Prevention of Minor Anesthetic Problems

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Prevention of Minor Anesthetic Problems Speaker：R2 章宏吉 Modulator : VS 詹偉弘 Supervisor：VS 王永彬 Outlines   Myalgia Pain on injection Myalgia     After succinylcholine administration Most frequently at 24 hr after surgery Last for days Minor surgery, women, outpatients  Myoglobinemia Increases in serum creatine kinase Sore thorat < Miller's Anesthesia, 6th ed>   Succinylcholine  Mechanisms of fasciculation – Prejunctional depolarising action of succinylcholine – Uncoordinated contractions by muscle spindles – Unsynchonous activity in adjacent bundles – Fiber rupture or damage  Relationship between fasciculation and myalgia? Prevention of succinylcholine-induced fasciculation and myalgia: a meta-analysis of randomized trials  No clear relationship between the incidence of fasciculation and myalgia Dose of SCC gray squares：1 mg/kg clear circles ：1.5 mg/kg Method used to reduce myalgia  1990, a meta-analysis that included data – Significantly decreased the frequency of myalgia by 30%.       Atracurium d-tubocurarine Gallamine Pancuronium Diazepam Lidocaine < Anesth Analg 1990; 70:477–83 > Pretreatments Pretreatments  Prevention of succinylcholine-induced fasciculation and myalgia: a meta-analysis of randomized trials Prevention of fasciculation – NSAID：no significantly difference from placebo – BZD：a favorable effect only on fasciculation – Small dose of a nondepolarizing neuromuscular blocker ：clearly prevents fasciculations Pretreatments  Prevention of myalgia – BZD：almost no effect on myalgia – NSAID： best efficacy – All nondepolarizing muscle relaxants ：there was a ： statistically significant effect on myalgia Pretreatments  Relation between doses of nondepolarizing neuromuscular blocking agents and efficacy in preventin myalgia – For all nondepolarizing muscle relaxants   Degree of efficacy ：very similar No clear evidence of dose–responsiveness  Not enough data to allow for sensitivity analyses that addressed the time point Underlying risk  Thiopentone：lower incidence of myalgia in comparison with propofol Opioids: no impact on occurrence of myalgia In comparison with lower doses, high doses of succinylcholine decrease the risk of myalgia   Prevention of Succinylcholine-related Myalgia     Avoid the use of succinylcholine itself NSAID Lidocaine (1.5mg/kg) Small dose of a nondepolarizing neuromuscular blocker Conclusions    High incidence Symptoms sometimes last for several days. Small doses of nondepolarizing muscle relaxants prevent fasciculation and myalgia to some extent  Higher doses of succinylcholine decrease the risk of myalgia    Opioids do not seem to have any impact, Less myalgia when thiopentone is used compared with propofol. No clear relation between succinylcholine-related fasciculation and myalgia. Pretreatment with lidocaine or NSAID (diclofenac and aspirin) may prevent myalgia.  Pain on Injection    Propofol (Diprivan; 2,6-diisopropyl phenol) Etomidate-Lipuro Barbiturate – Thiopental ( Pentothal )  Rocuronium ( Esmeron ) Propofol   Using a large vein The diameter of venous catheters and speed of injection had impact no  i.v. bolus infusion rate of propofol does induced local pain on injection not influence drug- – Temperature： no significant effect  DLIS (double lumen i.v. set) significantly reduced the incidence of propofol injection pain compared with SLIS  Simultaneous iv infusion of carrier fluid has no particular effect on local pain following iv administration of propofol.  Microbiological filter(Supor, Pall Life Sciences) may provide a nonpharmacological alternative to a lidocaine/propofol mixture – 5-microm filter does not reduce pain associated with injection of propofol drawn from a vial with a rubber bung  Analgesic interventions  Lidocaine (0.5 mg/kg) with a rubber tourniquet on the forearm,30 to 120 s before the injection of propofol   Lidocaine (40 mg IV) immediately before propofol injection Lidocaine (40 mg IV) mixed with propofol – No statistically significant difference in the doses whether administered as a freshly prepared propofol 1%/lidocaine 1% 10:1 mixture or as a separate injection after a dose of lidocaine  A lidocaine dose of 40 mg for young patients and 20 mg for old patients, with venous occlusion for two minutes  Topical 60% lidocaine tape reduces the pain associated with injection of propofol  Epidural 2% lidocaine and iv lidocaine equally reduced the severity of propofol injection pain despite higher lidocaine plasma concentrations in epidurally administered lidocaine  Topical anesthesia with 5% lidocaine-prilocaine (EMLA) cream applied for 60 min does not significantly reduce propofol injection pain  Iontophoretically applied lidocaine decreased the pain of cannulation and propofol injection  The iontophoretic administration of lidocaine 60 mg does not compare favourably with lidocaine 40 mg mixed with propofol for the reduction of pain on administration of propofol  Small dose (30 mg/kg) of ephedrine reduces the incidence and intensity of the pain without significant adverse hemodynamic effects  An admixture of 3 mg/kg of propofol and 3 mg/kg of thiopentone reduces pain on injection in pediatric anesthesia < Canadian Journal of Anaesthesia. 