Efficacy of ethyl chloride as a local anesthetic for venipuncture and intravenous cannula insertion in a pediatric emergency department

Local analgesia for the relief of pain in children undergoing venipuncture and intravenous cannulation: a systematic review and network meta-analysis

BACKGROUND

Venipuncture and intravenous cannulation are common procedures in hospitals that often cause pain, particularly in children. Despite the availability of various local analgesia methods to alleviate needle-associated pain, the most effective approach remains unknown. The objective of this study is to compare and rank the efficacy of different local analgesia methods in reducing pain in children undergoing venipuncture and intravenous cannulation.

METHOD

Six databases including PubMed, Embase, CINAHL, Scopus, Web of Science, and the Cochrane Library were searched from January 1,1990 to December 1,2024. The primary outcome is the self-reported pain. We assessed the certainty of the body of evidence from the NMA for the primary outcome based on CINeMA.

RESULT

40 RCTs consisting of 4481 children and 9 local analgesia methods were included in the analysis. Results showed that vapocoolant spray was no more effective than placebo or routine care in reducing needle-associated pain in children. Other interventions including EMLA cream, lidocaine cream, lidocaine iontophoresis, amethocaine, needle-free lidocaine injection system, EMLA patch, lidocaine/tetracaine heating patch and Buzzy produced greater pain reduction in children compared to placebo and routine care. Amethocaine was the most effective local analgesia method with the probability of 57.6% being the best, followed by Buzzy and lidocaine iontophoresis with the probability of 17.0% and 8.4%, respectively.

CONCLUSION

Most local analgesia methods were effective in relieving pain in children undergoing venipuncture and intravenous cannulation except vapocoolant spray which did not show greater pain reduction than placebo or routine care. Amethocaine, Buzzy and lidocaine iontophoresis are the top 3 local analgesia methods to relieve pain in children undergoing venipuncture and intravenous cannulation. However, due to the limited number of direct comparisons, interpretation of some results should be made with caution.

Efficacy and safety of vapocoolant spray for vascular puncture in children and adults: A systematic review and meta-analysis

OBJECTIVE

The aim was to evaluate the effectiveness and safety of the vapocoolants for vascular puncture in children and adults.

METHOD

The search was carried out in PubMed, Web of Science, Embase and The Cochrane Library, from inception to March 2022. Randomized controlled trials comparing vapocoolants to control conditions for participants received intravenous cannulation or arterial puncture were included. Two reviewers independently performed selection of studies, data extraction, and assessment of risk of bias. The analysis was performed using fixed or random-effects model with mean differences or standardized mean difference and risk ratios.

RESULTS

A total of 25 studies involving 3143 participants were included. Compared with control conditions, vapocoolants may not decrease the pain of patients with arterial puncture (SMD = -0.36, 95% CI = -0.92 to -0.19, P = 0.20), but may more effectively relieve pain for adults received vein puncture (SMD = -0.65, 95% CI = -0.85 to -0.45, P < 0.00001). The application of vapocoolant increased the procedural difficulty of medical personnel (RR = 2.49, 95% CI = 1.62 to 3.84, P<0.000 1) and participants were more willing to use the spray in the future (RR = 1.88, 95% CI = 1.34 to 2.64, P = 0.0002). There was no significant difference for the first attempt success rate of the procedure and the occurrence of adverse events.

CONCLUSIONS

Vapocoolant spray may relieve pain in adults received vein puncture and cannot cause severe side effects, but is ineffective in children. It also had no effect on patients with arterial puncture. In addition, the application of spray increases procedural difficulties for medical professionals, but does not decrease first attempt success rate, and many patients would like to use the spray again for pain relief in the future. Thus, more rigorous and large-scale studies are needed to determine its effectiveness in vascular access.

Local and Topical Anesthetics for Pediatric Patients in the Emergency Department

Painful diagnostic and therapeutic procedures are common in the emergency department. Adequately treating pain, including the pain of procedures is an essential component of the practice of emergency medicine. Pain management is also part of the core competency for emergency medicine residencies and pediatric emergency medicine fellowships. There are many benefits to providing local and/or topical anesthesia before performing a medical procedure, including better patient and family satisfaction and increased procedural success rates. Local and topical anesthetics when used appropriately, generally, have few, if any, systemic side effects, such as hypotension or respiratory depression, which is an advantage over procedural sedation. Use of local and topical anesthetics can do much toward alleviating the pain and anxiety of pediatric patients undergoing procedures in the emergency department.

