A randomized, double-blind comparison study of EMLA and ELA-Max for topical anesthesia in children undergoing intravenous insertion

Transdermal Application of Anesthetic Preparations Is Effective in Increasing Mechanical Nociceptive Threshold at Perineural Injection Sites in Horses

Perineural anaesthesia is an essential part of lameness investigation in horses. Painful reactions to injections imply a high risk of accidents for veterinarians. To evaluate the efficacy of two topical anaesthetic creams on desensitization of the skin at two perineural injection sites and to evaluate the effects these formulations may have on pain perception distally to the application sites. Randomized, blind, prospective study. 14 healthy horses were randomly divided in two groups of 7 horses each, one treated with EMLA and one with PLIAGLIS preparations. The mechanical nociceptive threshold (MNT) was recorded via pressure algometer at the baseline and one hour after application (T1) on palmar and palmar digital nerve blocks sites. Skin sensation was also assessed on the distal limb, recording MNT on the coronary band and on both bulbs of the heels. Data were compared with a 3-way ANOVA statistical analyses. No significant difference was encountered in the MNT values between baseline records and records at T1 at the control sites. A significant difference of MNT values was detected between the two time points in the treated limbs. The significant sources of variation in our study were the time and the presence of anaesthetic cream. The type of treatment did not determine any differences. Furthermore, no significant difference of MNT values at sites distal to treatment was recorded between the two time points, both in the treated limb and control limbs. Both formulations are effective to obtain superficial skin desensitization.

A narrative review with practical advice on how to decrease pain and distress during venepuncture and peripheral intravenous cannulation

Venepuncture and peripheral intravenous cannulation are two of the most commonly paediatric performed medical procedures in many healthcare settings. These procedures can cause significant pain and distress at any age, during childhood, so appropriate management is strongly recommended. This review examines the evidence related to pain and distress management during venepuncture and peripheral intravenous cannulation, including preparing the environment, assessing and preparing patients, parental involvement and psychological and pharmacological interventions. It specifically refers to neonates, children with cognitive impairment and children with difficult intravenous access. We provide a brief management strategy, with easily implemented techniques to improve daily practice.

Pediatric pain treatment and prevention for hospitalized children

Introduction:

Prevention and treatment of pain in pediatric patients compared with adults is often not only inadequate but also less often implemented the younger the children are. Children 0 to 17 years are a vulnerable population.

Objectives:

To address the prevention and treatment of acute and chronic pain in children, including pain caused by needles, with recommended analgesic starting doses.

Methods:

This Clinical Update elaborates on the 2019 IASP Global Year Against Pain in the Vulnerable “Factsheet Pain in Children: Management” and reviews best evidence and practice.

Results:

Multimodal analgesia may include pharmacology (eg, basic analgesics, opioids, and adjuvant analgesia), regional anesthesia, rehabilitation, psychological approaches, spirituality, and integrative modalities, which act synergistically for more effective acute pediatric pain control with fewer side effects than any single analgesic or modality. For chronic pain, an interdisciplinary rehabilitative approach, including physical therapy, psychological treatment, integrative mind–body techniques, and normalizing life, has been shown most effective. For elective needle procedures, such as blood draws, intravenous access, injections, or vaccination, overwhelming evidence now mandates that a bundle of 4 modalities to eliminate or decrease pain should be offered to every child every time: (1) topical anesthesia, eg, lidocaine 4% cream, (2) comfort positioning, eg, skin-to-skin contact for infants, not restraining children, (3) sucrose or breastfeeding for infants, and (4) age-appropriate distraction. A deferral process (Plan B) may include nitrous gas analgesia and sedation.

Conclusion:

Failure to implement evidence-based pain prevention and treatment for children in medical facilities is now considered inadmissible and poor standard of care.

Managing pain and distress in children undergoing brief diagnostic and therapeutic procedures

Common medical procedures to assess and treat patients can cause significant pain and distress. Clinicians should have a basic approach for minimizing pain and distress in children, particularly for frequently used diagnostic and therapeutic procedures. This statement focuses on infants (excluding care provided in the NICU), children, and youth who are undergoing common, minor but painful medical procedures. Simple, evidence-based strategies for managing pain and distress are reviewed, with guidance for integrating them into clinical practice as an essential part of health care. Health professionals are encouraged to use minimally invasive approaches and, when painful procedures are unavoidable, to combine simple pain and distress-minimizing strategies to improve the patient, parent, and health care provider experience. Health administrators are encouraged to create institutional policies, improve education and access to guidelines, create child- and youth-friendly environments, ensure availability of appropriate staff, equipment and pharmacological agents, and perform quality audits to ensure pain management is optimal.

