Comparison of ethyl chloride spray with topical anaesthetic in children experiencing venepuncture

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 Impact of Cold Spray and Ice Application During Intravenous Access on Pain and Fear in Children Aged 7-15 Years in the Pediatric Emergency Unit: A Randomized Controlled Trial

INTRODUCTION

Many strategies have been developed to prevent procedural pain in pediatric emergency units, where nurses play a vital role in ensuring patient comfort. Easy-to-use and inexpensive nonpharmacologic analgesic methods are important in emergency units. This study was conducted to determine the effect of cold spray and ice applied during venipuncture on the level of fear and pain in children aged 7 to 15 years.

METHODS

This was a randomized controlled experimental study of 96 children between the ages of 7 and 15 years (cold spray group, ice group, and control group) who were scheduled to have venous access in the pediatric emergency clinic and met the sampling criteria.

RESULTS

Evaluations of the children, parents, and observers in the groups found a statistically significant difference between the pain and fear scores after the intervention compared with the preintervention (P < .001). The pain and fear scores of the children in the control group were higher than the scores of those in the spray and ice groups (P < .001); the pain and fear scores of the children in the spray group were lower than the scores of the children in the ice group and statistically significant (P < .001).

DISCUSSION

In conclusion, cold spray applied during intravenous access in children aged 7 to 15 effectively reduces pain and fear and should be used in the emergency unit.

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.

Prevention of pruritus with ethyl-chloride in skin prick test: a double-blind placebo-controlled prospective study

Background

Ethyl-chloride (EC) spray was recently shown to be an effective antipruritic agent, when given 15 min after histamine skin-prick test (SPT), without changing the wheal and flare reaction. We aimed to investigate the antipruritic effect of EC on SPT, when given prior to SPT.

Methods

A double-blind placebo-controlled prospective study. Overall, 44 volunteers underwent histamine SPT on both arms to trigger local pruritus. Prior to test, they were randomly treated with EC spray on one arm and saline spray (placebo) on the other. Subjects as well as researchers were blinded to the type of applied sprays. The wheal and flare reaction was measured after the SPT and subjects reported the intensity of pruritus following EC/placebo using a validated pruritus questionnaire (indexes 1–3) and a visual analog scale (VAS).

Results

Significant improvement in pruritus was reported following treatment with EC compared with placebo for all four studied parameters. Index 1 in EC 3.7 ± 2.3 versus 5 ± 3.5 (p = 0.007) in placebo, index 2 in EC 2.6 ± 2.1 versus 3.8 ± 2.8 (p = 0.002) in placebo, index 3 of EC 6.3 ± 3.8 versus 8.8 ± 5.8 (p = 0.03) and VAS in EC 3.7 ± 1.9 versus 4.4 ± 2.3 (p = 0.003). There were no significant differences between EC and placebo in terms of the wheal and flare indurations area.

Conclusions

Ethyl-chloride has an effective antipruritic agent, when given before histamine SPT. Its use did not change the wheal and flare reaction, making it ideal for prevention of pruritus, secondary to allergy skin test, without masking the results.

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.

Evaluation of methods to relieve parental perceptions of vaccine-associated pain and anxiety in children: a pilot study

INTRODUCTION

The pain and anxiety associated with vaccination is a significant reason why parents are reluctant to have their children vaccinated. Distraction methods and vapocoolant sprays may be use to modify the parent's perceptions of their child's pain and anxiety, thus encouraging parents to return for the child's next vaccination.

METHODS

A convenience sample of 68 parents with children ranging in age from 2 to 12 years was selected. The parents and the child were randomly assigned to three groups: a control group, a DVD distraction group, or a vapocoolant spray group. After the child was vaccinated, parents evaluated the child's pain and anxiety.

RESULTS

No significant difference in the parents' perception of their child's pain or anxiety was found between the two treatment groups compared with the control group. Some parents expressed the desire to be able to choose the type of distraction method their child received rather than having them randomly assigned to a group.

DISCUSSION

Although quantitative results were not statistically significant in this pilot study, parents commented that the DVD distraction method seemed helpful before and/or after vaccination, but not during vaccination, and parents appreciated the distraction. Parents, however, would prefer to choose the intervention rather than being randomly assigned to a group. The effectiveness of interventions with regard to parental perceptions of pain or anxiety warrants further study.

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.

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 systematic review of faces scales for the self-report of pain intensity in children

CONTEXT

Numerous faces scales have been developed for the measurement of pain intensity in children. It remains unclear whether any one of the faces scales is better for a particular purpose with regard to validity, reliability, feasibility, and preference.

OBJECTIVES

To summarize and systematically review faces pain scales most commonly used to obtain self-report of pain intensity in children for evaluation of reliability and validity and to compare the scales for preference and utility.

METHODS

Five major electronic databases were systematically searched for studies that used a faces scale for the self-report measurement of pain intensity in children. Fourteen faces pain scales were identified, of which 4 have undergone extensive psychometric testing: Faces Pain Scale (FPS) (scored 0-6); Faces Pain Scale-Revised (FPS-R) (0-10); Oucher pain scale (0-10); and Wong-Baker Faces Pain Rating Scale (WBFPRS) (0-10). These 4 scales were included in the review. Studies were classified by using psychometric criteria, including construct validity, reliability, and responsiveness, that were established a priori.

RESULTS

From a total of 276 articles retrieved, 182 were screened for psychometric evaluation, and 127 were included. All 4 faces pain scales were found to be adequately supported by psychometric data. When given a choice between faces scales, children preferred the WBFPRS. Confounding of pain intensity with affect caused by use of smiling and crying anchor faces is a disadvantage of the WBFPRS.

CONCLUSIONS

For clinical use, we found no grounds to switch from 1 faces scale to another when 1 of the scales is in use. For research use, the FPS-R has been recommended on the basis of utility and psychometric features. Data are sparse for children below the age of 5 years, and future research should focus on simplified measures, instructions, and anchors for these younger children.

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.