Injections, pain

Most short-term applications of EPO are non-renal related, and generally display very few side-effects i.v. administration can sometimes prompt a transient flu-like syndrome, while s.c. administration can render the site of injection painful. This latter effect appears, however, to be due to excipients present in the EOP preparations, most notably the citrate buffer. EPO administration can also cause bone pain, although this rarely limits its clinical use. 

Water-soluble Stable in solution Pain on IV injection Non-irritant on subcutaneous injection Painful on arterial injection No sequelae from arterial injection Low incidence of venous thrombosis Pharmacodynamic characteristics Rapid onset Cumulation Excitatory effects Respiratory complications Hypotension Tachycardia Analgesic... 

Injection pain is iess with the new formuiation containing iipofundin as the soivent rather than propyiene giycoi. 

Paromomycin sulfate is an aminoglycoside antibiotic that until recently was used in parasitology only for oral therapy of intestinal parasitic infections (see previous text). It has recently been developed for the treatment of visceral leishmaniasis. A phase 3 trial in India showed excellent efficacy for this disease, with a daily intramuscular dosage of 11 mg/kg for 21 days yielding a 95% cure rate, and noninferiority compared with amphotericin. The drug was registered for the treatment of visceral leishmaniasis in India in 2006. In initial studies, paromomycin was well tolerated, with common mild injection pain, uncommon ototoxicity and reversible liver enzyme elevations, and no nephrotoxicity. Paromomycin is much less expensive than liposomal amphotericin or miltefosine, the other promising new therapies for visceral leishmaniasis. 

Sodium and potassium (supplement) Adverse in cases of low sodium/potassium diet, stomach upset, diarrhea. Phlebitis and injection pain with potassium [7,14]... 

Kemp JR, Kilbride MJ, Winnie AP. Intrathecal alcohol neurolysis for the treatment of injectable pain. Pain Digest 1995 5 186-91. 

A controlled study in 100 women showed that pretreatment with intravenous ketamine 10 mg reduced the incidence of injection pain from 84 to 26% of patients (25). 

Uda R, Kadono N, Otsuka M, Shimizu S, Mori H. Strict temperature control has no effect on injection pain with propofol. Anesthesiology 1999 91(2) 591-2. 

Ozturk E, Izdes S, Babacan A, Kaya K. Temperature of propofol does not reduce the incidence of injection pain. Anesthesiology 1998 89(4) 1041. 

Huang YW, Buerkle H, Lee TH, Lu CY, Lin CR, Lin SH, Chou AK, Muhammad R, Yang LC. Effect of pretreatment with ketorolac on propofol injection pain. Acta Anaesthesiol Scand 2002 46(8) 1021. ... 

Pang WW, Huang PY, Chang DP, Huang MH. The peripheral analgesic effect of tramadol in reducing propofol injection pain a comparison with lidocaine. Reg Anesth Pain Med 1999 24(3) 246-9. 

Mok MS, Pang WW, Hwang MH. The analgesic effect of tramadol, metoclopramide, meperidine and hdocaine in amehorating propofol injection pain a comparative study. J Anaesthesiol Chn Pharmacol 1999 15 37 2. 

Memis D, Turan A, Karamanlioglu B, Kaya G, Pamukcu Z. The prevention of propofol injection pain by tramadol or ondansetron. Eur J Anaesthesiol 2002 19(1) 47-51. 

There are several reports of pain during injection of rocuronium (5,6). Eight of 10 patients complained of severe pain, one complained of moderate pain, and another reported an unpleasant sensation (5). This suggests that rocuronium will almost invariably cause pain. The mechanism of this phenomenon is not clear, but there appear to be some similarities to propofol injection pain. Several authors have suggested that rocuronium should not be given to awake patients (5,6). On the other hand, small doses of rocuronium have been used, with some success, to prevent fasciculations and myalgia after suxamethonium (7-10). With regard to the severity of injection pain, rocuronium pretreatment in awake patients does not seem advisable. 

