A randomized, controlled trial to evaluate topical anesthetic for 15 minutes before venipuncture in pediatrics

Efficacy of Buzzy Device Versus EMLA Cream for Reducing Pain During Needle-Related Procedures in Children: A Randomized Controlled Trial

OBJECTIVES

Several pain management tools exist but with limitations in their efficacy or applicability. The EMLA (eutectic mixture of local anesthetics) cream is currently used for pain relief for needle-related procedures; however, it needs a minimum of 30 to 45 minutes to be effective. The Buzzy is a device that generates vibrations with cold leading to quicker pain relief. Our aim was to evaluate the effect of the Buzzy device in pain and anxiety reduction compared with EMLA cream in children requiring intravenous cannulation or venepuncture.

METHODS

This was a randomized clinical trial comparing pain and anxiety reduction by Buzzy device with the standard care (EMLA cream) in children aged 2 to 14 years who required blood extraction or intravenous cannulation based on their clinical needs. Eligible patients were randomized to either Buzzy device as the intervention or EMLA cream as the control. The outcome measures were the degree of pain scores and anxiety ratings at different stages of the needle-related procedures.

RESULTS

A total of 300 patients with a mean age of 6.5 ± 3.1 years were enrolled. Baseline characteristics were similar between the Buzzy device and EMLA cream groups. The observed pain scores by research nurses and a parent were significantly lower in the EMLA group compared with the Buzzy device group; however, the pain scores by the self-assessment scale were not statistically significant with mean difference of -0.332, 95% confidence interval, -0.635 to -0.028 ( P = 0.062). The level of anxiety was significantly lower in EMLA compared with Buzzy device ( P = 0. 0.0001). Both staff and parents' satisfaction, success rate of cannulation, type of blood tests, and comment on the physician on the results were similar in both groups.

CONCLUSIONS

Pain and anxiety relief using the Buzzy device is not as effective as EMLA cream in children requiring venepuncture. However, rapid onset of action of the Buzzy device is valuable in decreasing waiting time in a busy emergency department.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT05354739.

Formulation and In Vivo Pain Assessment of a Novel Niosomal Lidocaine and Prilocaine in an Emulsion Gel (Emulgel) of Semisolid Palm Oil Base for Topical Drug Delivery

This study aimed to formulate semisolid niosomal encapsulated lidocaine and prilocaine using the patented palm oil base Hamin-C® for further characterization and in vivo pain assessment. Seven formulations were initially studied with various chemical compositions. A thin-layer film hydration method was used to produce niosome using a mixture of surfactant (Span® 40 or Span® 60) and cholesterol (CHOL) at a 1:1 ratio, with/without a charge-inducing agent (diacetyl phosphate) (DCP) and with/without labrasol®. Niosome F1 formulation had been identified as the highest %EE achieved, at 53.74 and 55.63% for prilocaine and lidocaine, respectively. Furthermore, NIO-HAMIN F1 emulgel indicated the best formulation with higher permeability of prilocaine and lidocaine compared to the rest of the formulations. The reformulation of optimization of NIO-HAMIN F1 emulgel using a cold process to NIO-HAMIN F1-C emulgel to improve the viscosity resulted in higher diffusion of prilocaine and lidocaine by 5.71 and 33.38%, respectively. In vivo pain perception studies by verbal rating score (VRS) and visual analogue score (VAS) on healthy subjects show a comparable local anesthetic effect between NIO-HAMIN F1-C emulgel and EMLA® cream.

The use of virtual reality in children undergoing vascular access procedures: a systematic review and meta-analysis

Venous access procedures are painful and feared by children and their parents. Virtual reality has become increasingly prominent and has been shown to be effective in various procedures. The aim of this meta-analysis was to examine virtual reality's effect on pain and fear in children from 4 to 12 in the context of vascular access. From the 20th to the 26th December 2020, we searched Sciencedirect, Springerlink, CENTRAL, Pubmed and PMC. Studies using virtual reality versus a control in vascular access for children were included in a meta-analysis to evaluate the effect of virtual reality regarding pain as a primary and fear/anxiety as a secondary endpoint during the procedures. The Jadad scale and Delphi List were used to assess study quality. 20,894 citations were identified, 9 met our inclusion criteria. One publication was conducted in two different situations and was thus considered as 2 studies. Compared to standard of care, virtual reality significantly reduced pain (10 studies, 930 participants: standardized mean difference [SMD] 2.54, 95%CI 0.14-4.93, p = 0.038), and fear/anxiety (6 studies, 648 participants: SMD 0.89, 95%Cl 0.16-1.63, p = 0.017). For both parameters, we found significant heterogeneity between studies. This is the first meta-analysis to look at the use virtual reality in young children undergoing vascular access procedures, providing weak to moderate evidence for its use. Although large effect sizes provide evidence for a positive effect of virtual reality in reducing pain and fear, there is significant heterogeneity between studies. More research with larger groups and age stratification is required.