Prospective, double blind, randomized, controlled trial comparing vapocoolant spray versus placebo spray in adults undergoing intravenous cannulation

OBJECTIVES

Painful diagnostic and therapeutic procedures are common in the health care setting. Eliminating, or at least, minimizing the pain associated with various procedures should be a priority. Although there are many benefits of providing local/topical anesthesia prior to performing painful procedures, ranging from greater patient/family satisfaction to increased procedural success rates; local/topical anesthetics are frequently not used. Reasons include the need for a needlestick to administer local anesthetics such as lidocaine and the long onset for topical anesthetics. Vapocoolants eliminate the risks associated with needlesticks, avoids the tissue distortion with intradermal local anesthetics, eliminates needlestick pain, have a quick almost instantaneous onset, are easy to apply, require no skills or devices to apply, are convenient, and inexpensive. The aims of this study were to ascertain if peripheral intravenous (PIV) cannulation pain would be significantly decreased by using a vapocoolant (V) versus sterile water placebo (S) spray, as determined by a reduction of at least ≥1.8 points on numerical rating scale (NRS) after vapocoolant versus placebo spray, the side effects and incidence of side effects from a vapocoolant spray; and whether there were any long term visible skin abnormalities associated with the use of a vapocoolant spray.

MATERIALS AND METHODS

Prospective, randomized, double-blind controlled trial of 300 adults (ages 18-80) requiring PIV placement in a hospital ED, randomized to S (N=150) or V (N=150) prior to PIV. Efficacy outcome was the difference in PIV pain: NRS from 0 (none) to worst (10). Safety outcomes included a skin checklist for local adverse effects (i.e., redness, blanching, edema, ecchymosis, itching, changes in skin pigmentation), vital sign (VS) changes, and before/after photographs of the PIV site.

RESULTS

Patient demographics (age, gender, race), comorbidity, medications, and vital signs; and PIV procedure variables (e.g., IV needle size, location, number of IV attempts, type and experience of healthcare provider performing the IV) were not significantly different for the two groups. Median (interquartile range) PIV pain was 4 (2, 7) (S) and 2 (0, 4) (V) (P<0.001). Skin checklist revealed minimal erythema: S 0% (N=0/150), V: 2.7% (4/150), which resolved within 5min, and no blanching, skin pigmentation changes, itching, edema, or ecchymosis. Photographs at 5-10min revealed no visible skin changes in any patient (N=300), vapocoolant (N=150) or placebo groups (N=150). Complaints (N=26) were coolness/cold feeling S 8.7% (N=13), V 7.3% (N=11), coolness/numbness S 0% (N=0), V 0.7% (N=1), and burning S 0.7% (N=1), V 0 (0%). Patient acceptance of the vapocoolant spray was high: 82% (123/150) of the patients stated they would use the spray in the future, while only 40.7% (61/150) of the placebo group stated they would use the placebo spray in the future.

CONCLUSIONS AND IMPLICATIONS

Vapocoolant spray significantly decreased peripheral intravenous cannulation pain in adults versus placebo spray and was well tolerated with minor adverse effects that resolved quickly. There were no significant differences in vital signs and no visible skin changes documented by photographs taken within 5-10min postspray/PIV.

Randomized controlled trial of topical EMLA and vapocoolant spray for reducing pain during wDPT vaccination

BACKGROUND

Intramuscular vaccination is among the most common source of iatrogenic pain in infants. Vapocoolant sprays are rapid-acting alternative to topical anesthetics. They provide transient anesthesia via evaporation induced skin cooling, and reduce pain due to vaccine injection in children and adults. The objective was to compare the synergistic analgesic effect of eutectic mixture of local anesthetics (EMLA) with breastfeeding (EB group) and vapocoolant spay with breastfeeding (VB group) to that of only breastfeeding (BO group) during whole cell diptheria, pertussis and tetanus (wDPT) vaccination.

