Vol 44 # 2 June 2012 - Kma.org.kw

123
Determining the Effect of Sufentanil on Propofol Injection Pain
June 2012
DISCUSSION
Propofol is a 2,6 disopropyl phenol and like all
phenols it irritates the skin , mucous membranes and
venous intima. PIP is still a common problem and the
ideal method for its prevention is still controversial.
Among 33 clinical problems, PIP has been seventh in
the list, when both clinical importance and frequency
were considered [15] . There are a lot of factors that affect
the incidence of PIP. These are site of injection, size
of vein, speed of injection, aqueous phase propofol
concentration, and the speed of carrier fluid, propofol
temperature, syringe material and drugs used before
propofol injection. PIP can be immediate or delayed.
Direct irritant effect probably causes immediate pain
and kinin cascade activation causes the delayed one.
Lidocaine and opioids are most used pretreatment
drugs for prevention of PIP. Lidocaine decreases PIP by
inhibiting bradykinin production via kinin cascade [16] .
Its pH and dilution of propofol in the aqueous phase
causes less pain. But sometimes lidocaine fails to
decrease pain and can cause some side effects like
anaphylactic shock developing immediately after
intravenous administration of lidocaine without
preservative added to the propofol to decrease injection
pain [17] .
Opioids such as alfentanil, remifentanil and fentanil
are reported to decrease PIP [1,3,11,18] . Opioids effect
centrally or peripherally [3] . Opioid receptors are found
in the dorsal root ganglia, central terminals of primary
afferent nerves and in the periphery [19] . Therefore, the
pain reduction effect of opioids on PIP might be on
peripheral receptors [20] .
Several studies have confirmed effect of opioids on
PIP. Basaranoğlu et al [18] reported that 1 mcg/kg dose
of fentanil and remifentanil are effective in prevention
of PIP. Roehm [21] et al compared 0.25 mcg/kg/ min
remifentanil with 40 mg lidocaine and found that
both were equally effective. Nathanson et al reported
that 1 mg alfentanil and 40 mg lidocaine are effective
for prevention of PIP [10] . Lyilikci and colleagues found
that alfentanil and remifentanil decreased PIP severity
and frequency and also that remifentanil should be
used in dose of at least 0.02 mg for this purpose [19] .
Kırdemir et al concluded that remifentanil 0.5 mcg/
kg and alfentanil 1 mg prevent PIP as effectively as
lidocaine [22] . Optimum dose of alfentanil in children
that reduced PIP was 15 mcg/kg [23] . Fentanyl 100
μg, preceded by one minute venous occlusion was
effective in pain reduction during propofol injection in
Japanese adults [24] . Cho reported that the combination
of cold propofol (4 °C) and pretreatment with 0.5 μg/kg
IV remifentanil more effectively decreased the incidence
of pain than either treatment alone [25] . Kwak et al reported
the combination of 0.35 μg/kg/min pretreatment with
remifentanil and premixture of lidocaine with propofol
was more effective in reducing the incidence of pain on
injection of propofol than either treatment alone [26] . Aouad
et al assessed the combination of two different analgesic
modalities (2% 40 mg lidocaine premixed with 180 mg
propofol and pretreatment with 2 μg/kg fentanil) [27]
and found that both the drugs completely abolished
moderate and severe PIP, and significantly reduces the
incidence of mild pain when compared with each drug
used alone. If all these opioids have a decrement effect
on PIP, sufentanil must have the same effect, but at what
dosage was our question in this study.
Sufentanil has 10-15 times greater potency than
fentanil and 50 times that of alfentanil. It has an
immediate onset of action. It is used as an analgesic
adjunct in the maintenance of balanced general
anesthesia in surgical procedures, for the postoperative
management of pain following general surgery, thoracic
or orthopedic procedures and cesarean sections via
epidural route and as an analgesic adjunct to epidural
bupivacaine during labor and vaginal deliveries. Its
effects on central nervous system, minimal alveolar
concentration levels of volatile anesthetics and
respiratory depression is similar to the other opioids.
Doses more than 2.6 mcg/kg can cause respiratory
depression, increase in airway resistance and muscle
stiffness after surgery [28] . Its analgesic dose was
between 0.01 - 0.03 mcg/kg [29] .
Nathanson, Fletcher and İyilikçi et al. showed
that PIP decreased 30 seconds after alfentanil and
remifentanil [10,11,20] . We injected propofol 30 seconds
after sufentanil. Sufentanil decreased overall pain
incidence from 92.5 to 70%. Sufentanil at 1 mcg dose
decreased PIP to 77.5% and at 2mcg dose to 44.5%
and this was significant compared to control group.
Chung et al compared 0.1 mcg/kg, 0.2 mcg/kg, 0.3
mcg/kg sufentanil doses 5 minutes before propofol
injection [30] . They reported that 0.3 μg/kg reduced the
severity of PIP. Honarmand and Safavi, found that
pretreatment with sufentanil 1 mcg did not reduce the
incidence and degree of injection pain compared with
0.02 mg remifentanil [31] . However, it decreased pain to
75% compared with saline as we found in our study
(77.5%). Low sufentanil dose or the insufficient time
period of one minute may have caused this difference.
Although we injected propofol 30 seconds after
sufentanil, sufentanil decreased overall pain incidence
from 92.5 to 70%. Sufentanil at 1 mcg dose decreased
PIP to 77.5% and at 2 mcg dose to 44.5% and this was
significant when compared to the control group.
CONCLUSION
In conclusion, sufentanil at 1 mcg and 2 mcg doses
reduced the incidence and severity of pain on propofol
injection. Added to the known advantage of being an
adjunct in induction, rapid recovery and lesser need