadol in reducing propofol injection pain: a comparison with lidocaine.
Reg Anesth Pain Med.
1999;
24
246-249
-
35
Wong W H, Cheong K F.
Role of tramadol in reducing pain on propofol injection.
Singapore Med J.
2001;
42
193-195
-
36
Lyons B, Lohan D, Flynn C, Mc Carroll M.
Modification of pain on injection of propofol. A comparison of pethidine and lignocaine.
Anaesthesia.
1996;
51
394-395
-
37
Karasawa F, Ehata T, Okuda T, Satoh T.
Propofol injection pain is not alleviated by pretreatment with flurbiprofen axetil, a prodrug of nonsteroidal antiinflammatory drug.
J Anesth.
2000;
14
135-137
-
38
Smith A J, Power I.
The effect of pretreatment with ketorolac on pain during intravenous injection of propofol.
Anaesthesia.
1996;
51
883-885
-
39
Huang Y W, Buerkle H, Lee T H, Lu C Y, Lin C R, Lin S H, Chou A K, Muhammad R, Yang L C.
Effect of pretreatment with ketorolac on propofol injection.
Acta Anaesthesiol Scand.
2002;
46
1021-1024
-
40
Cheng K I, Tang C S, Chiu S L, Chen T I, Wang C J, Fan K T, Yu K L.
Injection pain with propofol: the effectiveness of thiopentone induction.
Kaohsiung J Med Sci.
1998;
14
480-485
-
41
Jones D, Prankerd R, Lang C, Chilvers M, Bignell S, Short T.
Propofol-thiopentone admixture-hypnotic dose, pain on injection and effect on blood pressure.
Anaesth Intensive Care.
1999;
27
346-356
-
42
Kau Y C, Wu R S, Cheng K S.
Propofol-sodium thiopental admixture reduces pain on injection.
Acta Anaesthesiol Sin.
2000;
38
9-13
-
43
Pollard R C, Makky S, McFadzean J, Ainsworth L, Goobie S M, Montgomery C J.
An admixture of 3 mg/kg of propofol and 3 mg/kg thiopentone reduces pain on injection in pediatric anesthesia.
Can J Anaesth.
2002;
49
1064-1069
-
44
Azma T, Kawai K, Tamura H, Okada K, Okida M.
Comparative benefit of preemptively applied thiopental for injection pain: the advantage over lidocaine.
Hiroshima J Med Sci.
2004;
53
13-16
-
45
Agarwal A, Ansari M F, Gupta D, Pandey R, Raza M, Singh P K, Shiopriye M BBS, Dhiraj S, Singh U.
Pretreatment with thiopental for prevention of pain associated with propofol injection.
Anesth Analg.
2004;
98
683-686
-
46
Barbi E, Marchetti F, Gerarduzzi T. et al .
Pretreatment with intravenous ketamine reduces propofol injection pain.
Paediatr Anaesth.
2003;
13
764-768
-
47
Tan C H, Onsiong M K, Kua S W.
The effect of ketamine pretreatment on propofol injection pain.
Anaesthesia.
1998;
53
302-305
-
48
Tobias J D.
Prevention of pain associated with the administration of propofol in children: lidocaine versus ketamine.
Am J Anesthesiol.
1996;
2
231-232, 241
-
49
Lembert N, Wodey E, Geslot D, Ecoffey C.
Prévention de la douleur à l'injection du propofol chez l'enfant: comparaison de l'inhalation de protoxyde d'azote à l'injection de lidocaïne.
Ann Fr Anesth Réanim.
2002;
21
263-270
-
50
Harmon D, Rozario C, Lowe D.
Nitrous oxide/oxygen mixture and the prevention of pain during injection of propofol.
Eur J Anaesthesiol.
2003;
20
158-161
-
51
Beh T, Splinter W, Kim J.
In children, nitrous oxide decreases pain on injection of propofol mixed with lidocaine.
Can J Anaesth.