METHODS

A double blind randomized controlled trial was done to include infants up to 3 months of age who came for their first wDPT vaccination. The primary outcome variable was the duration of cry after vaccination. Secondary outcome variables were Modified Facial Coding Score, Neonatal Infant Pain Scale and latency of onset of cry.

RESULTS

Of the 201 eligible participants, 111 babies were excluded and remaining 90 babies were randomized into three groups of thirty each. The groups did not differ significantly in baseline characteristics. Median (interquartile range, IQR) of duration of cry was lesser [35.86 (21.07-107.75) seconds] in babies receiving EMLA cream with breast feeding (EB group) and in babies receiving vapocoolant spray with breast feeding (VB group) [32.58 (21.25-106.21) seconds] as compared to babies receiving only breast feeding (BO group) [67.5 (27.6-180) seconds] (P=0.147). Difference in median (IQR) of latency of cry was not statistically significant. Modified Facial Coding Score and Neonatal Infant Pain Scale at 1 minute and 3 minutes was significantly lower in the EB and VB group, as compared to the BO group (P<0.05).

CONCLUSION

Addition of topical EMLA application or vapocoolant spray to breastfeeding during wDPT vaccination does not reduce duration of cry in infants up to 3 months of age. However, they are able to show reduction in pain score and further studies are warranted to assess their efficacy as pain relief measures in infants and children.

Use and Effectiveness of Ethyl Chloride for Hand Injections

PURPOSE

Limited literature supports using ethyl chloride topical spray as an anesthetic for hand injections whereas documented risks include frostbite, skin irritation, and inhalation toxicity. We hypothesize that ethyl chloride spray imparts no benefit to patients' perception of pain or anxiety for routine hand injections.

METHODS

We first surveyed all members of the American Society for Surgery of the Hand to discern the prevalence of ethyl chloride use during routine injections. We then performed a prospective, randomized, study at 2 institutions evaluating the efficacy of ethyl chloride spray compared with "routine injection" (no topical spray) in patients indicated for a hand injection. All patients completed a pre- and postinjection 11-point questionnaire that inquired about various components of pain and anxiety.

RESULTS

A total of 2,083 (73% response rate) American Society for Surgery of the Hand members responded to the survey and revealed that 59% of hand surgeons always or often use ethyl chloride, and 24% never use it. There were no differences for region or practice setting, but experienced surgeons were less likely to routinely use ethyl chloride (35%) compared with younger surgeons (66%). Among 151 patients participating in the clinical study (75 with ethyl chloride), there were no differences for any outcome measure assessed. Injection pain in the spray and no-spray groups, pain after 1 minute, and overall anxiety were equivalent. Subgroup analysis demonstrated no effect of sex, anticipated anxiety, or pain threshold.

CONCLUSIONS

Ethyl chloride is widely used among hand surgeons but imparts no benefit for routine hand injections in the clinical setting. The potential risks and costs of ethyl chloride use may outweigh its benefits.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Managing Pediatric Pain in the Emergency Department

Far more attention is now given to pain management in children in the emergency department (ED). When a child arrives, pain must be recognized and evaluated using a pain scale that is appropriate to the child's development and regularly assessed to determine whether the pain intervention was effective. At triage, both analgesics and non-pharmacological strategies, such as distraction, immobilization, and dressing should be started. For mild pain, oral ibuprofen can be administered if the child has not received it at home, whereas ibuprofen and paracetamol are suitable for moderate pain. For patients who still require pain relief, oral opioids could be considered; however, many EDs have now replaced this with intranasal fentanyl, which allows faster onset of pain relief and can be administered on arrival pending either intravenous access or definitive care. Intravenous opioids are often required for severe pain, and paracetamol or ibuprofen can still be considered for their likely opioid-sparing effects. Specific treatment should be used for patients with migraine. In children requiring intravenous access or venipuncture, non-pharmacological and pharmacological strategies to decrease pain and anxiety associated with needle punctures are mandatory. These strategies can also be used for laceration repairs and other painful procedures. Despite the gaps in knowledge, pain should be treated with the most up-to-date evidence in children seen in EDs.