49(10):1064-9, 2002 Dec >  Pretreatment with thiopental 0.5 mg/kg after manual venous 1 min effectively attenuated pain associated with propofol injection occlusion for  Pretreatment with ketamine (0.5 mg/kg) is very effective in preventing propofol infusion pain  ketamine 0.1 mg/kg immediately before propofol injection provided the optimal dose and timing to reduce propofol-induced pain on injection. – Despite the reduction in injection pain intensity after ketamine, the study drugs were found to be ineffective in lowering the injection pain incidence  15 and 30 mg ketorolac reduces pain following propofol injection  10 mg with venous occlusion for 120 s achieves the same pain relief effect  Alfentanil 1 mg and lidocaine 40 mg are both effective in reducing pain during injection of propofol  Remifentanil provided effective pain relief, comparable with lidocaine – Remifentanil was effective in preventing propofol injection pain, and should be used at a dose of at least 0.02 mg for this purpose < Journal of Clinical Anesthesia. 16(7):499-502, 2004 Nov >  Using -minute retention in veins, both tramadol and lidocaine significantly reduced propofol injection pain  Pretreatment with butorphanol with propofol injection 2 mg for attenuation of pain associated  The inhalation of a nitrous oxide/oxygen incidence of pain during propofol injection mixture significantly reduces the < Annales Francaises d Anesthesie et de Reanimation. 21(4):263-70, 2002 Apr >  Nitrous oxide reduces pain during induction with propofol mixed with lidocaine in healthy children.  Combination of i.v. lidocaine and N2O in O2 inhalation pretreatment is more effective than either treatment alone in decreasing pain on propofol injection  Older patients require less metoclopramide, with venous occlusion for 1 minute, to reduce pain on injection of propofol than do younger patients  A lidocaine/metoclopramide combination is more effective than lidocaine alone for reducing pain on injection of propofol in a peripheral vein < Canadian Journal of Anaesthesia. 52(5):474-7, 2005 May >  Nitroglycerin ointment applied to the back of the hand before injection reduces the incidence of painful injection with propofol – Topical nitroglycerin ointment : No impact  Magnesium sulfate, 2.48 mmol, injected 20 s before the administration of propofol significantly reduced the incidence of pain < Anesthesia & Analgesia. 95(3):606-8, table of contents, 2002 Sep > – No justification in the use of magnesium pretreatment for attenuating pain associated with i.v. propofol  Oral clonidine (5.5 mg/kg) followed by i.v. propofol significantly reduces pain  Combination of clonidine and ephedrine effectively reduced propofolinduced pain, but did not prevent propofol-induced hypotension  Pretreatment with nafamostat (kallikrein inhibitor) 0.02 mg/kg significantly reduced pain on propofol injection and this effect may be caused by a reduction in kallikrein activity  IV ondansetron (4 mg) pretreatment was used to alleviate pain on injection of propofol – Tramadol (50mg) or ondansetron(4mg) are equally effective in preventing pain from propofol injection. The added benefit of a reduction in nausea and vomiting after operation in the ondansetron group < European Journal of Anaesthesiology. 19(1):47-51, 2002 Jan >  Granisetro(2mg) pretreatment may be used to reduce the incidence of pain on injection of propofol, an advantage added to the useful prevention of postoperative nausea and vomiting  Pretreatment with intravenous metoprolol (2 mg) was equally as effective as lidocaine (20mg)in reducing the pain associated with propofol injection.  Flurbiprofen 50 mg i.v. just before propofol injection completely abolished propofol injection pain. When it was administered 1 min before propofol injection it was less effective. – In this study of Japanese adult surgical patients, flurbiprofen axetil at doses of 50 and 75 mg, preceded by venous occlusion for 2 minutes, was found to be effective in reducing propofol-induced pain on injection – In this small clinical trial in Japanese surgical patients undergoing general anesthesia, 50 mg in young adults (age 20-40 years) and 25 or 50 mg in older adults (age 60-80 years) regardless of weight, preceded by venous occlusion for 2 minutes  Bisulfite-containing formulation of propofol  prodrug which is hydrolyzed to release propofol , was well tolerated without pain on injection  GPI 15715 (AQUAVAN injection) is a new water-soluble Pain on injection and thrombophlebitis occurred AM149 than with Disoprivan more frequently with  Although both groups received pretreatment with intravenous lidocaine, Ampofol was associated with more pain on injection < Anesthesiology. 100(5):1072-5, 2004 May> < Anesthesia & Analgesia. 