A randomized controlled trial of vapocoolant for pediatric immunization distress relief

Effectiveness of vapocoolant spray compared to eutectic lidocaine/prilocaine cream to enhance tolerance during intravenous catheterisation: a randomised controlled trial

OBJECTIVES

To determine if tolerance of intravenous catheterisation differs following the application of vapocoolant spray compared to lidocaine/prilocaine cream in dogs and cats.

MATERIALS AND METHODS

A randomised controlled trial of client-owned dogs and cats requiring intravenous catheterisation was performed. They were randomly allocated to either have lidocaine/prilocaine cream applied to their skin 1 hour prior to intravenous catheterisation or a swab saturated with vapocoolant spray applied immediately prior to intravenous catheterisation. The procedure was video-recorded and a single blinded observer reviewed the recordings and assigned reaction scores (0 to 3) at 4 time points (initial restraint, limb handling, swab application and skin puncture).

RESULTS

Between October 2020 and March 2022, a total of 101 animals (83 dogs and 18 cats) were enrolled, with 56 patients randomised to receive vapocoolant spray and 45 to receive lidocaine/prilocaine cream. There was no significant difference in the age, sex status, number of cross and pure breeds, and mentation detected between the groups. There was no significant difference in reaction scores between the treatments when comparing all patients at any time point except for a significantly increased swab application reaction score in patients receiving vapocoolant spray. Vapocoolant spray was significantly less effective in reducing adverse reaction to skin puncture than lidocaine/prilocaine cream in the small number of cats evaluated.

CLINICAL SIGNIFICANCE

When considering all patients together, no single method of anaesthesia appeared superior for improving tolerance of intravenous catheter placement. However, vapocoolant spray may be less effective than lidocaine/prilocaine cream in reducing adverse response to skin puncture during catheterisation in cats.

Use of a cooling pack to reduce subcutaneous vaccine injection pain in children aged 3-6 years: A single-blind, randomized, parallel-group multicenter study

BACKGROUND

There are many evidence-based treatments available for pain-relief during subcutaneous vaccine injection in children. However, these methods are commonly labor-intensive and not routinely applied in clinical settings.

OBJECTIVES

To evaluate the safety and pain-relieving effect of local cooling during subcutaneous vaccine injection in young children.

METHOD

This single-blind, randomized, parallel-group multicenter study was conducted at two pediatric clinics in Hyogo Prefecture, which included preschool children aged 3-6 years scheduled for vaccination against Japanese encephalitis or influenza virus. Participants were randomly assigned to either the cooled group (local cooling applied using a cooling pack before vaccination) or the non-cooled group (provided with a room temperature cooling pack). Randomization was performed using a computer-generated block method. The primary endpoint was infant pain, measured using the FLACC scale (Facial expression, Leg movement, Activity, Crying, Consolability), rated by a third-party reviewing videos of the vaccination process.

RESULTS

A total of 60 children were randomized into the cooling (n = 30) and non-cooling (n = 30) groups, with all participants completing the study. Fifty-four participants received the Japanese encephalitis vaccine, and six received the influenza vaccine. Demographic data, including age, sex, and vaccine type, did not differ significantly between the two groups. The median FLACC score in the cooled group was significantly lower (1 [IQR 0-1.25]) compared to the non-cooled group (2.5 [IQR 1-6]) (P = 0.011). No adverse effects related to cooling were observed.

CONCLUSION

Local cooling during subcutaneous vaccine administration is a safe and effective method to reduce pain in children aged 3-6 years. This method can be easily implemented in routine vaccinations to improve patient comfort.

TRIAL REGISTRATION

Japan Registry of Clinical Trials, jRCTs052200149, Mar 09, 2021, https://jrct.niph.go.jp/en-latest-detail/jRCTs052200149.

Interventions to alleviate anxiety and pain during venipuncture in children with chronic gastrointestinal and/or liver disease: A single-center prospective observational study

Objectives

The goal of this longitudinal study was to reduce anxiety and pain in children with chronic conditions from the gastrointestinal tract during venipuncture. These children undergo regular venipuncture as part of their medical management and the procedure is often accompanied with anxiety and pain. In addition, children as well as their parents and health care professionals (HCPs) often suffer "compassionate pain" because of emotional interference.

