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Tayeb BO, Eidelman A, Eidelman CL, McNicol ED, Carr DB. Topical anaesthetics for pain control during repair of dermal laceration. Cochrane Database Syst Rev 2017; 2:CD005364. [PMID: 28230244 PMCID: PMC6464542 DOI: 10.1002/14651858.cd005364.pub3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Topical local anaesthetics provide effective analgesia for patients undergoing numerous superficial procedures, including repair of dermal lacerations. The need for cocaine in topical anaesthetic formulations has been questioned because of concern about adverse effects, thus novel preparations of cocaine-free anaesthetics have been developed. This review was originally published in 2011 and has been updated in 2017. OBJECTIVES To assess whether benefits of non-invasive topical anaesthetic application occur at the expense of decreased analgesic efficacy. To compare the efficacy of various single-component or multi-component topical anaesthetic agents for repair of dermal lacerations. To determine the clinical necessity for topical application of the ester anaesthetic, cocaine. SEARCH METHODS For this updated review, we searched the following databases: Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 11), Cumulative Index to Nursing and Allied Health Literature (CINAHL; 2010 to December 2016), Embase (2010 to December 2016) and MEDLINE (2010 to December 2016). We did not limit this search by language or format of publication. We contacted manufacturers, international scientific societies and researchers in the field. Weemailed selected journalsand reviewed meta-registers of ongoing trials. For the previous version of this review, we searched these databases to November 2010. SELECTION CRITERIA We included randomized controlled trials (RCTs) that evaluated the efficacy and safety of topical anaesthetics for repair of dermal laceration in adult and paediatric participants. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial quality and extracted data. We contacted study authors for additional information when needed. We collected adverse event information from trial reports. We assessed methodological risk of bias for each included study and employed the GRADE approach to assess the overall quality of the evidence. MAIN RESULTS The present updated review included 25 RCTs involving 3278 participants. The small number of trials in each comparison group and the heterogeneity of outcome measures precluded quantitative analysis of data for all but one outcome: pain intensity. In two pooled studies, the mean self-reported visual analogue scale (VAS; 0 to 100 mm) score for topical prilocaine-phenylephrine (PP) was higher than the mean self-reported VAS (0 to 100 mm) score for topical tetracaine-epinephrine-cocaine (TAC) by 5.59 points (95% confidence interval (CI) 2.16 to 13.35). Most trials that compared infiltrated and topical anaesthetics were at high risk of bias, which is likely to have affected their results. Researchers found that several cocaine-free topical anaesthetics provided effective analgesic efficacy. However, data regarding the efficacy of each topical agent are based mostly on single comparisons in trials with unclear or high risk of bias. Mild, self-limited erythematous skin induration occurred in one of 1042 participants who had undergone application of TAC. Investigators reported no serious complications among any of the participants treated with cocaine-based or cocaine-free topical anaesthetics. The overall quality of the evidence according to the GRADE system is low owing to limitations in design and implementation, imprecision of results and high probability of publication bias (selective reporting of data). Additional well-designed RCTs with low risk of bias are necessary before definitive conclusions can be reached. AUTHORS' CONCLUSIONS We have found two new studies published since the last version of this review was prepared. We have added these studies to those previously included and have conducted an updated analysis, which resulted in the same review conclusions as were presented previously.Mostly descriptive analysis indicates that topical anaesthetics may offer an efficacious, non-invasive means of providing analgesia before suturing of dermal lacerations. Use of cocaine-based topical anaesthetics might be hard to justify, given the availability of other effective topical anaesthetics without cocaine. However, the overall quality of the evidence according to the GRADE system is low owing to limitations in design and implementation, imprecision of results and high probability of publication bias (selective reporting of data). Additional well-designed RCTs with low risk of bias are necessary before definitive conclusions can be reached.