Health care provider's responses to children's resistance to peripheral vein cannulation: A qualitative observational study

AIMS AND OBJECTIVES

Health care and treatment should be voluntary, but restraint is often used during treatment of children. Knowledge about how health care providers respond to preschool children's resistance is lacking and can help understand current paediatric care in hospitals. The aim of the present article was to provide knowledge about how healthcare providers respond to preschool children's resistance during the clinical procedure of peripheral vein cannulation.

DESIGN

An explorative qualitative research design was developed for this study.

METHODS

Observations with video recording were used to collect data. Eight nurses and seven physicians participated in the study (n = 15). Their responses to preschool children's (n = 6) resistance were studied during 14 attempts of peripheral vein cannulation. Consolidated criteria for reporting qualitative research (COREQ) were used.

RESULTS

The healthcare providers made 380 responses to children's resistive expressions, interpreted within four main types, responses to acknowledge the child, responses to distract the child, responses to persuade the child and responses to reject the child. All main types of responses were used by both nurses and physicians. Regardless of the amount of resistance the children expressed, all children received distracting and acknowledging responses. Rejecting responses were used approximately twice as much in the implementation phase as in the preparation phase. Distraction, persuasion and rejection began in the preparation phase and increased in the implementation phase.

CONCLUSIONS

The main types and sub-types of responses showed how healthcare providers use a wide array of responses to meet children's resistance during peripheral vein cannulation.

RELEVANCE TO CLINICAL PRACTICE

The results can enable health care providers to become aware of their own practices during peripheral vein cannulation and other clinical procedures and to elaborate on their use of responses that can be considered intrinsically less child-friendly.

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.

Use of Lidocaine for Pain Management in the Emergency Medicine: A Systematic Review and Meta-Analysis

Background: Lidocaine is a well-known medium-acting local anesthetic with a short onset time. It is a valuable drug for managing both acute and chronic pains and is being used as a popular agent for pain control in the emergency department (ED). In this systematic review, we intended to define the effectiveness of lidocaine in pain management of the patients referring to ED. Methods: The preferred reporting items for systematic reviews and meta-analysis (PRISMA) statement was utilized for this Systematic Review (SR). We searched the databases of PubMed, Scopus, ProQuest, and Medline (Ovid) from 1990 to August 2017 for Randomized Controlled Trials (RCTs) in which the study population was referred to the emergency department and received lidocaine. Full-texts of the studies that were published in English were reviewed for inclusion. Both authors individualistically evaluated all studies. Seven articles were eligible for the meta-analysis based on their common outcomes. Results: The total number of subjects was 671. The studies were categorized based on the type of drug and administration route. Mean pain, regardless of the drug administration method, in the placebo group was 0.69 units higher than the lidocaine group. Considering the administration route, mean pain in the placebo group was 0.35 units higher than the lidocaine group when administered topically, and it was lower in the subcutaneous method than the topical method by 1.41 units. Conclusion: Infiltration of lidocaine decreases pain of different procedures in the ED whereas the effect of topical lidocaine is controversial issue.

External cold and vibration for pain management of children undergoing needle-related procedures in the emergency department: a randomised controlled non-inferiority trial protocol

INTRODUCTION

Needle-related procedures are considered as the most important source of pain and distress in children in hospital settings. Considering the physiological and psychological consequences that could result from these procedures, management of pain and distress through pharmacological and non-pharmacological methods is essential. Therefore, it is important to have interventions that are rapid, easy-to-use and likely to be translated into clinical practice for routine use. The aim of this study will be to determine whether a device combining cold and vibration (Buzzy) is non-inferior to a topical anaesthetic (liposomal lidocaine 4% cream) for pain management of children undergoing needle-related procedures in the emergency department.