A phase-3 assessment of the accuracy of Levovist (SHU508A, Schering, Berlin) in investigating the portal system has been reported (8). It was injected into peripheral veins in 588 patients in concentrations of 200-400 mg/ml. During the 24 hours after the last injection, pain at the site of injection, vasodilatation, and paresthesia were the only adverse effects definitely related to the injection. There were 18 adverse events in 12 patients and the only severe reaction (fever) was not considered to have been related to Levovist. 

One disadvantage is that intramuscular injection can result in localized (at the site of injection) pain. Furthermore, when drugs arc administered intramuscularly by a person who is not formally trained to do so, the risk of infection from irritating drugs and tissue damage is high. 

Intramuscular Rapid if an aqueous solution less rapid if depot forms Moderate volumes lipid vehicles irritant drugs Inadvertent intravenous injection pain or necrosis at injection site... 

Rhinorrhea may precede miosis as the first indication of exposure to even small amounts of nerve agent vapor. After exposure to high concentrations/ doses by any route, rhinorrhea occurs as part of the generalized increase in secretions. Direct ocular contact to nerve agents may cause miosis, conjunctival injection, pain in or around the eyes, and dim or blurred vision. 

When an initially painful intravenous or intramuscular injection must be administered repetitively, patient reluctance develops. Injection pains are usually accompanied by hemorrhage, edema, inflammation, and tissue necrosis." Among the factors responsible for painful injections, the most important are the drug solubility in aqueous medium, the viscosity, the pH and the hypo- or hyperosmotic character of the injected drug solution, the amount of the injected volume, the site of injection, the pain tolerance of the patient, and the technique of administration. Other factors include precipitation of the drug at the injection site, and localized cell lysis. ... 

Children consistently report that needles and shots are what they fear most. However, with the current immunization schedule that recommends 14 to 33 injections before adolescence, interventions to decrease injection pain need to be performed (Table 7-1). 

Advantages Vapocoolant is sprayed directly onto the skin or applied to a cotton ball that is held on the area to be anesthetized provides local anesthesia within 15 seconds effective in reducing injection pain in children 4-6 years of age. 

Disadvantages Brief duration of action so that procedure should be completed in 1 or 2 min may not be effective in reducing injection pain in infants aged 2-6 months. 

Because octreotide inhibits many other gastrointestinal hormones, it has a variety of intestinal side effects. With prolonged use, gallbladder and biliary tract complications such as cholelithiasis have been reported. About 5% to 10% of patients complain of nausea, diarrhea, and abdominal pain. Local injection pain occurs with about an 8% incidence. With high doses, octreotide may reduce dietary fat absorption, leading to steatorrhea. 

Gl upset. Ilosone prep may cause cholestatic hepatitis. Injections painful due to venodestruction. Increases plasma level of many drugs. Toxicity may result when coadministered w/theophylline, anticoagulants, carbamazepine. 

Most clients state that there is less injection pain associated with the insulin pen than with the traditional insulin syringe. 

Fowler-Kerry S, Lander JR (1987) Management of injection pain in children. Pain 30 169-175 French GM, Painter EC, Coury DL (1994) Blowing away shot pain a technique for pain management during immunization. Pediatrics 93 384-388... 

The reported incidence of pain during injection of propofol is 80%. The mechanism is not known, but direct irritation via nociceptors and activation of the kallik-rein-kinin cascade caused by kininogen release from the vascular wall have been proposed. Various strategies have been used in attempts to prevent propofol injection pain, including concomitant administration of lidocaine, ketamine, sodium thiopental, and fentanyl alteration of the speed of injection and adjusting the temperature of the injection solution. The most effective method to date has been the addition of lidocaine, which reduces the incidence to 40%. Four studies addressing this problem have been reported. 

Ghai B, Makkar JK, Wig J. Effect of pare-coxib pretreatment and venous occlusion on propofol injection pain a prospective, randomized, double-blinded, placebo-controlled study. J Clin Anesth 2010 22 88-92. 

In a prospective double-blind study in 120 children who were randomized to alfentanil 15 micrograms/kg 90 seconds before propofol 3 mg/kg or to propofol 3 mg/kg mixed with 0.1% lidocaine, or both, the incidence of injection pain was significantly lower in the combined group (2.6%) than either of the other two groups (38% and 30% respectively). 

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