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Affiliation(s)
- Baraa O Tayeb
- Tufts University School of MedicinePain Research, Education and Policy (PREP) Program, Department of Public Health and Community Medicine136 Harrison Avenue, Stearns 203BostonMassachusettsUSA
- King Abdulaziz UniversityCollege of MedicineJeddahSaudi Arabia
| | - Anthony Eidelman
- Division of Neuromedicine Pain, University of RochesterDepartment of NeurosurgeryRochesterNew YorkUSA
| | - Cristy L Eidelman
- Children’s Mercy HospitalDepartment of Clinical Pharmacology,Toxicology, and Individualized Pediatric TherapeuticsKansas CityMissouriUSA
| | - Ewan D McNicol
- Tufts University School of MedicinePain Research, Education and Policy (PREP) Program, Department of Public Health and Community Medicine136 Harrison Avenue, Stearns 203BostonMassachusettsUSA
- Tufts Medical CenterDepartment of Anesthesiology and Perioperative MedicineBostonMassachusettsUSA
- Tufts Medical CenterDepartment of PharmacyBostonMassachusettsUSA
| | - Daniel B Carr
- Tufts University School of MedicinePain Research, Education and Policy (PREP) Program, Department of Public Health and Community Medicine136 Harrison Avenue, Stearns 203BostonMassachusettsUSA
- Tufts Medical CenterDepartment of AnesthesiologyBostonMassachusettsUSA
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Kouba DJ, LoPiccolo MC, Alam M, Bordeaux JS, Cohen B, Hanke CW, Jellinek N, Maibach HI, Tanner JW, Vashi N, Gross KG, Adamson T, Begolka WS, Moyano JV. Guidelines for the use of local anesthesia in office-based dermatologic surgery. J Am Acad Dermatol 2016; 74:1201-19. [PMID: 26951939 DOI: 10.1016/j.jaad.2016.01.022] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 12/19/2015] [Accepted: 01/15/2016] [Indexed: 10/22/2022]
Abstract
There are an increasing number and variety of dermatologic surgical procedures performed safely in the office setting. This evidence-based guideline addresses important clinical questions that arise regarding the use and safety of local anesthesia for dermatologic office-based procedures. In addition to recommendations for dermatologists, this guideline also takes into account patient preferences while optimizing their safety and quality of care. The clinical recommendations presented here are based on the best evidence available as well as expert opinion.
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Affiliation(s)
- David J Kouba
- Toledo Clinic Facial Plastics and Dermatology, Toledo, Ohio
| | - Matteo C LoPiccolo
- Toledo Clinic Facial Plastics and Dermatology, Toledo, Ohio; Department of Dermatology, Henry Ford Health System, Detroit, Michigan; Dermatology Specialists of Shelby, Shelby, Michigan
| | - Murad Alam
- Department of Dermatology, Northwestern Memorial Hospital, Chicago, Illinois
| | - Jeremy S Bordeaux
- Department of Dermatology, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Bernard Cohen
- Department of Dermatology-Pediatrics, Johns Hopkins Children's Center, Baltimore, Maryland
| | - C William Hanke
- Laser and Skin Surgery Center of Indiana PC, Carmel, Indiana
| | - Nathaniel Jellinek
- Department of Dermatology, Brown University, East Greenwich, Rhode Island
| | - Howard I Maibach
- Department of Dermatology, UCSF School of Medicine, San Francisco, California
| | - Jonathan W Tanner
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Neelam Vashi
- Department of Dermatology and Center for Ethnic Skin, Boston University School of Medicine, Boston, Massachusetts
| | | | - Trudy Adamson
- Department of Nursing, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Wendy Smith Begolka
- Department of Science, Quality and Practice, American Academy of Dermatology, Schaumburg, Illinois
| | - Jose V Moyano
- Department of Science, Quality and Practice, American Academy of Dermatology, Schaumburg, Illinois.
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Eidelman A, Weiss JM, Baldwin CL, Enu IK, McNicol ED, Carr DB. Topical anaesthetics for repair of dermal laceration. Cochrane Database Syst Rev 2011:CD005364. [PMID: 21678347 DOI: 10.1002/14651858.cd005364.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Topical local anaesthetics are recognized as providing effective analgesia for numerous superficial procedures, including repair of dermal lacerations. The need for cocaine in topical anaesthetic formulations has been questioned due to concern about adverse effects, and so novel preparations of cocaine-free anaesthetics have been developed. OBJECTIVES To compare the efficacy and safety of infiltrated local anaesthetics with those of topical local anaesthetics for repair of dermal lacerations and to evaluate the efficacy and safety of various single or multi-component topical anaesthetics to identify cocaine-free topically applied local anaesthetics that may provide equivalent analgesia to those containing cocaine. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 10); MEDLINE (1966 to November 2010); EMBASE (1980 to November 2010); CINAHL (1982 to November 2010); and reference lists of articles. We also handsearched selected journals, reviewed abstracts presented at international society meetings, reviewed metaregisters of ongoing trials and contacted manufacturers and researchers in the field. SELECTION CRITERIA We included randomized controlled trials (RCTs) that evaluated the efficacy and safety of topical anaesthetics for repair of torn skin in adult and paediatric patients. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial quality and extracted data. We contacted study authors for additional information. We collected adverse event information from the trials. MAIN RESULTS We included 23 RCTs involving 3128 patients. The small number of trials in each comparison group and the heterogeneity of outcome measures precluded quantitative analysis of data in all but one outcome, pain scores using a visual analogue scale. The majority of trials that compared infiltrated and topical anaesthetics are at high risk of bias, which is likely to affect the interpretation of the results. Several cocaine-free topical anaesthetics were found to provide effective analgesic efficacy. However, the data regarding the efficacy of each topical agent is mostly based upon single comparisons, in trials that have unclear or high risk of bias. Mild, self-limited erythematous skin induration occurred in one case after application of topical tetracaine-adrenaline-cocaine (TAC) where a total of 1042 patients were exposed. No serious complications were reported in any of the patients treated with either cocaine-based or cocaine-free topical anaesthetics. AUTHORS' CONCLUSIONS Based on mostly descriptive analysis, topical anaesthetics are possibly an efficacious, non-invasive means of providing analgesia prior to suturing of dermal lacerations. However, additional well designed RCTs with low risk of bias are necessary before definitive conclusions can be made.