La gestion de la douleur et de l’anxiété chez les enfants lors de brèves interventions diagnostiques et thérapeutiques

Les interventions médicales courantes utilisées pour évaluer et traiter les patients peuvent causer une douleur et une anxiété marquées. Les cliniciens devraient adopter une approche de base pour limiter la douleur et l’anxiété chez les enfants, notamment à l’égard des interventions diagnostiques et thérapeutiques fréquentes. Le présent document de principes est axé sur les nourrissons, les enfants et les adolescents qui subissent des interventions médicales courantes mineures, mais douloureuses. Il n’aborde pas les soins prodigués à l’unité de soins intensifs néonatale. Les auteurs examinent des stratégies simples et fondées sur des données probantes pour gérer la douleur et l’anxiété et donnent des conseils pour en faire un volet essentiel de la pratique clinique. Les professionnels de la santé sont invités à utiliser des façons de procéder peu invasives et, lorsque les interventions douloureuses sont inévitables, à combiner des stratégies simples de réduction de la douleur et de l’anxiété pour améliorer l’expérience du patient, du parent et du professionnel de la santé. Les administrateurs de la santé sont encouragés à créer des politiques pour leurs établissements, à améliorer la formation et l’accès aux lignes directrices, à créer des environnements propices aux enfants et aux adolescents, à s’assurer de la disponibilité du personnel, de l’équipement et des agents pharmacologiques appropriés et à effectuer des contrôles de qualité pour garantir une gestion de la douleur optimale.

Treating and reducing anxiety and pain in the paediatric emergency department-TIME FOR ACTION-the TRAPPED quality improvement collaborative

BACKGROUND/OBJECTIVES

In 2013, the TRAPPED-1 survey reported inconsistent availability of pain and distress management strategies across all 15 Canadian paediatric emergency department (PEDs). The objective of the TRAPPED-2 study was to utilize a procedural pain quality improvement collaborative (QIC) and evaluate the number of newly introduced pain and distress-reducing strategies in Canadian PEDs over a 2-year period.

METHODS

A QIC was created to increase implementation of new strategies, through collaborative information sharing among PEDs. In 2015, 11 of the 15 Canadian PEDs participated in the TRAPPED QIC. At the end of the year, the TRAPPED-2 survey was electronically sent to a representative member at each of the 15 PEDs. The successful introduction of the chosen strategies by the QIC was assessed as well as the addition of new strategies per site. The number of new strategies introduced in the participating and nonparticipating QIC sites were described.

RESULTS

All 15 PEDs (100%) completed the TRAPPED-2 survey. Overall, 10/11 of QIC-participating sites implemented the strategy they had initially identified. All 15 Canadian PEDs implemented some new strategies during the study period; participants in the QIC reported a mean of 5.2 (1-11) new strategies compared to 2.5 (1-4) in the nonactively participating sites.

CONCLUSION

While all PEDs introduced new strategies during the study, QIC-participating sites successfully introduced the majority of their previously identified new strategies in a short time period. Sharing deadlines and information between centres may have contributed to this success.

Dermatochirurgie bei Kindern: Gegenwärtiger Stand zu Indikation, Anästhesie, Analgesie und potentiellen perioperativen Komplikationen

HINTERGRUND

Anders als Erwachsene benötigen Kinder bei dermatochirurgischen Eingriffen besondere Aufmerksamkeit; die Anwendung verschiedener Analgetika, Anästhetika oder Sedativa erfordert eine gründliche Kenntnis von Pharmakokinetik und -dynamik der Medikamente. Außerdem können Medikamente zur Sedierung/Allgemeinanästhesie bei operierten Kindern zu Anästhesie- oder Analgesie-bedingten Komplikationen einschließlich Störungen der geistigen Entwicklung führen. ZIEL: Auf Basis unserer klinischen Erfahrung und einer Literaturübersicht stellen wir die gängigsten in der pädiatrischen Dermatochirurgie verwendeten Analgetika, Anästhetika und Sedativa dar und diskutieren Risiken und Komplikationen nach dermatochirurgischen Eingriffen.