Method

In a realistic clinical setting, different psychological and medical interventions were examined: (1) Psychoeducational brochures and (2) four different medical-technical interventions during venipuncture. In a large hospital in Germany, 169 children, their parents, and HCPs were asked to rate anxiety and pain during venipuncture before and after the intervention.

Results

Children showed a clear preference for some of the medical-technical interventions. Using Linear Mixed Models anxiety and pain rated by the children themselves showed no significant reduction. However, parents and HCPs reported a significant reduction. Age, gender, and status of liver transplantation were associated with a reduction in anxiety and pain in most of the analyses.

Conclusion

Both psychoeducational brochures and medical-technical interventions had a positive impact on anxiety and pain. However, effectivity for the medical-technical interventions was lower than in previous studies utilizing individual interventions. Reasons for this difference as well as possibilities to improve the intervention are discussed. In addition, this study provides practical day-to-day information about the implementation of interventions for the work in pediatric units such as when and how to provide psychoeducational materials.

The effects of vibration and pressure interventions on children's pain, fear and anxiety: A randomized controlled trial

AIM

The effects of vibration and pressure methods on the level of fear, anxiety, and pain of pediatric patients who were admitted to the emergency department for intramuscular injection were evaluated.

METHODS

This was a parallel group and a randomized controlled study conducted in Turkey. The study sample consisted of 114 children aged between 5 and 10 years who presented to the emergency department to receive intramuscular ceftriaxone injection as part of their treatment. The children were randomized into three groups: Vibration Intervention Group (n = 38), Pressure Intervention Group (n = 38) and Control Group (n = 38). Before the procedure, the level of anxiety and fear of the children were evaluated, and the level of perceived pain during the procedure was immediately evaluated after the intervention. Parents and nurses also rated the level of pain. Data were analyzed with non-parametric tests using SPSS version 26.0.

RESULTS

According to the evaluations made by children, mothers, and nurses, there was a significant difference between pain scores of children in the vibration and pressure intervention groups during the procedure and children in the control group (p < 0.000). There was a significant difference between anxiety and fear scores of children in the vibration and pressure groups and children in the control group before and after the intervention according to the evaluations of the children, mothers, and nurses (p < 0.000).

CONCLUSION

Vibration and pressure interventions used during intramuscular injections administered to children in the emergency department were found to reduce pain, anxiety, and fear based on the evaluations of children, mothers, and nurses.

PRACTICE IMPLICATIONS

Vibration and pressure are effective and useful in relieving pain associated with intramuscular injections in children aged between 5 and 10 years.

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.

The efficacy of vapocoolant spray for the improved tolerance of catheter pain in emergency patients

OBJECTIVES

This study aimed to determine if dogs and cats presenting as an emergency had improved tolerance of intravenous catheterisation following the application of vapocoolant spray when compared to a saline control.

MATERIALS AND METHODS

A randomised controlled trial of client-owned dogs and cats presenting as an emergency and requiring intravenous catheterisation was performed. Patient signalment and mentation score were recorded. All animals were restrained and had their fur clipped over the catheterisation site. They were then randomly allocated to either have a swab saturated with vapocoolant spray (treatment) or a swab saturated with saline (control) applied to the clipped area before intravenous catheterisation. The procedure was video recorded and a single blinded observer reviewed the recordings and assigned reaction scores (0 to 3) at four time points (initial restraint, limb handling, swab application and skin puncture).

RESULTS

Between October 2020 and January 2021, a total of 100 patients (79 dogs, 21 cats) were enrolled, with 50 in each group. No significant difference in species, age, breed, sex or mentation score was detected between the two groups. There was no significant difference in reaction scores between the groups at any time point with the exception of a significantly increased swab application reaction score in the treatment group compared to the control group.

CLINICAL SIGNIFICANCE

The indirect application of vapocoolant spray via a swab before catheterisation does not significantly reduce the reaction of dogs and cats to intravenous catheterisation in an emergency setting.

