Needle phobia and malignant vasovagal syndrome

A Randomised Controlled Trial of Ice to Reduce the Pain of Immunisation-The ICE Trial

BACKGROUND AND OBJECTIVES

vaccine injections are a common cause of iatrogenic pain and anxiety, contributing to non-compliance with scheduled vaccinations. With injection-related pain being recognised as a barrier to vaccination uptake in both adults and children, it is important to investigate strategies to effectively reduce immunisation pain. This prospective randomised controlled trial investigated the effects of applying an ice pack on vaccine-related pain in adults.

METHODS

medical students receiving the flu vaccination were randomised to receive an ice pack (intervention) or placebo cold pack (control) at the injection site for 30 s prior to needle insertion. Immediate post-vaccination pain (VAS) and adverse reactions in the proceeding 24 h were recorded.

RESULTS

pain scores between the intervention (n = 19) and control groups (n = 16) were not statistically significant (intervention: median pain VAS = 7.00, IQR = 18; control: median pain VAS = 11, IQR = 14 (p = 0.26). There were no significant differences in the number of adverse events between the two groups (site pain p = 0.18; localised swelling (p = 0.67); bruising p = 0.09; erythema p = 0.46).

DISCUSSION

ice did not reduce vaccination-related pain compared to cold packs. COVID-19 related restrictions impacted participant recruitment, rendering the study insufficiently powered to draw conclusions about the results.

Double blind randomized control trial to evaluate the efficacy of ketoprofen patch to attenuate pain during venous cannulation

Background

Venipuncture pain is an uncomfortable suffering to the patient. It creates anxiety, fear and dissatisfaction. The ketoprofen transdermal patch is a proven treatment for musculoskeletal and arthritic pain. We planned this study to evaluate the efficacy of the ketoprofen patch to reduce venipuncture pain.

Methods

Two hundred adult patients, aged 18–60 years, of either sex, ASA grade I or II, were enrolled. Presuming that therapy would decrease venipuncture pain by 30%, a power calculation with α = 0.05 and β = 0.80 required enrollment of at least 24 patients into each group. However, 100 patients in each group were recruited. Group I (Control) received a placebo patch; Group II (Ketoprofen) received a 20 mg ketoprofen patch. A selected vein on the dorsum of the patient's non-dominant hand was cannulated with 18 g intravenous cannula 1 h after the application of the respective patch. Assessment of pain was done by a 10 cm visual analogue scale (VAS) of 0–10, where 0 depicts “no pain” and 10 is “the worst imaginable pain”. The venipuncture site was assessed for the presence of skin erythema, swelling and rashes at 12 h, 24 h and at the time of decannulation.

Results

Incidence of pain was 100% (94/94) in the control group as compared to 93% (85/91) in the ketoprofen group. The severity of the venipuncture pain was 6 (2) and 2 (2) for control and ketoprofen groups respectively (P < 0.05).

Conclusions

Application of a ketoprofen patch at the proposed site of venipuncture one hour before the attempt is effective and safe for attenuating venipuncture pain.

Probable vasovagal reaction following cystocentesis in two cats

Case summary

This case report describes an acute reaction, thought to be vagally mediated, in two cats immediately following cystocentesis. Both cats were being evaluated for feline idiopathic cystitis and developed bradycardia, hypersalivation, urination and weakness after a blind cystocentesis. Both cats recovered uneventfully with supportive care.

Relevance and novel information

A vagally mediated response may occur in cats after cystocentesis, which is a common procedure performed by veterinary professionals in cats. This response may be very profound and dramatic. Affected cats will likely make an uneventful recovery. This vagally mediated response to cystocentesis, though reported by word of mouth among veterinarians, has not been described in the literature. This is the first documentation of its occurrence in cats.

A cardiovascular collapse occurred in the beach chair position for shoulder arthroscopy under general anesthesia -A case report-

The occurrence of severe hypotension and bradycardia, following placing to the beach chair position from supine during general anesthesia for repair of tendon injury of the rotator cuff of shoulder in a healthy 50 year-old man was described. The Bezold-Jarisch reflex, which is known to inhibit cardiovascular reflex and composed of three kinds of symptoms such as vasodilation, bradycardia and hypotension, has been reported mainly in peripheral nerve block, and may occur during orthostasis, hypovolemia, hemorrhage, supine inferior vena cava compression in pregnancy, interscalene block for shoulder surgery in the sitting position and so on. The bradycardia and hypotension can be more aggravated when causative elements overlaps each other. Anticholinergics and vasopressor were injected intravenously, and position of the patient was changed to the supine position immediately resulting in a normal vital signs dramatically.