ERGEBNISSE

Topische Anästhetika können bei Kindern für oberflächliche dermatologische Eingriffe oder vor einer Infiltrationsanästhesie eingesetzt werden. Die Berechnung der empfohlenen Maximaldosen auf Basis des Körpergewichts ist erforderlich, um eine Überdosierung von Lokalanästhetika zu vermeiden. Die Allgemeinanästhesie gilt bei der Dermatochirurgie als sicher und hat eine geringe Nebenwirkungsrate. Allerdings ist bei Kindern im ersten Lebensjahr aufgrund potentieller langfristiger neurologischer Nebenwirkungen Vorsicht angebracht. NSAR und Opioide spielen bei der Analgesie von Kindern eine bedeutende Rolle.

SCHLUSSFOLGERUNGEN

Dieser Artikel gibt eine Übersicht über die derzeit verfügbaren Daten zu Analgesie, Anästhesie und Komplikationen, die im Rahmen der pädiatrischen Dermatochirurgie auftreten können. Diese Daten können dabei helfen, die Sicherheit und Qualität der Versorgung zu optimieren und die Beratung der Eltern zu verbessern.

Dermatologic surgery in children: an update on indication, anesthesia, analgesia and potential perioperative complications

BACKGROUND

Children undergoing dermatosurgical procedures require, unlike adults, particular attention; the administration of various analgesics, anesthetics or sedatives requires a thorough knowledge of drug pharmacokinetics and pharmacodynamics. Furthermore, there are concerns that drugs used for sedation/general anesthesia may result in anesthetic/analgesic complications in children undergoing surgery, with a risk of impaired mental development.

OBJECTIVES

Based on our clinical experience and a literature review, we illustrate the most commonly used analgesic, anesthetic and sedative drugs in pediatric dermatosurgery, and identify risk factors and complications following dermatosurgical procedures.

RESULTS

Topical anesthetics can be used in children for superficial dermatologic procedures or prior to infiltration anesthesia. Maximum recommended doses based on body weight should be calculated in order to avoid overdosage of local anesthetics. General anesthesia in dermatosurgery is considered safe and has a low rate of side effects. However, caution is advised in children under the age of one due to potential long-term neurological side-effects. NSAIDs and opioids play a significant role in analgesia for children.

CONCLUSIONS

This article reviews currently available data on analgesia, anesthesia and complications that may arise in pediatric dermatosurgery. These data may be useful in optimizing the safety and quality of care and in improving parent counseling.

Design and evaluation of lidocaine- and prilocaine-coloaded nanoparticulate drug delivery systems for topical anesthetic analgesic therapy: a comparison between solid lipid nanoparticles and nanostructured lipid carriers

Purpose

Topical anesthesia analgesic therapy has diverse applicability in solving the barrier properties of skin and unfavorable physicochemical properties of drugs. Lidocaine (LID) combined with prilocaine (PRI) has been used as a topical preparation for dermal anesthesia for treatment of conditions such as paresthesia.

Materials and methods

In this study, for combination anesthesia and overcoming the drawbacks of LID and PRI, respectively, LID- and PRI-loaded solid lipid nanoparticles (SLNs) and nanostructured lipid carriers (NLCs) were prepared and characterized by determination of their particle size, drug loading capacity, stability, in vitro drug release behavior and in vitro cellular viability. Ex vivo skin permeation and in vivo anesthesia analgesic efficiency of these two systems were also evaluated and compared.

Results

Results revealed that combination delivery of the dual drugs exhibited more remarkable efficiency than signal drug-loaded systems. SLN systems have better ex vivo skin permeation ability than NLCs. NLC systems revealed a stronger in vivo anesthesia analgesic effect than SLN systems.

Conclusion

It can be concluded that SLNs and NLCs have different advantages, and that both carriers are promising dual drug delivery systems for topical anesthetic analgesic therapy.

Increasing ED Use of Jet Injection of Lidocaine for IV-Related Pain Management

BACKGROUND AND OBJECTIVE

Venipuncture is a leading cause of procedural pain for children. Jet injection of lidocaine (JIL; J-Tip) has been demonstrated to be effective in controlling intravenous (IV) placement-related pain and, due to its rapid onset, is particularly suited to emergency department (ED) use. Our objective was to increase JIL use with IV placements in our ED from 11% at baseline to 50% within 12 months.

METHODS

We initiated the project at our urban, tertiary pediatric ED in July 2014. We surveyed medical and nursing teams to identify barriers to JIL use. We initiated changes at monthly intervals: (1) order set changes, (2) online education, (3) hands-on workshops, (4) improved accessibility, (5) standing order policy revision, and (6) reminders. We collected biweekly data on IV placements for all ED patients, except level 1 (critical) triage patients. We used standard quality improvement methodology and statistical process control for statistical analysis.