Effect of Lignocaine and a Topical Vapocoolant Spray on Pain Response during Surgical Castration of Beef Calves

Simple Summary

Ensuring a good state of welfare in farm animals is important for ethical reasons and sustainability of livestock industries. Addressing pain in farm animals during and following surgical husbandry procedures is a significant component of animal welfare. Until recently, practical constraints associated with delivery of traditional forms of analgesia have prevented widespread uptake by producers, especially in large, extensively managed animal production systems. In recent years, novel anaesthetic and analgesic products have been developed to facilitate practical delivery of post-operative pain relief to livestock. However, the issue of intra-operative pain during husbandry procedures remains unaddressed. Therefore, this study investigated the efficacy of pre-operative injected lignocaine and peri-operative topical vapocoolant spray, administered as most practical for incorporation into routine procedures, for pain relief during castration of calves. Results from this study provide no evidence that lignocaine or vapocoolant spray reduced pain during castration of calves. Pulling of the spermatic cords appeared to be the most painful component of the castration procedure. This finding may assist in clarifying what methods for relieving procedural pain associated with castration of calves merit future research.

Abstract

This study assessed the efficacy of pre-operative injected lignocaine and peri-operative topical vapocoolant spray, administered as most practical for incorporation into routine calf castration procedures. Calves were randomly allocated to: (1) sham castration (SHAM); (2) surgical castration (CAST); (3) surgical castration with lignocaine (LIG); and (4) surgical castration with vapocoolant spray (VAPO). Calf behavioural responses were scored at different stages of the sham castration or castration procedure. Maximum ocular temperatures were measured at three time-points relative to restraint and treatment. There were significant effects of treatment (p < 0.001) and stage of procedure (p < 0.001) on calf behavioural response. SHAM calves were more likely to display less severe responses compared to all other calves and LIG calves were more likely to display less severe responses compared to VAPO calves. Calves were more likely to display more severe responses to extrusion of the first spermatic cord compared to all other stages of castration, and to extrusion of the second spermatic cord compared to severing of the second spermatic cord. There was a significant effect of time (p < 0.001) on ocular temperature, with ocular temperature being greater following sham castration or castration. In this study, there was no evidence of pain reduction during castration of calves by either lignocaine or vapocoolant spray.

Comparison of the Effectiveness of Two Different Methods of Decreasing Pain During Phlebotomy in Children: A Randomized Controlled Trial

PURPOSE

The purpose of this study was to examine the effect of the applications of external cold and vibration and blowing soap bubbles during phlebotomy in children aged between 3 and 6 years.

DESIGN

This study is a randomized controlled trial.

METHODS

The sample was obtained using block randomization. Children were divided into three groups: "external cold and vibration group," "blowing soap bubbles group," and "control group." Children, their parents, the nurse, and the researcher rated the children's pain during phlebotomy.

FINDINGS

A statistically significant difference between groups was found on pain scores. Pain scores were lower in the groups of external cold and vibration, and blowing soap bubbles than the control group.

CONCLUSIONS

The methods of external cold and vibration and blowing soap bubbles had a pain relieving effect in children aged between 3 and 6 years during phlebotomy.

Effects of Vapocoolant Spray Prior to SC LMWH Injection: An Experimental Study

The aim of this study was to evaluate the effects of vapocoolant spray administration prior to subcutaneous (SC) low molecular weight heparin injection on local ecchymosis, hematoma, and pain. This randomized controlled study was carried out on 64 patients (n = 128 injections) in an orthopedics and traumatology clinic. After randomization, vapocoolant spray and then heparin injection was applied on one arm. The second necessary dose of heparin was applied to his or her other arm as a placebo by a water spray. Then, the pain of the patients was assessed. After 2 days, ecchymosis and hematoma were evaluated. Significant lower pain scores were determined in applications in which the vapocoolant spray was used. There was no statically significant difference between the mean diameter values of ecchymosis in both arm groups. There was no hematoma on the injection site after injections. However, this method did not create any significant reductive effect on ecchymosis. Nurses are advised to take advantage of vapocoolant spray effects prior to SC heparin injection.