Vasovagal cardiac arrest during spinal anesthesia for Cesarean section -A case report-

The vasovagal response is characterized by an inappropriate combination of bradycardia and paradoxical vasodilation. During a general or neuraxial anesthesia-induced sympathectomy, a sudden vagal activation and/or an acute reduction in sympathetic tone can cause serious vasovagal responses. Neuraxial anesthesia for Cesarean section may trigger vasovagal response, due to multiple risk factors; high neuraxial block, sudden hemorrhage, aortocarval compression, peritoneal manipulation, and emotional stress. A 39-year-old pregnant woman, at 38 weeks of gestation with episodes of non-sustained ventricular arrhythmia and newly developed vasovagal syncope during pregnancy, was scheduled to undergo a spinal anesthesia for an elective Cesarean section. Immediately after the placental expulsion, a sudden severe bradycardia, followed by a cardiac arrest occurred. The patient fully recovered after prompt cardiopulmonary resuscitation with chest compression, manual ventilation with oxygen, rapid injection of epinephrine and hydration. This case illustrates a serious potential risk of vasovagal response superimposed on neuraxial anesthesia, during a Cesarean section, especially during placental expulsion.

Use of needle-free injection systems to alleviate needle phobia and pain at injection

Needle phobia affects at least 10% of the general population. Subcutaneous injections are used for many reasons, including immunizations, administration of medications such as insulin and heparin, and to provide local anesthesia, both for surgery and for intravenous cannulation. Whatever the reason for its application, the injection itself may cause discomfort and/or pain. In children, in patients with needle phobia, in those who require frequent intravenous cannulations, or in those who need daily medication, the pain at injection can reach unbearable intensity that could lead to refusal of medical care. Various approaches are employed to alleviate the pain caused by intravenous cannulation. These include the use of topical analgesia [i.e., EMLA, Ametop (tetracaine], Numby Stuff and ethylchloridespray], skin infiltration with lidocaine using 25-30-gauge needles and jet injectors. This article will review the complex topic of needle phobia and needle pain, and will summarize the currently available alternatives and the new developments intended to reduce the intensity of injection pain.

A systematic review of measures for reducing injection pain during adult immunization

OBJECTIVE

To evaluate the effectiveness of different pain-relieving interventions to reduce pain from immunization in adults.

DATA SOURCES

MEDLINE (1950 to October Week 3 2008) PsycINFO (1967 to December Week 1 2008), CINAHL (1982 to October Week 4 2008), EMBASE (1980 to 2008 Week 43) and the Cochrane Central Register of Controlled Trials (3rd Quarter 2008).

REVIEW METHODS

Databases were searched for trials of pharmacological, behavioural, physical or operator-dependant techniques to reduce pain from immunization in adults. The primary outcome was pain as assessed by visual analogue scale or other numeric rating scale.

RESULTS

Six studies representing 853 participants were identified. One study evaluating pharmacological interventions (lidocaine-prilocaine) found them to be effective in reducing pain from immunization. Similarly, two studies evaluating physical pain relieving techniques, either skin cooling interventions (Fluori-Methane) or tactile stimulation (manual pressure at the site of injection) found them to reduce pain. One study of jet injectors found them to be more painful than conventional needle and syringe. Neither freezing needles nor warming vaccines was found to be effective in reducing pain. No studies investigated psychological interventions or oral analgesics (acetaminophen and ibuprofen).

CONCLUSION

There was limited evidence to support the use of lidocaine-prilocaine, Fluori-Methane and manual pressure for reducing immunization pain in adults. There was limited evidence of more pain with jet injectors compared to needle and syringe. Due to limited data, we recommend further investigation of methods to reduce immunization pain in adults, primarily psychological and physical techniques.

Severe Needle Phobia in the Perianesthesia Setting

Needle phobia is a peculiar type of specific phobia, with unique clinical features, that may be encountered in some surgical patients. It may present a serious acute problem to the perianesthesia care team and requires careful psychological and/or pharmacological management. This article provides a clinical report and detailed discussion of severe needle phobia in the perianesthesia setting.