RESULTS

JIL use with IV placement increased to 54% over 7 months and has remained >50% for >12 months. For all eligible IV placements (n = 12 791), 76.4% of those where JIL was used were successful on the first attempt compared with 75.8% without JIL (χ²_{1degrees of freedom} = 0.33, P = .56), with no significant difference in the success at IV placement.

CONCLUSIONS

We sustainably increased JIL use with IV placement. The use of JIL was not associated with a difference in first-attempt IV placement success rates. We are expanding the project to other parts of the institution.

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.

Does Topical Anesthetic Reduce Pain During Intraosseous Pin Removal in Children? A Randomized Controlled Trial

BACKGROUND

The purpose of this study was to determine the effectiveness of topical liposomal lidocaine in reducing the pain perceived by children undergoing percutaneous intraosseous pin (PP) removal in the outpatient orthopaedic clinic.

METHODS

A triple-blinded, randomized, placebo-controlled clinical trial comparing topical liposomal lidocaine to a placebo was conducted at the Stollery Children's Hospital between September 2008 and February 2011. Subjects undergoing the removal of PP in the orthopaedic outpatient clinic between ages 3 and 16 years were recruited. A computer-generated variable-block randomization scheme was used to determine each subject's group assignment. Pain was recorded just before randomization and immediately after the procedure using the Oucher Scale (for subjects) and a 10-cm Visual Analog Scale (for parents and an observing orthopaedic technician). In a subset of individuals, follow-up telephone calls were made 24 hours postprocedure to inquire about any adverse event from the use of the topical liposomal lidocaine. Data were analyzed using the Student t test.

RESULTS

Of a total of 296 recruited subjects, complete data were available on 281 subjects (140 intervention and 141 control). There were no significant differences between the 2 groups with regards to baseline characteristics, including preprocedure pain scores. Although postprocedure pain scores demonstrated an increase in pain in both groups (2.3 points in the treatment group and 2.0 points in the placebo group), no statistically significant difference was seen in postprocedure pain scores between groups (P=0.81). No adverse events were observed or reported.

CONCLUSIONS

Topically applied liposomal lidocaine was not effective in reducing pain during this procedure, compared with a placebo. However, this study demonstrates that PP removal is a painful procedure in children. Given the large volume of patients who undergo this procedure and the long-term consequences of experiencing painful procedures in childhood, it is important to find safe and fast-acting methods to decrease procedural pain associated with PP removal.

Problems Facing the Visiting Anesthesia Team in an Underdeveloped Nation and Possible Solutions

More than 50% of the population in most developing countries is younger than 18 years, and it has been estimated that 85% of these children may require some sort of surgery before their 15th birthday. Common congenital surgical requirements are for cleft lip and palate, inguinal hernia, meningomyelocele, as well as hydrocephalus. In addition, there is a greater incidence of trauma experienced by pediatric patients. Burn and scald injuries are also common because of the proximity of domestic open fires and boiling pots of water. Infectious conditions such as osteomyelitis and skin abscesses are more frequent in developing countries than in the developed world.Given this backdrop, the visiting anesthesiology team is faced with significant logistic issues related to a large and varied set of surgeries. This requires careful planning to ensure there will be enough personnel, equipment, and drugs available for the trip. Anesthesia teams very often have to rely on their own supplies on these excursions. Careful questioning of previous visiting groups is vital in preparation. For example, it is pointless to bring cases of sevoflurane to an operating room where the anesthesia machine only has a halothane vaporizer.

Comparative Efficacy and Patient Preference of Topical Anaesthetics in Dermatological Laser Treatments and Skin Microneedling

Background:

Topical anaesthetics are effective for patients undergoing superficial dermatological and laser procedures. Our objective was to compare the efficacy and patient preference of three commonly used topical anaesthetics: (2.5% lidocaine/2.5% prilocaine cream (EMLA^®), 4% tetracaine gel (Ametop™) and 4% liposomal lidocaine gel (LMX4^®)) in patients undergoing laser procedures and skin microneedling.

Settings and Design:

This was a prospective, double-blind study of patients undergoing laser and skin microneedling procedures at a laser unit in a tertiary referral dermatology centre.