Vapocoolants (cold spray) for pain treatment during intravenous cannulation

BACKGROUND

Intravenous cannulation is a painful procedure that can provoke anxiety and stress. Injecting local anaesthetic can provide analgesia at the time of cannulation, but it is a painful procedure. Topical anaesthetic creams take between 30 and 90 minutes to produce an effect. A quicker acting analgesic allows more timely investigation and treatment. Vapocoolants have been used in this setting, but studies have reported mixed results.

OBJECTIVES

To determine effects of vapocoolants on pain associated with intravenous cannulation in adults and children. To explore variables that might affect the performance of vapocoolants, including time required for application, distance from the skin when applied and time to cannulation. To look at adverse effects associated with the use of vapocoolants.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Latin American Caribbean Health Sciences Literature (LILACS), the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Institute for Scientific Information (ISI) Web of Science and the http://clinicaltrials.gov/, http://www.controlled-trials.com/ and http://www.trialscentral.org/ databases to 1 May 2015. We applied no language restrictions. We also scanned the reference lists of included papers.

SELECTION CRITERIA

We included all blinded and unblinded randomized controlled trials (RTCs) comparing any vapocoolant with placebo or control to reduce pain during intravenous cannulation in adults and children.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed trial quality and extracted data, contacted study authors for additional information and assessed included studies for risk of bias. We collected and analysed data for the primary outcome of pain during cannulation, and for the secondary outcomes of pain associated with application of the vapocoolant, first attempt success rate of intravenous cannulation, adverse events and participant satisfaction. We performed subgroup analyses for the primary outcome to examine differences based on age of participant, type of vapocoolant used, application time of vapocoolant and clinical situation (emergency vs elective). We used random-effects model meta-analysis in RevMan 5.3 and assessed heterogeneity between trial results by examining forest plots and calculating the I(2) statistic.

MAIN RESULTS

We found nine suitable studies of 1070 participants and included them in the qualitative analyses. We included eight studies of 848 participants in the meta-analysis for the primary outcome (pain during intravenous cannulation). Use of vapocoolants resulted in a reduction in pain scores as measured by a linear 100 mm visual analogue scale (VAS 100) compared with controls (difference between means -12.5 mm, 95% confidence interval (CI) -18.7 to -6.4 mm; moderate-quality evidence). We could not include in the meta-analysis one study, which showed no effects of the intervention.Use of vapocoolants resulted in increased pain scores at the time of application as measured by a VAS 100 compared with controls (difference between means 6.3 mm, 95% CI 2.2 to 10.3 mm; four studies, 461 participants; high-quality evidence) and led to no difference in first attempt success compared with controls (risk ratio (RR) 1.00, 95% CI 0.94 to 1.06; six studies, 812 participants; moderate-quality evidence). We documented eight minor adverse events reported in 279 vapocoolant participants (risk difference (RD) 0.03, 95% CI 0 to 0.05; five studies, 551 participants; low quality-evidence).The overall risk of bias of individual studies ranged from low to high, with high risk of bias for performance and detection bias in four studies. Sensitivity analysis showed that exclusion of studies at high or unclear risk of bias did not materially alter the results of this review.

AUTHORS' CONCLUSIONS

Moderate-quality evidence indicates that use of a vapocoolant immediately before intravenous cannulation reduces pain during the procedure. Use of vapocoolant does not increase the difficulty of cannulation nor cause serious adverse effects but is associated with mild discomfort during application.

An Evidence-Based Approach to Minimizing Acute Procedural Pain in the Emergency Department and Beyond

BACKGROUND

Painful procedures are common in the ED setting and beyond. Although these procedures are often essential to patient management, they can also be distressing for children, parents, and health providers. As such, it is imperative that effective pain and anxiety-minimizing strategies be used consistently in all settings where painful procedures take place for children.

OBJECTIVES

This review article aims to provide a summary of several strategies, which are supported by definitive and systematically reviewed evidence, that can be implemented alone or in combination to reduce procedural pain and anxiety for children in the ED and beyond.