Pharmacological interventions for reducing pain related to immunization or intramuscular injection in children: A mixed treatment comparison network meta-analysis of randomized controlled clinical trials

Various interventions were observed to reduce pain following vaccination in children. This study is a network meta-analysis comparing pharmacological interventions. Electronic databases were searched for appropriate randomized controlled clinical trials comparing active pharmacological agents to reduce pain following vaccination or intramuscular injection in neonates, infants, or children. Pain score was the primary outcome measure. Random effects model was used for generating pooled estimates. A total of 23 studies were included in the network meta-analysis. Topical eutectic mixture of local anesthetics (EMLA) significantly reduced pain scores. Crying time was also observed to be lower with vapocoolant spray and 25% sucrose and glucose solutions. Quality of the evidence was observed to be either low or very low. Topical EMLA significantly reduce pain following intramuscular injections particularly vaccination. However, due to low grade quality of the evidence, more studies are obligatory.

Improving vaccine-related pain, distress or fear in healthy children and adolescents-a systematic search of patient-focused interventions

OBJECTIVE

The WHO recently highlighted the need for research into potential interventions that can be used to mitigate pain during mass vaccinations, in addition to interventions specific for adolescents. The current review examines the literature on potential interventions that can be used during mass vaccination settings in healthy individuals between the ages of 4 and 15 years old.

METHODS

Criteria for inclusion were: 1)participants between the ages of 4-15 years, 2)interventions that were patient-focused, 3)vaccinations in healthy individuals, 4)outcome measures to include self-reported pain, fear or distress.

RESULTS

Twenty-seven articles were identified with a total of 31 interventions. Eleven interventions used injection-site specific interventions, 17 used patient-led interventions and three used a combination of both site-specific and patient-led interventions.

CONCLUSION

Interventions using coolant and vibration together, as well as a combination of site-specific and patient-led interventions, showed the most consistent effects in reducing self-reported pain, fear or distress.

The Use of Locally Applied Vibration to Minimize Pain during Fractional CO2 Laser Therapy in Living Liver-Donor Scar Management

BACKGROUND

Fractional CO2 laser is an effective treatment for scars, but most patients complain about sharp burning pain, even after the application of lidocaine ointment. This study analyzed the impact of a vibrating device to nonpharmacologically reduce the acute pain of laser treatment, in accordance with the gate control theory of pain management.

METHODS

This is a prospective study performed from May 2013 through March 2014. Fifty-three patients (mean age, 26.7 years; range, 16-44 years) who had donated livers for liver transplantation were treated with a fractional CO2 laser (10,600 nm; model eCO2, Lutronic Corp) for their abdomen scars. Laser treatment was applied 4 months after surgery. A commercially available, locally applied vibrating device (model UM-30M, Unix Electronics Co. Ltd.) was used, in an on-and-off pattern, together with the CO2 laser. A visual analogue scale (VAS; 0, no pain; 10, most severe pain) of pain sensation was assessed and statistically analyzed using a paired t-test.

RESULTS

The average VAS score for pain with the vibrating device was 4.60 and the average VAS score without the vibrating device was 6.11. The average difference between scores was 1.51 (P=0.001).

CONCLUSIONS

A locally applied vibrating device was demonstrated to be effective in reducing pain when treating with a fractional CO2 laser. Vibration treatment could be helpful when treating scars with fractional CO2 laser in pain-sensitive patients, particularly children.

Distraction Using the BUZZY for Children During an IV Insertion

Needle pricks are rated by children as their most feared medical event resulting in acute pain, anxiety and distress, which negatively affects both the child and his/her parents.

OBJECTIVES

To investigate the effects of external cold and vibration via the "BUZZY" on pain ratings of children, their parents and nurses during peripheral IV insertion, to measure the time to a successful IV insertion and to assess the factors that are associated with pain perception of children.

METHODS

In this randomized control trial (RCT), children between the ages of 4 to 12years were assigned to either an intervention or a control group. The intervention group (n=25) had the "BUZZY" applied during IV insertion while the control group (n=23) did not have the "BUZZY". Children were asked to rate their pain along with their parents and nurses on the Wong-Baker FACES Pain Rating Scale. Time to successful IV insertion and background characteristic of children were assessed and compared.