Materials and Methods:

All 29 patients had three topical anaesthetics applied under occlusion for 1 hour prior to the procedure, at different treatment sites within the same anatomical zone. A self-assessment numerical pain rating scale was given to each patient to rate the pain during the procedure and each patient was asked to specify their preferred choice of topical anaesthetic at the end of the procedure.

Statistical Analysis:

Parametric data (mean pain scores and frequency of topical anaesthetic agent of choice) were compared using the paired samples t-test. A P-value of ≤0.05 was considered as statistically significant.

Results and Conclusions:

Patients reported a mean (±SD; 95% confidence interval) pain score of 5 (±2.58; 3.66-6.46) with Ametop™, 4.38 (±2.53; 2.64-4.89) with EMLA^® and 3.91 (±1.95; 2.65-4.76) with LMX4^®. There was no statistically significant difference in pain scores between the different topical anaesthetics. The majority of patients preferred LMX4^® as their choice of topical anaesthetic for dermatological laser and skin microneedling procedures.

Peripheral intravenous cannulation with support of infrared laser vein viewing system in a pre-operation setting in pediatric patients

BACKGROUND

Venous access, a prerequisite for anesthesiological and surgical intervention in pediatric patients, is often difficult to establish and potentially painful. AV300 uses near infrared laser light to improve visibility of peripheral veins and could help cannulating them. The aim of this study was to examine if use of Accuvein(®) AV300 vein viewer could facilitate venous cannulation in children.

METHODS

From January to March 2011, 238 consecutive pediatric patients (0-17 years) preceding surgical interventions were included. All participants including newborns, infants and children were allocated to groups [control group (124 patients) and intervention group (114 patients)] in a non-random way. Randomization was not feasible because data was acquired retrospectively from a clinical quality management project. In control group, peripheral IV cannulation was performed without supporting device, in intervention group with support of AV300. Time and number of attempts until successful venous cannulation were defined as primary end points.

RESULTS

Median time until successful cannulation was 2 min (range 0.1-20, quartiles: 25 %: 1; 75 %: 5) in the intervention group and 1 min (range 0.1-18, quartiles: 25 %: 0.2; 75 %: 2) in the control group (p < 0.01). Median number of attempts was higher in the intervention group (2; range 1-6, quartiles: 25 %: 1; 75 %: 3) than in the control group (1; range 1-6, quartiles: 25 %: 1; 75 %: 2, p < 0.01). Rate of cannulations successful at first attempt was 0.45 (51 of 114, 95 % CI 0.35-0.54) in the intervention group and 0.73 (90 of 124, 95 % CI 0.65-0.81) in the control group (p < 0.01).

CONCLUSIONS

In our study we were not able to reduce neither time nor number of attempts until a successful venous cannulation in children using the vein viewer. Given certain limitations of our study as the lack of randomization and no control for inter-operator variability, the conclusions drawn from it are also limited, but by our results laser-supported cannulation cannot be recommended for standard procedures.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01434537. Registered 29 July 2011.

Treating and Reducing Anxiety and Pain in the Paediatric Emergency Department: The TRAPPED survey

BACKGROUND

Management of children's pain and anxiety in the emergency department is likely suboptimal.

OBJECTIVE

To determine the availability of currently used strategies in Canadian paediatric emergency departments.

METHODS

A cross-sectional survey involving all centres of the Pediatric Emergency Research Canada group was performed. The primary outcome was the availability of specific procedures for pain and anxiety management for children in the emergency department. One person per centre was identified to complete the survey. Data were collected from October 2013 to January 2014 using an electronic survey tool.

RESULTS

All 15 Pediatric Emergency Research Canada centres agreed to participate. The verbal numerical scale was widely used (80%) to assess pain. One-half of respondents (53%) had access to a child life specialist. The following techniques were available for minor procedures: television as a distraction tool (87% of respondents), topical anesthetic before intravenous needle insertion (73%) and positioning of the child on parent's lap (60%); most remaining centres reported that these could be easily implemented. Intravenous morphine was available at every centre. Intranasal fentanyl was available (60%) or considered to be easy to implement (33%). Few centres reported availability of clinical guidelines regarding pain for doctors (27%) and nurses (40%); all respondents considered them to be easy to implement.

CONCLUSIONS

There was wide variation in paediatric pain and anxiety management strategies among tertiary care Canadian emergency departments. Several pain-reduction procedures (distraction, positioning on parent's lap, topical anesthetic, intranasal administration) were identified that could be easily implemented to address the gap.