RESULTS

For neonates, breastfeeding, nonnutritive sucking, swaddling, and sucrose administration have all been shown to decrease pain during painful interventions. For neonates, venipuncture is much less painful than heel lance for blood draws. For infants, there is some support for sucrose use. For infants and older children, there is strong evidence for distraction techniques. In addition, the use of fast-acting topical anesthetic creams as an alternative or adjunct to infiltrating anesthetic before laceration repair or vascular access/venipuncture is recommended. Further, buffering of lidocaine can decrease pain during injection. Lastly, if a laceration is amenable to the use of tissue adhesive, this should be preferentially used.

CONCLUSIONS

In summary, there currently remains a knowledge-to-practice gap in the treatment of children's procedure-related pain. This article has identified multiple age-specific methods to improve the treatment of procedural pain. These simple interventions can improve the care provided to ill and injured children.

A systematic review of vapocoolants for reducing pain from venipuncture and venous cannulation in children and adults

BACKGROUND

Studies of vapocoolants for pain reduction from venipuncture have demonstrated conflicting results.

OBJECTIVE

Our aim was to systematically review the literature regarding the analgesic effectiveness of vapocoolants in children and adults.

METHODS

We searched MEDLINE, EMBASE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Cochrane Central Register of Trials using key words: vapocoolant, pain, venipuncture, and cannulation. We included randomized or quasi-randomized studies comparing vapocoolants to placebo or no treatment. Two authors reviewed titles and abstracts and extracted data. Quality was assessed by consensus using the Cochrane risk of bias tool. The primary outcome was self-reported pain using a 100-mm visual analog scale, a 0- to 10-point numerical scale, or observational scale for preverbal children. Data were pooled using a random effects model.

RESULTS

Twelve studies including 1266 patients (509 children, 757 adults) were identified. No significant pain reduction was found in children receiving vapocoolants vs. placebo or no treatment (mean difference -10 mm; 95% confidence interval [CI] -26 to 6). In adults, less pain was reported when vapocoolants were compared with no treatment: -10 mm on a 100-mm scale (95% CI -17 to -4); but not when compared to placebo (-12 mm; 95% CI -26 to 2). Pain from application of vapocoolants was greater than placebo (8 mm; 95% CI 4 to 2).

CONCLUSIONS

Vapocoolants were ineffective in children and adults when compared to placebo, and effective in adults only when compared to no treatment. The magnitude of effect was low and was offset by increased pain from application. They cannot be recommended for routine use in children or adults.

Common office procedures and analgesia considerations

This article reviews common office procedures and analgesia considerations for pediatric outpatients. Layer times of onset of analgesics to coincide with procedures. Pediatric procedural distress is multimodal. Always address parent and child fear and attention, along with pain.

Cryotherapeutic topical analgesics for pediatric intravenous catheter placement: ice versus vapocoolant spray

OBJECTIVES

Intravenous catheter placement is one of the most common sources of pain for children in inpatient settings. We sought to compare the efficacy of 2 cryotherapeutic treatments for this procedure: vapocoolant spray versus topical ice pack.

METHODS

We prospectively enrolled 95 patients, aged 9 to 18 years, in a pediatric emergency department who required intravenous (IV) catheters as part of their treatment. Subjects were randomly assigned to receive vapocoolant spray or topical ice pack for 3 minutes, before IV catheter placement. Subjects completed visual analog scale (VAS) scores for 3 time points: baseline, pretreatment with ice or spray, and IV insertion. The principal investigator and 2 physicians viewing video recordings of the procedure also completed VAS scores for observed pain levels. Visual analog scale scores were compared using the Wilcoxon rank sum test.

RESULTS

Although median VAS scores were similar, the change in VAS from baseline was of greater magnitude in the Painease group, indicating that it may be more effective. More subjects in the Painease group (76%) felt their treatment worked well, compared with 49% in the ice group. Physician-assigned VAS scores were lower and less variable than those of subjects. Most IV insertions were successful (83%).

CONCLUSIONS

Vapocoolant spray may be more effective than ice as an analgesic for IV insertion. Subjects were more satisfied with vapocoolant spray. Neither agent caused a decrease in successful IV insertion rates.