METHODS AND ANALYSIS

This study will be a randomised controlled non-inferiority trial comparing the Buzzy device to liposomal lidocaine 4% cream for needle-related pain management. A total of 346 participants will be randomly assigned in a 1:1 ratio to one of the two study groups. The primary outcome will be the mean difference in pain intensity between groups during needle-related procedures. A non-inferiority margin of 0.70 on the Color Analogue Scale will be considered. A Non-inferiority margin of 0.70 on the Color Analogue Scale will be considered. The secondary outcomes will be the level of distress during the procedure, the success of the procedure at first attempt, the occurrence of adverse events, the satisfaction of both interventions and the memory of pain 24 hours after the procedure. The primary outcome will be assessed for non-inferiority and the secondary outcomes for superiority.

ETHICS AND DISSEMINATION

This study protocol was reviewed and approved by the institutional review board of the study setting. Findings of this trial will be disseminated via peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

NCT02616419.

"But Perhaps they could Reduce the Suffering?" Parents' Ambivalence toward Participating in Forced Peripheral Vein Cannulation Performed on their Preschool-Aged Children

PURPOSE

The purpose of this study was to provide a better understanding of how parents experience the use of restraint during the performance of peripheral vein cannulation (PVC) on their child.

DESIGN/METHODS

Qualitative, semi-structured interviews were performed with seven parents and one close relative who had accompanied their 3-5-year-old child while the child resisted the medical procedure of PVC. The analysis was guided by symbolic interactionism and resulted in two themes.

RESULTS

The first theme that emerged, "Negotiating What Quality of Performance Should be Expected", was based on 1) Parents expected child-friendly encounters, 2) Performance of PVC caused unexpected and unnecessary suffering for the child, and 3) Parents explained and excused the performance of PVC. The second theme: "Negotiating One's Own Role and Participation in a Child's Suffering During the Procedure", was based on 1) Parents desired to be acknowledged and approached for suggestions regarding ways to ease the trauma surrounding the procedure, 2) Parents expressed uncertainty regarding the consequences that the procedure would have for the children, and 3) Parents desired to play a protective role, and they tended to engage in self-criticism.

CONCLUSION

When the PVC was less child-friendly, poorly planned and chaotic or performed with lacking skills, the parents became unwilling partners in the unnecessary suffering of the child. A practical implication is that if pediatric health care providers are aiming for the reduction of restraint, they must better understand parents' expectations and experiences and ensure that the use of restraint is used as the last resort.

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.

Phlebotomy, a bridge between laboratory and patient

The evidence-based paradigm has changed and evolved medical practice. Phlebotomy, which dates back to the age of ancient Greece, has gained experience through the evolution of medicine becoming a fundamental diagnostic tool. Nowadays it connects the patient with the clinical laboratory dimension building up a bridge. However, more often there is a gap between laboratory and phlebotomist that causes misunderstandings and burdens on patient safety. Therefore, the scope of this review is delivering a view of modern phlebotomy to "bridge" patient and laboratory. In this regard the paper describes devices, tools and procedures in the light of the most recent scientific findings, also discussing their impact on both quality of blood testing and patient safety. It also addresses the issues concerning medical aspect of venipuncture, like the practical approach to the superficial veins anatomy, as well as the management of the patient's compliance with the blood draw. Thereby, the clinical, technical and practical issues are treated with the same relevance throughout the entire paper.

Local Anesthetics: What's New in Minimal Pain Injection and Best Evidence in Pain Control

SUMMARY

Local anesthesia in plastic surgery is undergoing a revolution. In the last 10 years, significant improvements in technique have permitted surgeons to do more and more under pure local anesthesia to increase patient safety and convenience while maintaining total patient comfort during the injection of the local anesthesia and while the procedure is accomplished. Many procedures which used to require sedation are now being performed without it. This article explores some of the new advances in local anesthesia such as painless blunt-tipped cannula local anesthetic infiltration, decreased pain with sharp needle tip injection, and long-lasting local anesthetics with delayed release from liposomal encapsulation. This article also examines the best evidence of the last 10 years of advances of pain control with local anesthesia.