[Non-pharmaceutical measures, topical analgesics and oral administration of glucose in pain management: Austrian interdisciplinary recommendations on pediatric perioperative pain management]

Non-pharmaceutical procedures are increasingly being used in pediatric pain therapy in addition to pharmaceutical procedures and have a supporting function. This article describes the non-pharmaceutical procedures which have an influence on perioperative and posttraumatic pain in children and adolescents. Prerequisites for every adequate pain therapy are affection, imparting a feeling of security, distraction and the creation of a child-oriented environment. Topical analgesics are indicated for application to intact skin for surface anesthesia. For a safe use consideration must be given to the duration of application, the dose and the maximum area of skin treated in an age-dependent manner. For simple but painful procedures in premature infants, neonates and infants, pain can be effectively reduced by the oral administration of glucose. The positive effect is guaranteed particularly for the use in a once only pain stimulation. Non-nutritive sucking, swaddling, facilitated tucking and kangaroo mother care, for example can be used as supportive measures during slightly painful procedures. There is insufficient evidence for a pain reducing effect in older infants and small children. Physical therapeutic procedures can be used as accompanying measures for acute pain and are individually adapted. However, the limited amount of currently available data is insufficient to make a critical scientific assessment of the individual measures. The effects can, however, be observed in the daily routine practice. Psychological methods can facilitate coping with pain. In situations with mental and psychiatric comorbidities or psychosocial impairment, a psychologist should be consulted. Acupuncture and hypnosis are also a meaningful addition within the framework of multimodal pain therapy.

Transdermal analgesia with local anesthetics in children: review, update and future directions

Topical local anesthetics in one form or another have been used for the past 20 years to alleviate the skin pain associated with needle puncture and venous cannulation in children. Although the application of topical anesthetic creams is painless compared with traditional local anesthetic infiltration of the skin and subcutaneous tissues prior to venipuncture and minor skin procedures, they remain underutilized, primarily due to their slow analgesic onset and inconsistent effectiveness. For a topical local anesthetic to be of practical use in busy clinical settings, it must be easy to apply, have minimal side effects, not require cumbersome equipment and be reasonably cost effective. Until recently, limitations in one or all of these areas have dissuaded pediatric practitioners from their routine use. However, recent advances in transdermal delivery technologies, have led to the emergence of a number of new delivery approaches that accelerate the onset time to 20 min or less and provide more consistent and deeper sensory skin analgesia. Although still in the early stages of investigation, technologies that promote the flux of drugs of all sizes through the skin by creating transient microchannels show great promise in circumventing the skin barrier and promoting the transdermal delivery of not only local anesthetics but also other drugs. Ultimately, the rationale to change clinical practice and use a new transdermal delivery system will depend upon the cost, ease of use, frequency of adverse events and the benefits to the patient relative to an alternative method.

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 intervention to improve pain management in the pediatric emergency department

OBJECTIVE

The objective of this study was to measure the impact of a structured intervention on pain management in a pediatric emergency department (ED).

METHODS

Data were prospectively collected from children presenting to an urban tertiary care pediatric ED before and after intervention. Data were collected on the rate and timeliness of analgesic administration, the assessment and reassessment of pain, periprocedural anesthesia, and patient satisfaction. The intervention was developed by a multidisciplinary committee composed of physicians, nurses, and child life specialists and was focused on correcting deficiencies identified before intervention data collection. It consisted of a policy defining pain, pain-appropriate analgesia, age-appropriate pain assessment, and adequate preprocedural and periprocedural analgesia. Implementation occurred through provider education, organizational changes, and patient empowerment.

RESULTS

One hundred two patients were enrolled during the preintervention period, and 109 were enrolled in the postintervention period. The percentage of patients in pain receiving any analgesic increased from 34% to 50%, an increase of 16% (95% confidence interval [CI], 1%-30%). The median time to medication administration decreased from 97 minutes to 57 minutes, a decrease of 40 minutes (95% CI, -84 to 4 minutes). The percentage of children receiving preprocedural analgesia increased from 10% to 62%, an increase of 52% (95% CI, 12%-74%). Reassessment of pain by physicians increased from 6% to 76%, an increase of 70% (95% CI, 59%-78%).

CONCLUSIONS

A structured intervention, tailored to pain management shortcomings commonly found in the pediatric ED, can lead to improvements in the treatment and prevention of pain in childhood emergencies.

