Annals of Emergency Medicine
Volume 51, Issue 3 , Pages 331-332, March 2008

Analgesic Effect of Propofol?

Department of Emergency Medicine, University of Mississippi Medical Center, Jackson, MS

Article Outline

 

To the Editor:

The authors of “Clinical Practice Advisory: Emergency Department Procedural Sedation with Propofol” are commended for an excellent and comprehensive review.

Propofol’s role as an analgesic, however, deserves further comment. The authors stated that propofol serves only as a sedative and amnestic and should be used only after full analgesia has been obtained with an opiate.1 Our experience using propofol as the sole procedural sedation agent for brief painful procedures in the emergency department prompted further review.

There has been controversy as to whether hypnotics exerted an analgesic or hyperalgesic effect. Studies with propofol have been conflicting with analgesic effects observed in some studies2, 3 while enhanced pain sensitivity was observed in others.4, 5, 6

More recent data suggest that propofol modulates the enhanced pain sensitivity seen after μ receptor agonist administration,7 and that it may do so by direct action at the spinal cord level via γ-amino-butyric acid A and glycine (both inhibitory neurotransmitters) receptor modulation.8, 9 Additional mechanisms of analgesia include propofol-induced release of β-endorphins and potential activation of cannabinoid receptors.10, 11

Also, propofol inhibits the N-methyl-D-aspartate (NMDA) receptor (NRI subunit) complex, which plays a profound role in the development of central (spinal) sensitization and subsequent post injury or post procedure pain.12, 13

In summary, an extensive and very satisfactory clinical experience at our institution using propofol as the sole procedural sedation agent (supported by both animal and human data) argues that propofol offers clinical analgesia for brief painful procedures.

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References 

  1. Miner JR, Burton JH. Clinical practice advisory: emergency department procedural sedation with propofol. Ann Emerg Med. 2007;50:182–187
  2. Anker-Moller E, Spangoberg N, Arendt-Nelson L, et al. Subhypnotic doses of thiopenton and propofol cause analgesia to experimentally induced acute pain. Br J Anaesth. 1991;185–188CG
  3. Kingston S, Mao L, Yang L, et al. Propofol inhibits phosporylation of N-methyl-d-aspartate recepeptor NRI submits in neurons. Anesthesiology. 2006;104:763–769
  4. Wilder-Smith OH, Kolletzkim , Wider-Smith CH. Sedation with intravenous infusions of propofol or thropentone; effects on pain perception. ? Anaesthesia. 1995;50:218–222
  5. Ewen A, Arches DP, Samanani N, Roth SH. Hyperalgesia during sedation: effects of barbiturates and propofol in the rat. Can J Anaesth. 1995;42:532–540
  6. Peterson-Felix S, Arendt-Neilson L, Bale P, et al. Psychophysical and electrophysiological responses to experimental pain may be influenced by sedation: comparison of the effects of hypnotic (propofol) and an analgesic (alfentamil). BR J Anaesth. 1996;77:165–171
  7. Frolich MA, Price DD, Robinson ME, et al. The effect of propofol on thermal pain perception. Anesth Analg. 2005;22:467–470
  8. Singler B, Twister A, Manering N, et al. Modulation of remifentanil induced post infusion hyperanalgesia by propofol. Anesth Anal. 2007;104:1397–1403
  9. Dong XP, Xu TL. The actions of propofol on Y-amino-butyric acid -A and glycine receptors in acutely dissociated spinal horns of the rat. Anesth Analg. 2002;995:907–914
  10. Wang QY, Cao JL, Zeng YM, et al. GABAa receptor partially mediated propofol induced hyperalgesia at supraspinal level and analgesia at spinal cord level in rats. Acta Pharmacol Sin. 2004;25:1619–1625
  11. Avwar MM, Abdel-Rahman MS. Effect on perception of pain in MICU. mechanisms of action Comp Biochem Physiol A. 1998;120:249–253
  12. Fowler CJ. Possible involvement of the endocannabinoid system in the actions of three clinically used drugs. Trends Pharmacol Sci. 2004;25:59–67
  13. Wooft CJ, Thompson SW. The induction and maintenance of central sensitisation is dependent on N-methyl-D aspartate acid receptor activation: implication for the treatment of post injury pain hypersensitivity states. Pain. 1991;44:293–299

 Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article, that might create any potential conflict of interest. The authors have stated that no such relationships exist. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement.

PII: S0196-0644(07)01631-9

doi:10.1016/j.annemergmed.2007.09.034

Refers to article:

  • Clinical Practice Advisory: Emergency Department Procedural Sedation With Propofol , 06 March 2007

    James R. Miner, John H. Burton
    Annals of Emergency Medicine August 2007 (Vol. 50, Issue 2, Pages 182-187.e1)

Annals of Emergency Medicine
Volume 51, Issue 3 , Pages 331-332, March 2008

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