title: Prevention of pain on injection of propofol: systematic review and meta-analysis.
abstract: OBJECTIVE
  To systematically determine the most efficacious approach for preventing pain on injection of propofol.
  
  
  METHODS
  Systematic review and meta-analysis.
  
  
  METHODS
  PubMed, Embase, Cochrane Library, www.clinicaltrials.gov, and hand searching from the reference lists of identified papers.
  
  
  METHODS
  Randomised controlled trials comparing drug and non-drug interventions with placebo or another intervention to alleviate pain on injection of propofol in adults.
  
  
  RESULTS
  Data were analysed from 177 randomised controlled trials totalling 25,260 adults. The overall risk of pain from propofol injection alone was about 60%. Using an antecubital vein instead of a hand vein was the most effective single intervention (relative risk 0.14, 95% confidence interval 0.07 to 0.30). Pretreatment using lidocaine (lignocaine) in conjunction with venous occlusion was similarly effective (0.29, 0.22 to 0.38). Other effective interventions were a lidocaine-propofol admixture (0.40, 0.33 to 0.48); pretreatment with lidocaine (0.47, 0.40 to 0.56), opioids (0.49, 0.41 to 0.59), ketamine (0.52, 0.46 to 0.57), or non-steroidal anti-inflammatory drugs (0.67, 0.49 to 0.91); and propofol emulsions containing medium and long chain triglycerides (0.75, 0.67 to 0.84). Statistical testing of indirect comparisons showed that use of the antecubital vein and pretreatment using lidocaine along with venous occlusion to be more efficacious than the other interventions.
  
  
  CONCLUSIONS
  The two most efficacious interventions to reduce pain on injection of propofol were use of the antecubital vein, or pretreatment using lidocaine in conjunction with venous occlusion when the hand vein was chosen. Under the assumption of independent efficacy a third practical alternative could be pretreatment of the hand vein with lidocaine or ketamine and use of a propofol emulsion containing medium and long chain triglycerides. Although not the most effective intervention on its own, a small dose of opioids before induction halved the risk of pain from the injection and thus can generally be recommended unless contraindicated.
authors.affiliation: Department of Anesthesia and Perioperative Care, University of California at San Francisco, San Francisco, 94115 CA, USA.
authors.forename: Leena
authors.initials: L
authors.lastname: Jalota
authors.forename: Vicki
authors.initials: V
authors.lastname: Kalira
authors.forename: Elizabeth
authors.initials: E
authors.lastname: George
authors.forename: Yung-Ying
authors.initials: YY
authors.lastname: Shi
authors.forename: Cyrill
authors.initials: C
authors.lastname: Hornuss
authors.forename: Oliver
authors.initials: O
authors.lastname: Radke
authors.forename: Nathan L
authors.initials: NL
authors.lastname: Pace
authors.forename: Christian C
authors.initials: CC
authors.lastname: Apfel
mesh_terms: D000328:Adult; D018686:Anesthetics, Intravenous / Q000008:administration & dosage*; D015982:Bias; D006801:Humans; D006993:Hypnotics and Sedatives / Q000008:administration & dosage*; D007275:Injections, Intravenous / Q000009:adverse effects*; D010146:Pain / Q000209:etiology / Q000517:prevention & control*; D015742:Propofol / Q000008:administration & dosage*; D016032:Randomized Controlled Trials as Topic
chemical_list: D018686:Anesthetics, Intravenous; D006993:Hypnotics and Sedatives; D015742:Propofol