Efficacy of a near-infrared light device in pediatric intravenous cannulation: a randomized controlled trial

OBJECTIVES

To determine whether the use of a near-infrared light venipuncture aid (VeinViewer; Luminetx Corporation, Memphis, Tenn) would improve the rate of successful first-attempt placement of intravenous (IV) catheters in a high-volume pediatric emergency department (ED).

METHODS

Patients younger than 20 years with standard clinical indications for IV access were randomized to have IV placement by ED nurses (in 3 groups stratified by 5-year blocks of nursing experience) using traditional methods (standard group) or with the aid of the near-infrared light source (device group). If a vein could not be cannulated after 3 attempts, patients crossed over from one study arm to the other, and study nurses attempted placement with the alternative technique. The primary end point was first-attempt success rate for IV catheter placement. After completion of patient enrollment, a questionnaire was completed by study nurses as a qualitative assessment of the device.

RESULTS

A total of 123 patients (median age, 3 years) were included in the study: 62 in the standard group and 61 in the device group. There was no significant difference in first-attempt success rate between the standard (79.0%, 95% confidence interval [CI], 66.8%-88.3%) and device (72.1%, 95% CI, 59.2%-82.9%) groups. Of the 19 study nurses, 14 completed the questionnaire of whom 70% expressed neutral or unfavorable assessments of the device in nondehydrated patients without chronic underlying medical conditions and 90% found the device a helpful tool for patients in whom IV access was difficult.

CONCLUSIONS

First-attempt success rate for IV placement was nonsignificantly higher without than with the assistance of a near-infrared light device in a high-volume pediatric ED. Nurses placing IVs did report several benefits to use of the device with specific patient groups, and future research should be conducted to demonstrate the role of the device in these patients.

Parental preference for rehydration method for children in the emergency department

OBJECTIVE

To determine which rehydration method, oral or intravenous, parents would choose for their child when given the opportunity to make an informed decision and to determine factors influencing preference.

METHODS

Parents of children, aged 6 months to 5 years, who presented to a pediatric emergency department with a chief complaint of vomiting and/or diarrhea were eligible. After triage evaluation and before physician assessment, research assistants presented educational materials regarding the method, risks, and benefits of both oral and intravenous rehydration. Parents were then asked to complete a survey asking them their preference, reasons for their preference, questions about their child's current illness, and demographic information.

RESULTS

Two hundred sixty parents completed the study. Ninety eight (38%) preferred oral rehydration, and 162 (62%) preferred intravenous rehydration. Time of day, presence of siblings in the ED requiring parental attention, presence of another adult to provide support, parental age, educational attainment, and employment status were not statistically associated with the stated preference. Of those parents who selected intravenous rehydration, 53% stated that they would choose oral rehydration if there was an oral medication available that would significantly decrease vomiting. Of those parents who selected oral rehydration, 32% stated that they would choose intravenous rehydration if there was a topical medication available that would significantly decrease the pain of intravenous catheter placement.

CONCLUSIONS

When given the opportunity to make an informed decision, more parents chose intravenous rehydration. However, the prospect of an effective oral antiemetic medication might lead more parents to choose oral rehydration.

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.

On the front lines: lessons learned in implementing multidisciplinary peripheral venous access pain-management programs in pediatric hospitals

Venipuncture and intravenous cannulation are among the most common and widespread medical procedures performed on children today. Therefore, effective treatment of venous access pain can benefit from an integrated systems approach that enlists multiple players in the health care system. By using case studies that analyze this issue from the perspective of the nurse, the physician, the pharmacist, and the child life specialist, this article illustrates how multidisciplinary programs designed to manage needle pain have been developed successfully in several institutions. Common themes that arise from these case studies include the importance of a multidisciplinary evidence-based approach to advocate change; a system-wide protocol for the administration of local anesthetics; convenient access to topical local anesthetics; department and hospital-wide support for educational efforts, including training in nonpharmacologic techniques used by child life specialists; and ongoing quantification of the overall success of any program. Implementation of these strategies can result in significant improvements in the pediatric venous access experience.

Ultrasound-enabled topical anesthesia for pain reduction of phlebotomy for whole blood donation

BACKGROUND

Ultrasound-facilitated delivery of topical anesthetics has been used to achieve effective anesthesia within 5 minutes for venipuncture and the insertion of intravenous access devices, but has never been studied for blood donation.

