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Department of Anesthesiology; Harbor-UCLA Medical Center; Torrance, CA; ckakazu{at}msn.com
To the Editor:
We read with great interest the article written by Agarwal et al. (1) regarding pain attenuation of propofol injection with prior administration of IV butorphanol.
After reading the authors’ discussion, we would like to make several suggestions and corrections regarding IV butorphanol. Indeed, IV butorphanol’s onset time and peak effect is 1–2 min and 4–5 min, respectively’ however, the reference for this information is incorrect. After reading in Miller’s Anesthesia (5th edition), Bailey et al. (2) mentions only butorphanol’s effect upon IM administration. The original studies on IV butorphanol’s pharmacokinetics were published in 1977 by Lippmann et al. (3). In that double-blind placebo-controlled study, we found that IV butorphanol 2 mg was significantly better than placebo at the 1-min observation period with respect to pain intensity (P < 0.02), pain intensity difference (P < 0.02), and pain relief (P < 0.01). Butorphanol was also significantly better (P < 0.01) than placebo according to these same parameters for the remainder of the study (2-,3-,4-,5-,10-,15-,30-, and 60-min observation periods). While a high level of analgesic activity was maintained with butorphanol over the entire 60-min observation period, the peak effect was achieved in 4–5 min.
Butorphanol has excellent sedative effects alone and especially in combination with other agents such as promethazine (4). One must be careful in administering 2 mg butorphanol before administering propofol. The combination may lead to profound sedation, especially when also receiving fentanyl. Prolong awakening is undesirable when surgery is performed on an outpatient basis.
Finally, Dr. Agarwal also states that butorphanol is not a restricted drug like other narcotics. Here in the United States, it is designated as a Class IV drug by the Drug Enforcement Agency, because of its habit-forming potential. Therefore, it is considered a "controlled substance."
Butorphanol exerts its action mainly on the central nervous system rather than on the periphery. Because of its excellent analgesic effect along with its sedative action, the pain derived from the administration of IV propofol would indeed be markedly reduced.
References
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