Propofol has turned into one of the most common anesthetic agents for anesthesia due to its unique pharmacologic properties, providing smooth induction and rapid recovery from anesthesia (1). However, pain during injection is one of its major drawbacks. Not only may this pain be distressing for the patient, but it can also interfere with the induction of general anesthesia. As a solution, an intravenous lidocaine injection is commonly used to attenuate pain on propofol injection.
A dosage of 40 mg lidocaine is an appropriate dose to alleviate propofol injection pain within the same vein (2). When the dosage reaches 1.5 mg/kg, intravenous lidocaine can alleviate the pain of a propofol injection via both local anesthetic and central analgesic effects.
Some clinical research has demonstrated that lidocaine may even reduce the required propofol dose. Recent research in patients receiving endoscopy has shown that combining propofol with intravenous lidocaine reduced the median effective dose (ED50) of propofol for successful endoscope insertion in adult patients by nearly 1.7 mg/kg (3). Reducing the amount of propofol used can be beneficial for patients’ recovery, as well as cost-saving.
Data from various clinical research studies have demonstrated that lidocaine pre-treatment effectively reduces pain on injection linked to propofol (4). Specifically in pediatric populations, a study confirmed that adding lidocaine to a propofol-lipuro injection reduced pain scores to minimum levels. Therefore, this practice seems to be highly effective for reducing propofol injection pain during anesthesia in children (5). Managing pain and distress is especially important to surgical outcomes in pediatric patients. Finally, most recently, a large review of randomized clinical trial data found that both lidocaine admixture and pre-treatment were effective in reducing pain on propofol injection (6), with no significant differences between the two methods.
Various research initiatives have sought to assess the most effective way of administering lidocaine. One research group hypothesized that the intravenous administration of diluted lidocaine in a large volume before propofol injection could more effectively prevent both immediate and delayed pain associated with propofol injection than the more commonly used method of mixing lidocaine with propofol. Overall, their data confirmed a very significant reduction, as compared to the control group, in propofol injection pain in the patient group receiving a large intravenous volume of diluted lidocaine (7).
However, there remain a number of risk factors associated with the use of lidocaine to prevent pain on propofol anesthetic induction. A recent clinical research trial found that, while pain outcome was reduced in patients receiving lidocaine as compared to patients receiving saline when analyzing data at the group level, the positive effect was not consistent at the individual level (8). In fact, researchers saw therapeutic benefit in 1 out of 11 patients treated. This means that the treatment could unnecessarily expose a large number of patients to the risk of unwanted drug reactions alongside higher costs for health institutions. Therefore, in light of these risk factors, researchers suggested that the use of lidocaine prior to propofol application is not justified (8).
Additional research is clearly warranted in order to specify and optimize the best administration protocols for lidocaine in order to minimize the pain associated with propofol anesthesia.
References
- Kam, E., Abdul-Latif, S. & McCluskey, A. Comparison of Propofol-Lipuro with propofol mixed with lidocaine 10 mg on propofol injection pain. Anaesthesia (2004). doi:10.1111/j.1365-2044.2004.03964.x
- Xing, J. et al. Intravenous lidocaine alleviates the pain of propofol injection by local anesthetic and central analgesic effects. Pain Med. (United States) (2018). doi:10.1093/pm/pnx070
- Qi, X. R., Sun, J. Y., An, L. X. & Zhang, K. Effect of intravenous lidocaine on the ED50 of propofol for inserting gastroscope without body movement in adult patients: a randomized, controlled study. BMC Anesthesiol. 22, 1–8 (2022). doi: 10.1186/s12871-022-01861-9.
- Kunitz, O. et al. Propofol-LCT Versus Propofol-MCT/LCT with or without Lidocaine – A Comparison on Pain on Injection. Anasthesiol. Intensivmed. Notfallmedizin Schmerztherapie (2004). doi:10.1055/s-2004-815712
- Beyaz, Sg., Tüfek, A. & Tokgöz, O. The effect of propofol lipuro with and without lidocaine on injection pain in children. Niger. J. Clin. Pract. (2011). doi:10.4103/1119-3077.79252
- Euasobhon, P. et al. Lidocaine for reducing propofol-induced pain on induction of anaesthesia in adults. Cochrane Database of Systematic Reviews (2016). doi:10.1002/14651858.CD007874.pub2
- Shabana, A. M. Prevention of propofol injection pain, using lidocaine in a large volume does it make a difference? A prospective randomized controlled double blinded study. Egypt. J. Anaesth. (2013). doi:10.1016/j.egja.2013.04.003
- Luiza, B. et al. Lidocaine in prevention of pain on propofol anesthetic induction: A randomized double-blinded clinical trial to estimate the magnitude of the effect. Open J. Pain Med. (2020). doi:10.17352/ojpm.000021
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