STUDY DESIGN AND METHODS

This study was a single-center, prospective, randomized, sham treatment-controlled, single-blinded clinical evaluation. Repeat donors were randomly assigned to undergo treatment with ultrasound and topical anesthetic or sham ultrasound and placebo anesthetic before phlebotomy for whole blood donation. The primary outcome measures were pain assessments using the Verbal Categorical Scale (VCS) and the Visual Analogue Scale and the assessment of skin irritation at the target site.

RESULTS

One-hundred subjects were enrolled and all completed the study. Compared to the sham/placebo control group, donors receiving ultrasound/anesthetic had lower pain scores on the VCS (1.81 +/- 0.67 vs. 2.17 +/- 0.68; p = 0.01) and Visual Analog Scale (17.2 +/- 15.5 vs. 27.6 +/- 19.5; p = 0.006). The proportion of subjects in the treatment group who experienced skin irritation (8%) was similar to that in the control group (2%; p = 0.20).

CONCLUSION

Ultrasound-enhanced delivery of topical anesthetic was demonstrated to be a safe means of quickly achieving clinically meaningful reduction in the pain of phlebotomy for whole blood donation compared to sham/placebo treatment.

Use of the Synera™ Patch for Local Anesthesia Before Vascular Access Procedures: A Randomized, Double-Blind, Placebo-Controlled Study

OBJECTIVE

This randomized, double-blind, placebo-controlled, paired study compared the Synera patch, a drug delivery device comprised of an eutectic mixture of lidocaine (70 mg) and tetracaine (70 mg) whose onset is accelerated by a controlled heating device, with placebo. The objective of the study was to evaluate the efficacy of Synera in inducing local anesthesia before a vascular access procedure.

DESIGN

Before the vascular access procedures, adult volunteers randomly received a concurrent application of Synera and placebo to the right and left antecubital surfaces. Forty subjects received 20-minute treatments. After each vascular access procedure, efficacy evaluations were completed by the subject, investigator, and an independent observer. Median subject-reported pain intensity, using the visual analog scale scores (VAS, 0-100 mm scale) were significantly lower for Synera than placebo (5 mm vs 28 mm, P < 0.001).

RESULTS

Compared with placebo, more subjects reported adequate anesthesia following Synera (73% vs 31%, P = 0.002), and more subjects indicated they would use Synera again (70% vs 33%, P = 0.006). Investigators rated more subjects having no pain with Synera compared with placebo (63% vs 33%, P = 0.021), and more subjects having adequate anesthesia with Synera (60% vs 23%, P = 0.004). Independent observers rated 68% of subjects having no pain with Synera compared with 38% with placebo (P = 0.015). Side-effects were limited to localized pruritus and erythema. Erythema was more common with Synera than placebo (62% vs 42%, P = 0.018).

CONCLUSIONS

A 20-minute application of Synera consistently provided clinically useful anesthesia for vascular access procedures, and appears to be well suited for topical dermal anesthesia due to its reduced time required to produce adequate anesthesia and high subject and investigator acceptance.

Procedural sedation and analgesia research: state of the art

The authors review the current state of procedural sedation and analgesia research and clinical practice in adults and children, discuss the limitations in research methodology, and propose future areas of investigation.

Brief focal ultrasound with topical anesthetic decreases the pain of intravenous placement in children

OBJECTIVE

To determine whether brief, focal pretreatment of children's skin with low-frequency ultrasound followed by a 5-minute application of a 4% lidocaine topical anesthetic decreases the pain of intravenous (IV) catheter placement.

METHODS

A randomized, double-blind, placebo-controlled trial enrolling children 8 to 18 years of age undergoing IV placement as part of their care in a pediatric emergency department. Thirty-eight children received pretreatment followed by 5-minute application of a topical anesthetic. Thirty-nine children received pretreatment followed by 5-minute application of a placebo cream. Children and parents rated the pain associated with IV placement using the visual analog scale (VAS).

RESULTS

There were no significant differences in demographics between the 2 groups. Children in the treatment group had significantly lower VAS scores (mean, 2.29) than children in the control group (mean, 3.23) (P = 0.023; 95% confidence interval of the mean difference, -1.87 to -0.02). The parents' VAS scores of the child's pain were also lower for the treatment group (mean, 2.47 vs 3.39; P = 0.038; confidence interval, -1.97 to 0.11).

CONCLUSIONS

Visual analog scale scores measuring children's pain and parents' perception of the child's pain were lower in those who were pretreated with brief focal ultrasound and 5 minutes of 4% lidocaine cream when compared with those pretreated with ultrasound and placebo.