Relief of pain during blood specimen collection in pediatric patients

PURPOSE

To investigate the effect of external cold and vibration stimulation via Buzzy on pain and anxiety levels of children during blood specimen collection.

STUDY DESIGN AND METHODS

This study was a randomized controlled trial. The sample consisted of 120 children aged from 6 to 12 years undergoing phlebotomy. We randomly assigned subjects to a control group (no intervention) or an experimental group that received external cold and vibration via a device called Buzzy. External cold and vibration were applied just before the blood specimen collection procedure and continued until the end of the procedure. Preprocedural and procedural anxiety were assessed using the children's anxiety and pain scale along with parent and observer reports. Procedural pain was assessed via the faces pain scale-revised along with self-report of children, and parents' and observer's reports.

RESULTS

The experimental group showed significantly lower pain (p < .001) and anxiety levels (p < .001) compared to the control group during the blood specimen collection procedure. Use of Buzzy did not cause a significant difference in the success of the blood specimen collection procedure.

CLINICAL IMPLICATIONS

Use of external cold and vibration via Buzzy decreased perceived pain and reduced children's anxiety during blood specimen collection.

An integration of vibration and cold relieves venipuncture pain in a pediatric emergency department

OBJECTIVE

A randomized controlled trial compared a reusable device combining cold and vibration to standard care for pediatric venous access pain relief.

METHODS

Pediatric emergency department patients received either the cold vibration device placed 5 to 10 cm proximally throughout venipuncture or standard care control (primarily vapocoolant spray). Block randomization of patients with or without lidocaine cream already in place ensured equal allocation in both intervention groups. Pain was measured via self- and parent-report using the 0- to 10-point Faces Pain Scale-Revised and with coded videotaped observed behaviors. Venipuncture success, use of distraction, and access times were also assessed.

RESULTS

Eighty-one 4- to 18-year-olds were randomized to the device (n = 41) or standard care (n = 40) (median age, 10.09 years; 95% confidence interval [95% CI], 8.91-10.89). Median patient-reported pain scores with the device were lower than with standard care (-2; 95% CI, -4 to 0), as were parent-assessed pain scores (-2; 95% CI, -4 to -2). Observed distress behaviors were more common with standard care (2; 95% CI, 1-3) than with the device (1; 95% CI, 0-2). Venipuncture success was more likely with the device (odds ratio, 3.05; 95% CI, 1.03-9.02). There were no device refusals.

CONCLUSIONS

The combination of cold and vibration decreased venipuncture pain significantly more than standard care without compromising procedural success. A device incorporating these elements could overcome the common barriers to needle procedure pain control.

A randomized controlled trial of vapocoolant for pediatric immunization distress relief

OBJECTIVES

The purpose of this study was to evaluate the effectiveness of vapocoolant for preschoolers' immunization injection pain relief.

METHODS

Fifty-seven 4 to 6-year-old children were randomized into vapocoolant alone or typical care conditions. Pain was measured at the baseline and at injection via self-report, caregiver report, nurse report, and by an observational scale.

RESULTS

Self-report of pain suggested that children in the vapocoolant alone condition demonstrated stronger increases in pain from baseline to injection than children in the typical care condition. All other measures showed significant increases in pain from baseline to injection, but no other measures indicated treatment effects.

DISCUSSION

This study revealed that vapocoolant is not an effective pain management intervention for children's intramuscular injections.

Pharmacologic approaches for reducing venous access pain in children

A variety of pharmacologic options are available to clinicians who want to provide effective and safe topical local anesthesia to children undergoing venous access procedures. These options can be distinguished on the basis of how they deliver active drug through the impermeable outer layer of skin, the stratum corneum, to pain receptors located in the dermis and epidermis. Three general methodologies are typically used to bypass the stratum corneum: direct injection of local anesthetics, usually via a small-gauge hypodermic syringe; passive diffusion from topical creams or gels; and active needle-free drug strategies that enhance the rate of drug passage into the dermis and epidermis. Examples of the latter mechanisms include heat-enhanced diffusion, iontophoresis, sonophoresis, laser-assisted transdermal passage, and pressurized gas delivery of powdered drug particles. Pharmacologic options in this setting can also be distinguished on the basis of the time to onset of full anesthetic effect. Several available agents induce significant local anesthesia within 1 to 3 minutes of administration, or faster, allowing easy integration into the skin preparation and subsequent venous access procedure. In combination with nonpharmacologic approaches, these agents can be used to dramatically lessen this significant source of pediatric pain.