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Affiliation(s)
- Anthony Eidelman
- Department of Anesthesiology, Division of Pain Medicine, Barnes Jewish Hospital, Washington University School of Medicine, 660 South Euclid Ave,, Camous Box 8054, St Louis, MO, USA, 63110
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Eidelman A, Weiss JM, Enu IK, Lau J, Carr DB. Comparative efficacy and costs of various topical anesthetics for repair of dermal lacerations: a systematic review of randomized, controlled trials. J Clin Anesth 2005; 17:106-16. [PMID: 15809126 DOI: 10.1016/j.jclinane.2004.05.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2004] [Accepted: 05/24/2004] [Indexed: 11/16/2022]
Abstract
STUDY OBJECTIVES To compare the efficacy of infiltrated local anesthesia with topical anesthesia for repair of dermal laceration, to analyze the efficacy of single or multicomponent topical anesthetics, and to identify topical formulations that are potentially less costly and equally efficacious as cocaine-containing topical anesthetics. DESIGN Systematic review of randomized controlled trials. SETTING University-affiliated hospital. PATIENTS Pediatric and adult subjects. MEASUREMENTS AND MAIN RESULTS Twenty-two trials that randomized more than 3000 patients were identified. The majority of studies demonstrated equivalent or superior analgesic efficacy for topical formulations compared with conventional intradermal infiltration. We found that cocaine is not a mandatory component of topical anesthesia. The literature discloses no significant difference in anesthetic efficacy between topical tetracaine-epinephrine-cocaine and each of the following 6 cocaine-free formulations: lidocaine-epinephrine-tetracaine, lidocaine-epinephrine, tetracaine-phenylephrine, tetracaine-lidocaine-phenylephrine, bupivicaine-norepinephrine, or prilocaine-phenylephrine. CONCLUSION Topical anesthetics are an efficacious, noninvasive means of providing analgesia before suturing of dermal lacerations. The use of cocaine-containing topical anesthetics can no longer be justified in light of its high cost and potential adverse effects. We have summarized the evidence, mostly favorable, supporting the use of various non-cocaine-containing topical anesthetics.
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Affiliation(s)
- Anthony Eidelman
- Department of Anesthesiology and Pain Medicine, Caritas St. Elizabeth's Medical Center, Boston, MA 02135, USA
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Adriansson C, Suserud BO, Bergbom I. The use of topical anaesthesia at children’s minor lacerations: an experimental study. ACTA ACUST UNITED AC 2004; 12:74-84. [PMID: 15041008 DOI: 10.1016/j.aaen.2003.12.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2003] [Accepted: 12/08/2003] [Indexed: 10/26/2022]
Abstract
BACKGROUND In a great many situations within health care and treatment, children are subjected to unnecessary pain and suffering. When local anaesthetics is to be administered the child can experience this as incomprehensible especially when the nursing staff assures the child that no pain would be felt, only to discover soon after, that it actually did hurt at the moment of anaesthetic infiltration. The soothing of pain during the suturing of wounds in emergency wards can be reduced, ensuring that unnecessary pain in the cafe-and-treatment process is mot meted out to children. In order to prevent this (subjection to unnecessary pain), and by improving accepted practice, it was interesting to investigate whether children felt pain at the time of infiltration anaesthesia following the initial topical anaesthesia. AIM The aim of the present study was to investigate the effects of introductory topical anaesthesia using Xylocain solution dropped in the wound prior to a definitive infiltration-anaesthesia. An experimental, prospective design was used where children were included in either an experimental group or a control group. The experimental group (n=10) were given a Xylocain solution while the control group (n=10) received physiological Sodium solution. Data collection for the study was made by making VAS estimates and by interviews. RESULT The study shows that a certain alleviation of pain does occur when using Xylocain but no statistically significant difference exists between the two groups. Irrespective of whether the children received an introductory topical anaesthesia with Xylocain or Sodium solution at the time of infiltration anaesthesia, they expressed pain in connection with infiltration. The study also shows that many children express fear and anxiety. CONCLUSION Current research highlights the difficulties involved in offering children a really satisfactory form of pain relief in connection with infiltration anaesthesia and suturing of wounds. It is urgent to throw more light on children's pain, both from a nursing and from a medical point of view. No statistically significant difference was found in children's reported pain, after treatment with Xylocain but the solution can have a positive effect at the time of the infiltration jab, but a larger study needs to be done in order to establish this firmly.
