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Correspondence |
Chandigarh, India
To the Editor:
Pain on propofol injection is a recognized problem in the pediatric population and several methods have been studied to reduce its incidence and severity.1,2 We designed this study to assess the effectiveness of remifentanil in minimizing pain on injection of propofol in children. After Ethics Committee approval and written parental informed consent, healthy children ASA I or II status aged 5 to 12 yr scheduled for otolaryngological surgery were included in the study. Children with a past history of an adverse response to propofol, who refused iv induction, in whom we failed to insert an iv cannula on the back of the hand or who had cognitive or behavioural disorders were excluded from the study. When the patient arrived in the anesthetic room, a venipuncture was performed using a 22-gauge catheter without local anesthetic skin infiltration. This was flushed with 2 mL of normal saline. Children in Group I received remifentanil 0.25 µg•kg–1 (diluted with normal saline to 5 mL) over 30 sec followed 60 sec later by propofol. Group II received remifentanil 0.5 µg•kg–1 (diluted with normal saline to 5 mL) over 30 sec followed 60 sec later by propofol. The propofol (3 mg•kg–1) was injected over 20 sec and a blinded observer noted propofol pain on the four-point behavioural pain scale proposed by Cameron et al.:3 0 = no pain; 1 = mild pain (grimace); 2 = moderate pain (grimace + cry); and 3 = severe pain (cry + withdrawl). The injection was performed manually by one of the investigators who gauged the speed of injection from the wall-mounted clock. The incidence of pain was 60% in Group I compared with 23.5% in Group II (P < 0.001). Moderate and severe pain occurred in 22% and 14% respectively of patients in Group I, compared to 11.7% and 1.9% in Group II (P < 0.001). These results indicate that remifentanil pretreatment (0.5 µg•kg–1) 60 sec before propofol administration significantly reduces pain associated with propofol injection in children compared to remifentanil 0.25 µg•kg–1. The site of action of remifentanil in reducing pain may be either central or peripheral. The dose we used is low and is lower than the dose which one would choose if one wanted a central analgesic effect. Opioid receptors are present at peripheral sensory nerve terminals in humans. Remifentanil has a selective agonist action at µ opioid receptors.4 It is possible that the reduction in injection pain was the result of a peripheral action.
References
1 Tan CH, Onsiong MK. Pain on injection of propofol. Anaesthesia 1988; 53: 468–76.
2 Picard P, Tramer MR. Prevention of pain on injection with propofol: a quantitative systemic review. Anesth Analg 2000; 90: 963–9.
3 Cameron E, Johnston G, Croft S, Mortan NS. The minimum effective dose of lignocaine to prevent injection pain due to propofol in children. Anaesthesia 1992; 47: 604–6.[Medline]
4 James MK, Feldman PL, Schuster SV, Bilotta JM, Brackeen MF, Leighton HJ. Opioid receptor activity of GI 87084B, a novel ultra-short acting analgesic, in isolated tissues. J Pharmacol Exp Ther 1991; 259: 712–8.
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