RESULTS

Pain scores were significantly lower in the "BUZZY" group for children and the nurses. Time to a successful IV insertion did not differ between groups. Gender, age, previous hospitalization, diagnoses and analgesics were all factors associated with the children's pain scores. However, a multiple regression analysis found that only the "BUZZY" remained a significant predictor of pain scores in children.

CLINICAL IMPLICATIONS

The "BUZZY" may be an easily accessed, inexpensive ($39.95 each at $0.09 per 3 minute stick), and effective technique to control or reduce pain in young children undergoing IV insertion.

Pharmacological and Combined Interventions to Reduce Vaccine Injection Pain in Children and Adults: Systematic Review and Meta-Analysis

BACKGROUND

This systematic review assessed the effectiveness and safety of pharmacotherapy and combined interventions for reducing vaccine injection pain in individuals across the lifespan.

DESIGN/METHODS

Electronic databases were searched for relevant randomized and quasi-randomized controlled trials. Self-reported pain and fear as well as observer-rated distress were critically important outcomes. Data were combined using standardized mean difference (SMD) or relative risk with 95% confidence intervals (CI).

RESULTS

Fifty-five studies that examined breastfeeding (which combines sweet-tasting solution, holding, and sucking), topical anesthetics, sweet-tasting solutions (sucrose, glucose), vapocoolants, oral analgesics, and combination of 2 versus 1 intervention were included. The following results report findings of analyses of critical outcomes with the largest number of participants. Compared with control, acute distress was lower for infants breastfed: (1) during vaccination (n=792): SMD -1.78 (CI, -2.35, -1.22) and (2) before vaccination (n=100): SMD -1.43 (CI, -2.14, -0.72). Compared with control/placebo, topical anesthetics showed benefit on acute distress in children (n=1424): SMD -0.91 (CI, -1.36, -0.47) and self-reported pain in adults (n=60): SMD -0.85 (CI, -1.38, -0.32). Acute and recovery distress was lower for children who received sucrose (n=2071): SMD -0.76 (CI, -1.19, -0.34) or glucose (n=818): SMD -0.69 (CI, -1.03, -0.35) compared with placebo/no treatment. Vapocoolants reduced acute pain in adults [(n=185), SMD -0.78 (CI, -1.08, -0.48)] but not children. Evidence from other needle procedures showed no benefit of acetaminophen or ibuprofen. The administration of topical anesthetics before and breastfeeding during vaccine injections showed mixed results when compared with topical anesthetics alone. There were no additive benefits of combining glucose and non-nutritive sucking (pacifier) compared with glucose or non-nutritive sucking (pacifier) alone or breastfeeding and sucrose compared with breastfeeding or sucrose alone.

CONCLUSIONS

Breastfeeding, topical anesthetics, sweet-tasting solutions, and combination of topical anesthetics and breastfeeding demonstrated evidence of benefit for reducing vaccine injection pain in infants and children. In adults, limited data demonstrate some benefit of topical anesthetics and vapocoolants.

The impact of a locally applied vibrating device on outpatient venipuncture in children

OBJECTIVE

To assess the impact of a locally applied vibrating device on outpatient venipuncture in children.

METHOD

A retrospective review of survey data collected prospectively as part of a quality improvement project. Both patients and phlebotomists were surveyed. The sample consisted of 64 children aged 4 to 18 years (29 prior to the implementation of the vibrating device and 35 afterward) and 7 phlebotomists.

RESULTS

Prior to the use of the vibrating device, 17 children (59%) indicated that they wished something had been done to decrease venipuncture pain. Eighty percent of the cohort that used the vibrating device indicated that they would like it used for future procedures. Children with previous venipuncture experiences appeared to benefit most from use of the vibrating technique. The phlebotomists reported that vibration made the procedure easier in 81% of the cases; none reported that it complicated the procedure.

CONCLUSIONS

Locally applied vibration appears to be a well-accepted technique to minimize pediatric venipuncture discomfort that may facilitate completion of the procedure.