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Affiliation(s)
- Camilla Adriansson
- Borås University College, School of Health Sciences, Kunskapscentrum PreHospen, Borås 501 90, Sweden
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Shields BJ, Cohen DM, Harbeck-Weber C, Powers JD, Smith GA. Pediatric pain measurement using a visual analogue scale: a comparison of two teaching methods. Clin Pediatr (Phila) 2003; 42:227-34. [PMID: 12739921 DOI: 10.1177/000992280304200306] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The goals of this study were to evaluate the validity of the visual analogue scale (VAS) for young children and to compare a newly developed method of teaching children to use a VAS with one used in our previous studies. It was hypothesized that the new method would increase the number of children who understand the VAS and correctly mark their responses on the VAS line. The association between child's age and ability to understand the VAS was also evaluated. One hundred-six children with a laceration requiring sutures and receiving a lidocaine injection for local anesthesia participated in the study. They ranged in age from 5 to 14 years. Two outcome measures were used to assess the baseline and lidocaine injection pain: a 5-point Likert scale and a VAS. A calibration study was used to determine whether the subjects were able to use the VAS to make proportional judgments about their perceptions. Teaching method had no effect on the number of subjects who could correctly mark their responses on the VAS line, nor did it significantly increase the number of subjects who could understand the concept of the VAS. Subjects who were able to understand the VAS were significantly older (mean = 9.8 years, SD = 2.8) than those who did not (mean = 8.2 years, SD = 2.5). Overall, only about one third of the subjects were able to correctly mark the VAS and understand the concept of the VAS. Other measures of pain that are better understood by young children may be more valid indicators of pain than the VAS.
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Affiliation(s)
- Brenda J Shields
- Center for Injury Research and Policy, The Ohio State University College of Medicine and Public Health, Columbus, OH 43205, USA
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Affiliation(s)
- S Bush
- Accident and Emergency Department, St Jame's University Hospital, Leeds, UK.
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Kaplan RF, Yang CI. Sedation and analgesia in pediatric patients for procedures outside the operating room. ANESTHESIOLOGY CLINICS OF NORTH AMERICA 2002; 20:181-94, vii. [PMID: 11892504 DOI: 10.1016/s0889-8537(03)00060-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Sedation and analgesia in pediatric patients for procedures outside the operating room are becoming more frequent as health care is being driven to be more cost effective and "efficient." Although anesthesiologists may not be directly involved in sedation or analgesia outside of the operating room, there is a high likelihood that they will be asked by their institutions to be integrally involved in creating and supervising sedation policy given that the American Society of Anesthesiologists and the Joint Commission on Accreditation of Healthcare Organizations consider sedation and analgesia as part of a continuum ranging from minimal sedation to moderate sedation and analgesia, deep sedation and analgesia, and, finally, general anesthesia. Further, anesthesiologists will be asked to define, teach, and credential nonanesthesiology practitioners who perform deep sedation because these practitioners are now required to be qualified to "rescue from general anesthesia."
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Affiliation(s)
- Richard F Kaplan
- Department of Anesthesiology, Children's National Medical Center, George Washington University, Washington, DC, USA.
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Abstract
The ability to provide safe, effective procedural sedation and analgesia is a necessary skill for physicians caring for the acutely ill or injured pediatric patient. They physician should be familiar with the agent(s) chosen, including dosage, duration, adverse effects, and contraindications. The choice of agent and regimen should be individualized for the patient and situation. Successful outcomes depend on performing careful pre- and post-sedation evaluations, following appropriate monitoring and equipment guidelines, and having the knowledge and skills to manage any adverse cardiorespiratory event.
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Affiliation(s)
- Elliot Rodriguez
- Department of Emergency Medicine, State University of New York, Upstate Medical University, Syracuse, New York, USA.
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Moseley HS, Kumar AY, Shankar KB. Anesthesia outside the operating room for emergency procedures. Curr Opin Anaesthesiol 1999; 12:411-5. [PMID: 17013343 DOI: 10.1097/00001503-199908000-00003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Non-anesthetists usually provide sedation and anesthesia outside the operating room for emergency procedures. Techniques vary from no sedation to deep sedation using drugs with a good safety profile and few side effects. Newer methods of airway control may allow volatile agents such as sevoflurane to be used. Anesthetists may need to join sedation teams if they are to maintain control of their specialty.
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Affiliation(s)
- H S Moseley
- University of West Indies, Barbados, West Indies
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