Anaesthesia for arterial puncture in the emergency department: a randomized trial of subcutaneous lidocaine, ethyl chloride or nothing

OBJECTIVE

To determine whether the use of ethyl chloride and subcutaneous lidocaine are associated with a reduction in pain during arterial blood sampling compared with using no local anaesthesia.

METHODS

Patients over the age of 16 years and who required arterial blood sampling as part of their on-going emergency department management were randomly allocated to one of three groups. Group A received routine skin preparation before arterial puncture (AP); group B received 0.5 ml of 2% lidocaine 2 min before AP; and group C received ethyl chloride immediately before AP. Pain was measured using 100-mm visual analogue scale.

SETTING

Two urban emergency departments.

RESULTS

Fifty-four patients were recruited. Those receiving lidocaine before AP had lower pain scores [10.2 mm, 95% confidence interval (CI): 4.8-16.3 mm] compared with the use of ethyl chloride (23.9 mm, 95% CI: 12.4-35.5 mm) and nothing (23.4 mm, 95% CI: 11.7-35.0 mm). Lidocaine was more painful to administer (22.0 mm, 95% CI: 10.9-33.7 mm) compared with ethyl chloride (12.9 mm, 95% CI: 5.5-20.3 mm).

CONCLUSION

Ethyl chloride is not an effective local anaesthetic agent for AP. When the pain of local anaesthetic administration is taken into account the benefit of subcutaneous lidocaine for single AP is limited.

Jet Injection of 1% buffered lidocaine versus topical ELA-Max for anesthesia before peripheral intravenous catheterization in children: a randomized controlled trial

BACKGROUND

Peripheral intravenous (PIV) catheter insertion is a frequent, painful procedure that is often performed with little or no anesthesia. Current approaches that minimize pain for PIV catheter insertion have several limitations: significant delay for onset of anesthesia, inadequate anesthesia, infectious disease exposure risk from needlestick injuries, and patients' needle phobia.

OBJECTIVE

Comparison of the anesthetic effectiveness of J-Tip needle-free jet injection of 1% buffered lidocaine to the anesthetic effectiveness of topical 4% ELA-Max for PIV catheter insertion.

METHODS

A prospective, block-randomized, controlled trial comparing J-Tip jet injection of 1% buffered lidocaine to a 30-minute application of 4% ELA-Max for topical anesthesia in children 8 to 15 years old presenting to a tertiary care pediatric emergency department for PIV catheter insertion. All subjects recorded self-reported visual analog scale (VAS) scores for pain at time of enrollment and pain felt following PIV catheter insertion. Jet injection subjects also recorded pain of jet injection. Subjects were videotaped during jet injection and PIV catheter insertion. Videotapes were reviewed by a single blinded reviewer for observer-reported VAS pain scores for jet injection and PIV catheter insertion.

RESULTS

Of the 70 children enrolled, 35 were randomized to the J-Tip jet injection group and 35 to the ELA-Max group. Patient-recorded enrollment VAS scores for pain were similar between groups (P = 0.74). Patient-recorded VAS scores were significantly different between groups immediately after PIV catheter insertion (17.3 for J-Tip jet injection vs 44.6 for ELA-Max, P < 0.001). Blinded reviewer assessed VAS scores for pain after PIV catheter insertion demonstrated a similar trend, but the comparison was not statistically significant (21.7 for J-Tip jet injection vs 31.9 ELA-Max, P = 0.23).

CONCLUSION

J-Tip jet injection of 1% buffered lidocaine provided greater anesthesia than a 30-minute application of ELA-Max according to patient self-assessment of pain for children aged 8 to 15 years undergoing PIV catheter insertion.

