Trick of the Trade: Minimizing propofol injection pain

"Ow, that burnnnnssss... ow! ow! ow! ... zzzzzz..."

As many as 60% of patients report significant pain with the injection of IV propofol. Once a patient experiences pain, it's too late to reverse it. Often all you can do is to tell them that the pain will subside in a few seconds.

What can you do preemptively to minimize the pain of propofol injection?

Tricks of the Trade:

1. Place the IV in an antecubital vein (vs the hand).
2. Pretreat with IV opioids.
3. If the IV is in the hand, place a tourniquet proximally and pretreat with lidocaine.

The most effective thing you can do to minimize pain from propofol injection is to cannulate a vein in the antecubital fossa rather than in the hand. The relative risk reduction is 0.14. The larger, higher flow vein presumably reduces the pain. You should also pretreat the patient's pain with an IV opioid, such as fentanyl or morphine.

For the IV is in the hand, you should pre-treat with lidocaine. First, apply a tourniquet. Intravenously inject 0.5 mg/kg of lidocaine. For a 70 kg person, that's 35 mg. This equals 3.5 mL of 1% lidocaine. Release the tourniquet after 30-120 seconds, and inject the propofol. The number-needed-to-treat to prevent pain in one person, who would have had pain had they received placebo, is 1.6!

Thanks to Dr. Andy Neill (of Emergency Medicine Ireland blog fame) for the tip from the Life in the Fast Lane's Research and Reviews series.

Reference
Jalota L, et al. Perioperative Clinical Research Core. Prevention of pain on injection of propofol: systematic review and meta-analysis. BMJ. 2011 Mar 15;342:d1110. PMID: 21406529.
Free PDF

Picard P, Tramèr MR. Prevention of pain on injection with propofol: a quantitative systematic review. Anesth Analg. 2000 Apr;90(4):963-9. PMID: 10735808.