98(3):687-91, table of contents, 2004 Mar >  incidence of pain associated with IV administration of propofol and is comparable to that of mixing lidocaine with propofol Preinjection with bacteriostatic saline decreases the – Pain on injection Propofol-MCT/LCT appears to be superior to PropofolLCT in children aged 7-14 years – Intensity of local pain found to be associated with iv administration of the new drug formula Propofol-Lipuro < Acta Anaesthesiologica Scandinavica. 49(2):248-51, 2005 Feb > – Propofol-Lipuro is associated with reduced injection pain compared with Diprivan and also seems to attenuate subsequent injection pain of Diprivan when administered first < European Journal of Anaesthesiology 2006; 23: 971-974> – A lipid-free formulation produced more pain on injection as compared with the emulsion containing medium-chain triglyceride – The reason for less pain on injection with LCT/MCT propofol may be attributed to a decreased concentration of propofol in the aqueous phase. – Premixing of 20 mg of lidocaine to 200 mg of standard propofol LCT causes less pain on injection than propofol MCT/LCT < Anesthesia & Analgesia. 99(4):1076-9, table of contents, 2004 Oct > – No significant difference in pain scores between Propofol-Lipuro and propofol mixed with lidocaine 10 mg < Anaesthesia. 59(12):1167-9, 2004 Dec > – A new MCT-LCT propofol formulation was associated with a higher incidence of injection pain than LCT propofol with added lidocaine in children < British Journal of Anaesthesia. 95(2):222-5, 2005 Aug > – Propofol-MCT/LCT-lidocaine mixtures significantly reduce pain – Propofol MCT/LCT with lidocaine is one of the most effective measures < European Journal of Anaesthesiology. 24(1):33-8, 2007 Jan> – Frequency and severity of pain during TCI induction with propofol could be significantly reduced using LCT/MCT propofol rather than LCT propofol – Dilution of propofol to a 0.5% medium-chain-triglyceride/longchain-triglyceride emulsion reduced pain effectively during injection in children aged 2–6 yr Etomidate   Using a large vein Lidocaine (20 to 40 mg IV) immediately before etomidate injection Premedication with a BZD plus a narcotic： Less successful, but somewhat efficacious < Miller's Anesthesia, 6th ed>  Etomidate  HPCD may be superior to propylene glycol as a solvent for etomidate. – Less pain, less thrombophlebitis, and no hemolysis – No clinically important alteration of pharmacokinetics or pharmacodynamics  The lipid formulation of etomidate : much lower incidence of pain on injection, thrombophlebitis, and histamine release on injection – No relationship between pain or venous sequelae and histamine release.  Etomidate-Lipuro is associated with considerably less injection pain in children compared with propofol with added lidocaine < British Journal of Anaesthesia. 97(4):536-9, 2006 Oct > Barbiturate  Methohexital is associated with a higher incidence than with thiopental Rocuronium  Pain on injection of rocuronium in pediatric patients can be alleviated by pretreatment with i.v. lidocaine (0.1 mL/kg 1%)  Both lidocaine 10 mg and 30 mg i.v. given before administration of rocuronium significantly reduced the incidence and severity of pain on injection of rocuronium, and the higher dose was more effective.  Ondansetron (4mg), lidocaine (30mg), tramadol (50mg) , and fentanyl (100microg) were effective in preventing and decreasing the level of rocuronium injection pain. – lidocaine was the most effective, fentanyl was the least effective  Sodium bicarbonate 8.4%2 ml, when added to rocuronium 10mg, markedly reduces the experience of pain  Pretreatment with 2 mL (50 mg) thiopental is effective in reducing pain caused by the intravenous injection of rocuronium Yonsei Medical Journal. 46(6):765-8, 2005 Dec 31  Dilution of rocuronium to 0.5 mg/mL with 0.9% NaCl eliminates the pain  The incidence and the degree of withdrawal reactions in response to the injection of rocuronium were significantly higher in women than in men  Withdrawal after rocuronium can be eliminated by the pretreatment of lidocaine during the occlusion of the IV flow in adults and addition of sodium bicarbonate in children  Remifentanil 1 microg/kg reduced the incidence of rocuronium-associated withdrawal movement with haemodynamic stability in children Conclusion  Propofol – Lidocaine (0.5 mg/kg) with a rubber tourniquet on the forearm,30 to 120 s before the injection of propofol – Thiopental (0.5 mg/kg) after manual venous occlusion for 1 min – Alfentanil 1 mg  Rocuronium – Lidocaine 30mg – Fentanyl 100microg – Thiopental 50mg – Sodium bicarbonate 8.4%2 ml mixed with Rocuronium in child References   Miller's Anesthesia, 6th ed Succinylcholine-associated postoperative myalgia  Prevention of succinylcholine-induced fasciculation and myalgia: a meta-analysis of randomized trials  Prevention of Pain on Injection with Propofol: A Quantitative Systematic Review Thanks for your attention!!

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