2002;
49
1061-1063
-
52
Liaw W J, Pang W W, Chang D P, Hwang M H.
Pain on injection of propofol: the mitigating influence of metoclopramide using different techniques.
Acta Anaesthesiol Scand.
1999;
43
24-27
-
53
Ye J H, Miu W C, Ren J, Hunt T E, Wu W H, Zbuzek V K.
Ondansetron exhibits the properties of a local anesthetic.
Anesth Analg.
1997;
85
1116-1121
-
54
Ambesh S P, Dubey P K, Sinha P K.
Ondansetron preatreatment to alleviate pain on propofol injection: a randomized, controlled, double-blinded study.
Anesth Analg.
1999;
89
197-199
-
55
Dubey P K, Prasad S S.
Pain on injection of propofol: the effect of granisetron pretreatment.
Clin J Pain.
2003;
19
121-124
-
56
Piper N S, Röhm K D, Papsdorf M, Maleck W H, Mattinger P, Boldt J.
Dolasetron verringert den Propofol-induzierten Injektionsschmerz.
Anästhesiol Intensivmed Notfallmed Schmerzther.
2002;
37
528-531
-
57
Yoshikawa T, Wajima Z, Ogura A, Inoue T, Ogawa R.
Orally administered clonidine significantly reduces pain during injection of propofol.
Br J Anaesth.
2001;
86
874-876
-
58
Cheong M A, Kim K S, Choi W J.
Ephedrine reduces the pain from propofol injection.
Anesth Analg.
2002;
95
1293-1296
-
59
Asik I, Yorukoglu D, Gulay I, Tulunay M.
Pain on injection of propofol: comparison of metoprolol with lidocaine.
Eur J Anaesthesiol.
2003;
20
487-489
-
60
Wilkinson D, Anderson M, Gauntlett I S.
Pain on injection of propofol: modification by nitroglycerin.
Anesth Analg.
1993;
77
1139-1142
-
61
O'Hara J F, Sprung J, Laseter J T, Maurer W G, Carpenter T, Beven M, Mascha E.
Effects of topical nitroglycerin and intravenous lidocaine on propofol-induced pain on injection.
Anesth Analg.
1997;
84
865-869
-
62
Pang W W, Mok M S, Wang C S, Yeh M, Chang D P.
Can neostigmin reduce propofol injection pain?.
Acta Anaesth Sin.
2002;
40
65-69
-
63
Yoshimura Y, Iwasaki T, Shimizu Y, Takasaki M.
Nicorandil reduces incidence and severity of pain on propofol injection.
Masui.
2003;
52
1204-1206
-
64
Agarwal A, Dhiraj S, Raza M, Pandey R, Pandey C K, Singh P K, Singh U, Gupta D.
Vein pretreatment with magnesium sulfate to prevent pain on injection of propofol is not justified.
Can J Anesth.
2004;
51
130-133
-
65
Stokes D N, Robson N, Hutton P.
Effect of diluting propofol on the incidence of pain on injection and venous sequelae.
Br J Anaesth.
1989;
62
202-203
-
66
Nonaka A, Tamaki F, Sugawara T, Oguchi T, Kashimoto S, Kumazawa T.
Premixing of 5 % dextrose in Ringer`s acetate solution with propofol reduces incidence and severity of pain on propofol injection.
Masui.
1999;
48
862-867
-
67
McDonald D S, Jameson P.
Injection pain with propofol. Reduction with aspiration of blood.
Anaesthesia.
1996;
51
878-880
-
68
Gran L, Bleie H, Jeppson R, Maartmann-Moe H.
Etomidat mit Intralipid. Eine Lösung zur schmerzfreien Injektion.
Anaesthesist.
1983;
53
475-477
-
69
Larsen R, Beerhalter U, Erdkönig R, Larsen B.
Injektionsschmerz durch Propofol-MCT/LCT bei Kindern.
Anaesthesist.
2001;
50
676-678
-
70
Larsen B, Beerhalter U, Biedler A, Brandt A, Doege F, Brün K, Erdkönig R, Larsen R.
