Topical ketamine as a local anesthetic agent in reducing venipuncture pain: A randomized controlled trial

Immersive Virtual Reality for Pain Control and Anxiolysis During IV Blood Draws in Adults: A Randomized Controlled Trial

OBJECTIVE

To evaluate immersive virtual reality's (IVR) effectiveness as a distraction in reducing perceived pain and anxiety among adults undergoing intravenous (IV) blood draw.

METHODS

In this randomized controlled trial, we recruited adult patients 18-50 years of age scheduled for routine blood draws at the phlebotomy lab and randomized them into experimental and control groups. The experimental group underwent IV blood draw with IVR, and the control group underwent IV blood draw with standard practice. Before the procedure, subjects rated their anxiety level and the pain they "expected" to experience during blood draw. Immediately afterward, the subjects rated their actual "perceived" pain level. We measured the "expected" and the "perceived" pain and anxiety scores using a 100 mm visual analog scale. The primary outcome was the difference in "perceived" pain scores (0-100) between the two cohorts. Secondary outcomes were differences between the anxiety scores and the "expected" and "perceived" pain between the two cohorts, as well as degree of satisfaction with IVR during the blood draw and willingness to use IVR in future procedures.

RESULTS

Fifty-nine subjects completed the study, 31 in the experimental group and 28 in the control group. For the primary outcome, the control group reported a perceived median pain score of 6.5 vs. the experimental group of 5; P = .55. For the secondary outcomes, the median anxiety scores were 22 (6.25-45.75) and 24 (2.00-35.00) for the control and the experimental groups, respectively, P = .44. The control group reported an expected median pain score of 20 vs. a perceived score of 6.5; P = .25, and the experimental group reported an expected median pain score of 22 vs. a perceived score of 5; P < .01. Median Likert scores were 5 (1-5) for satisfaction and preference for future use during painful procedures.

CONCLUSIONS

The results of our study demonstrated that there was no significantly lower perceived pain or anxiety when using IVR compared to standard practice in adults undergoing IV blood draw.

Narrative Review: Low-Dose Ketamine for Pain Management

Pain is the leading cause of medical consultations and occurs in 50-70% of emergency department visits. To date, several drugs have been used to manage pain. The clinical use of ketamine began in the 1960s and it immediately emerged as a manageable and safe drug for sedation and anesthesia. The analgesic properties of this drug were first reported shortly after its use; however, its psychomimetic effects have limited its use in emergency departments. Owing to the misuse and abuse of opioids in some countries worldwide, ketamine has become a versatile tool for sedation and analgesia. In this narrative review, ketamine's role as an analgesic is discussed, with both known and new applications in various contexts (acute, chronic, and neuropathic pain), along with its strengths and weaknesses, especially in terms of psychomimetic, cardiovascular, and hepatic effects. Moreover, new scientific evidence has been reviewed on the use of additional drugs with ketamine, such as magnesium infusion for improving analgesia and clonidine for treating psychomimetic symptoms. Finally, this narrative review was refined by the experience of the Pain Group of the Italian Society of Emergency Medicine (SIMEU) in treating acute and chronic pain with acute manifestations in Italian Emergency Departments.

A Clinical Study for Removal of Impacted Mandibular Third Molar under Local Anaesthesia, with and without Ketamine - A Split Mouth Comparative Study

Introduction

Disimpaction is one of the most common operations done by oral and maxillofacial surgeons around the world. Ketamine is a well-known general anaesthetic and short-acting intraoperative analgesic. The aim of this study was to measure the efficacy of anaesthesia using combined treatment with local anaesthetic plus a subanaesthetic dose of ketamine and local anaesthetic alone in bilaterally impacted mandibular third molar surgery.

Methods and Materials

A total of 24 patients who consented were taken up for a split-mouth study. In the control group, surgical extraction of the impacted lower third molar was done using local anaesthesia (lignocaine 2% with 1:80,000 adrenaline) only, and in the study group, local anaesthesia with ketamine extraction was done using ketamine (0.2 mg/kg) along with local anaesthesia (LA). The time of onset and the duration of anaesthesia intraoperatively were recorded using a digital stopwatch. The depth of anaesthesia was noted on the 10th, 30th and 60th min. After extraction, the post-operative pain on the first, fourth, eighth and 12th hour was evaluated using a Visual Analogue Scale (VAS) score rating of 1-10. The pulse was also noted and compared for any differences in either of the groups.

Results

A statistically significant (P < 0.005) difference in result was obtained for the onset, duration, depth and pain score after surgical extraction in both the evaluated groups. The pain index score by the ketamine group was significantly low as compared to the local anaesthesia-only group. Intraoperative onset, duration and depth of anaesthesia obtained had a significant difference.

Discussion

Ketamine can be used as a viable option for surgical third molar extractions with reduced discomfort and post-operative pain.

Topical Lidocaine plus Diclofenac as a Local Anesthetic Agent in Central Venous Catheterization; a Randomized Controlled Clinical Trial

Introduction:

Various methods of analgesia can be used to reduce or prevent procedural pain in emergency department (ED). This study aimed to evaluate the effectiveness of topical lidocaine-diclofenac combination compared to lidocaine-prilocaine combination (Xyla-P) in reduction of the pain during central venous catheter (CVC) insertion.

Methods:

In this randomized clinical trial, 100 adult patients requiring CVC insertion in the ED were enrolled. These patients were randomly divided into two groups. The site of CVC insertion was covered with 2 g of topical Xyla-P cream in the first group, and 2 g of topical lidocaine-diclofenac cream in the second group. The primary outcome was the pain during CVC implantation. The secondary outcomes were physician satisfaction and the incidence of side effects.

Results:

 On the visual analog scale (VAS), the pain score during CVC insertion was significantly lower in the second group (p = 0.027). However, there was no difference in pain scores during lidocaine injection between the two groups (p = 0.386). Also, there was no significant difference in the rate of side effects between the two groups (p = 1.0). The physician’s satisfaction with the first group was significantly lower than the second group (p = 0.042).

Conclusion:

Although the CVC insertion pain was significantly lower in patients who received the topical combination of Lidocaine plus Diclofenac, there was no clinically important difference between the two groups and both topical anesthetics were effective and safe in reducing pain intensity. Also, lidocaine-diclofenac combination cream was more cost-effective than Xyla-P cream.