The effect of vapocoolant spray on pain due to intravenous cannulation in children: a randomized controlled trial

BACKGROUND

Established noninvasive pharmacologic means of alleviating pain and anxiety in children undergoing intravenous cannulation are time-consuming, and thus impractical for routine use in the emergency department. Vapocoolant sprays provide transient skin anesthesia within seconds of application. We compared the effect of a new vapocoolant spray to placebo on pain due to intravenous cannulation in children.

METHODS

In this double-blind randomized controlled trial, which we conducted between June 1 and Sept. 12, 2006, 80 children aged 6-12 years received either vapocoolant spray or placebo before cannulation. Children rated their pain using a 100-mm colour visual analogue scale. Secondary outcomes included success rate on first attempt at cannulation and pain ratings by the children's parents, nurses and child life specialists.

RESULTS

We found a modest but significant reduction in pain with the use of vapocoolant spray (mean difference 19 mm, 95% confidence interval [CI] 6-32 mm; p < 0.01). Cannulation on first attempt was more often successful with the use of vapocoolant spray (85.0%) than with placebo (62.5%) (mean difference 22.5%, 95% CI 3.2%-39.9%; p = 0.03). The number needed to treat to prevent 1 cannulation failure was 5 (95% CI 3-32). Parents (p = 0.04), nurses (p = 0.01) and child life specialists (p < 0.01) considered the children's pain to be reduced with the use of vapocoolant spray.

INTERPRETATION

The vapocoolant spray in our study quickly and effectively reduced pain due to intravenous cannulation in children and improved the success rate of cannulation. It is an important option to reduce childhood procedural pain in emergency situations, especially when time precludes traditional interventions. (http://ClinicalTrials.gov trial register no. NCT00130650.).

A novel needle-free powder lidocaine delivery system for rapid local analgesia

OBJECTIVE

To determine the analgesic effect and tolerability of a novel needle-free powder lidocaine delivery system in children undergoing venipuncture.

STUDY DESIGN

In this double-blind, placebo-controlled, single-center trial, 306 children age 3 to 18 years were randomized to receive a needle-free powder lidocaine delivery system or matching sham placebo at the back of the hand 2 to 3 minutes before venipuncture. Venipuncture pain was self-reported using the Wong-Baker FACES scale (in 3- to 12-year-olds) and a 100-mm visual analog scale (in 8- to 18-year-olds). Safety was assessed by adverse events, investigator skin site assessments, and children's self-report of the administration comfort of study treatments. Effect sizes were compared by 2-sample t test and Glass's Delta approach.

RESULTS

Subjects receiving the needle-free powder lidocaine delivery system exhibited mean pain reductions (effect size) of 33% to 46% relative to sham placebo. Pain reductions were statistically significant for all ages combined and also for the youngest and oldest age strata. Self-reported administration comfort levels were similar in the active system and sham placebo groups. Incidences of adverse events and dermal reactions were low; the most common dermal reaction was mild erythema.

CONCLUSIONS

The needle-free powder lidocaine delivery system was well tolerated and provided effective local analgesia when administered 2 to 3 minutes before venipuncture.

Ethyl chloride as a cryoanalgesic in pediatrics for venipuncture

INTRODUCTION

Ethyl chloride can be used as a cryoanalgesic, but with the availability of alternative and relatively safer topical analgesics, its use has decreased. However, it still has the advantage of being quicker to apply compared with other topical analgesics, making it ideal for use in the outpatient departments. We wanted to compare the effectiveness of ethyl chloride as an analgesic during venipuncture in children.

METHODS

Venipuncture was carried out using either no analgesia (NO), ethyl chloride spray (EC), or application of the topical anesthetic Ametop (TA) on children attending the phlebotomy outpatient service by experienced pediatric phlebotomists. A pain score was recorded using either the Faces scoring system or the Faces, Legs, Activity, Cry Consolability scoring system.

RESULTS

A total of 55 patients were included in the study, 18 from group EC, 18 from group TA, and 19 from group NO. Thirteen patients from both groups EC and TA and 17 from group NO scored 2 or less on the pain scores.

DISCUSSION

The use of ethyl chloride was as effective as topical anesthetics in preventing distress to children in venipuncture. However, in the appropriate situations, the use of NO could also be comfortable to the child if venipuncture was done by specialist pediatric phlebotomists.