Weniger Injektionsschmerz durch Propofol-MCT/LCT?.
Anaesthesist.
2001;
50
842-845
-
71
Schaub E, Kern C, Landau R.
Pain on injection: a double-blind comparison of propofol with lidocaine pretreatment versus propofol formulated with long- and medium-chain triglycerides.
Anesth Analg.
2004;
99
1699-1702
-
72
Röhm K D, Piper S N, Schöllhorn T AH, Suttner S W, Maleck W H, Boldt J.
Injektionsschmerz unter Propofol-MCT/LCT und Propofol-LCT - Vergleich einer Prophylaxe mit Lidocain.
Anästhesiol Intensivmed Notfallmed Schmerzther.
2003;
38
643-647
-
73
Barker P, Langton J A, Murphy P, Rowbotham D J.
Effect of prior administration of cold saline on pain during propofol injection. A comparison with cold propofol and propofol with lignocaine.
Anaesthesia.
1991;
46
1069-1070
-
74
Pickford A, Burden J, Lewis I.
Propofol and pain on induction: the effect of injectate temperature in children.
Paediatr Anaesth.
2000;
10
129-132
-
75
Parmar A K, Koay C K.
Pain on injection of propofol. A comparison of cold propofol with propofol premixed with lignocaine.
Anaesthesia.
1998;
53
79-83
-
76
Grauers A, Liljeroth E, Akeson J.
Propofol infusion rate does not affect pain on injection.
Acta Anaesthesiol Scand.
2002;
46
361-363
-
77
Langley M S, Heel R C.
Propofol. A review of its pharmacodynamic and pharmacokinetic properties and use as an intravenous anaesthetic.
Drugs.
1988;
35
334-372
-
78
Helmers J H, Kraaijenhagen R J, van Leuwen L, Zuurmond W W.
Reduction of pain on injection caused by propofol.
Can J Anaesth.
1990;
37
267-268
-
79
Bryson H M, Fulton B R, Faulds D.
Propofol. An update of its use in anaesthesia and conscious sedation.
Drugs.
1995;
50
513-559
-
80
Angst M S, Mackey S C, Zupfer G H, Tataru C D, Brock-Utne J G.
Reduction of propofol injection pain with a double lumen IV set.
J Clin Anesth.
1997;
9
462-466
-
81
Davies A F, Vadodaria B, Hopwood B, Dexter T, Conn D.
Efficacy of microfiltration in decreasing propofol-induced pain.
Anaesthesia.
2002;
57
557-561
-
82
Hellier C, Newell S, Barry J, Brimacombe J.
A 5-microm filter does not reduce propofol-induced pain.
Anaesthesia.
2003;
58
802-803
-
83
Kobayashi Y, Kamada Y, Kumagai A, Seki S, Ichimiya T, Tsuchida H, Namiki A.
Pain-free injection of propofol.
Masui.
1998;
47
835-838
-
84
Kobayashi Y, Naganuma R, Seki S, Aketa K, Ichimiya T, Namiki A.
Reduction of pain on injection of propofol: a comparison of fentanyl with lidocaine.
Masui.
1998;
47
963-967
-
85
Cox R G.
Are children just little adults when it comes to propofol injection pain?.
Can J Anesth.
2002;
49
1016-1020
-
86
Larsson B A, Tannfeldt G, Lagercrantz H, Olsson G L.
Allevation of the pain of venepuncture in neonates.
Acta paediatr.
1998;
87
774-779
-
87
Cordoni A, Cordoni L E.
Eutectic mixture of local anesthetics reduces pain during intravenous catheter insertion in the pediatric patient.
Clin J Pain.
2001;
17
115-118
Dr. med. Karen Auerswald
Klinik und Poliklinik für Anästhesiologie und Intensivtherapie · Universitätsklinikum Leipzig AöR
Liebigstraße 20a · 04103 Leipzig
Email: Karen.auerswald@medizin.uni-leipzig.de