Needle phobia and stress-reducing medical devices in pediatric and adult chemotherapy patients

Needle phobia--fear of medical devices--is a significant problem in pediatric and adult chemotherapy patients. Stress-reducing medical devices is a new, effective cognitive therapy for needle phobia. Twenty-five pediatric and 25 adult chemotherapy patients were randomly exposed to conventional or stress-reducing decorated butterfly needles and syringes. Emotional stress responses were determined with the Visual Aversion Scale, Visual Analogue Fear Scale, Visual Analogue Anxiety Scale, and Visual Overall Stress Score for each needle and syringe design. Sixty-eight percent of the pediatric and 52% of the adult patients were overtly needle phobic, but children demonstrated significantly more aversion and stress (P < .001). Stress-reducing medical devices effectively and significantly reduced aversion, anxiety, fear, and overall stress, and were 76% effective in preventing overt needle phobia in children and 92% effective in adults (P < .001). One hundred percent of children and adults felt that stress-reducing medical devices should be available in chemotherapy clinics. Needle phobia and stress in pediatric and adult chemotherapy patients are significantly reduced by the use of stress-reducing medical devices.

Perioperative vasovagal syncope with focus on obstetric anesthesia

Vasovagal syncope refers to a reflex cardiovascular depression that gives rise to loss of consciousness with bradycardia and profound vasodilatation. This response commonly occurs during regional anesthesia, hemorrhage or supine inferior vena cava compression in pregnancy. The changes in circulatory response from the normal maintenance of arterial pressure to parasympathetic activation and sympathetic inhibition may cause severe hypotension. This change is triggered by reduced cardiac venous return as well as episodes of emotional stress, excitement or pain. Occasionally, these vasovagal responses may be unpredictable and may dramatically proceed to asystole with circulatory collapse, and may even result in death. In these circumstances, hypotension may be more severe than that caused by bradycardia alone, because of unappreciated vasodilatation. Regional anesthesia, decreased venous return, hemorrhage and abnormal fetal presentation cumulatively increase the risk of vasovagal syncope in cesarean section patients. When a vasovagal response occurs, ephedrine is the drug of first choice because of its combined action on the heart and peripheral blood vessels. Epinephrine must be used early in established cardiac arrest, especially after high regional anesthesia.

Vasovagal syncope with asystole associated with intravenous access

Two cases of vasovagal syncope (VVS) during venous access are reported. Both patients had a history of fainting episodes and experienced bradycardia with asystole, hypotension, and fainting. Pain and phobic stress during venous access triggered an increase in parasympathetic tone, resulting in bradycardia with asystole and hypotension in both cases. Hypotension and bradycardia likely caused cerebral hypoperfusion, leading to fainting. The intense parasympathetic tone triggered by somatic or emotional stress was likely responsible for directly depressing the sinus node, leading to asystole and bradycardia. Bradycardia with asystole progressing to syncope is a potentially fatal dysrhythmia in patients with cardiovascular disease or older patients with decreased cardiac function. Appropriate treatment for VVS includes the administration of intravenous fluids, vagolytics, ephedrine, and the rapid use of the Trendelenburg position. Intravenous fluids and atropine were used to treat the present patients.

Needle Phobia During Pregnancy

The objective of this study was to understand the experience of a pregnant woman with needle phobia and examine its impact on her antepartum, intrapartum, and postpartum experience. A case study format was employed. A 21-year-old primiparous woman with diagnosed needle phobia was interviewed, and her prenatal and delivery records were reviewed. Three tasks during pregnancy were identified: seeking trusting relationships with health care providers; establishing and maintaining control and understanding; and coping with fear of needles, pain, and invasion. As frequent caregivers during childbearing, nurses with an understanding of needle phobia can help to establish trusting relationships with women with this phobia and support them and their families during childbearing and their encounters with needles.

Mask fear in children presenting for anesthesia: aversion, phobia, or both?

BACKGROUND

Anesthesia induction in children is commonly accomplished by introducing volatile agents by mask. Occasionally a child describes an excessive fear of the anesthesia facemask. Little is known of the cause of the fear or of the quality or magnitude of the feelings the child is experiencing. The purpose of this study was to allow children who have established mask fear as demonstrated by volunteering the presence of fear and requesting no mask be placed on the face during the induction of anesthesia and their parents to describe and compare the distress from the mask to the alternative intravenous anesthesia induction.

METHODS

Eight children describing mask fear on the preanesthetic examination were studied. An Anesthesia Mask Fear questionnaire developed by the investigators was answered by the children and their parents.

RESULTS

Six children and their parents completed the study. The age at presentation of mask fear ranged from 1.4 to 14 years. There were one to 16 anesthetic exposures prior to reporting mask fear. One child described an aversion to the odor of the mask. Another boy developed mask fear after a single anesthetic exposure. He was subsequently diagnosed with a generalized anxiety disorder. Four female children developed mask fear after repeated anesthetic exposures. These children rated mask fear with the greatest discomfort possible while venous cannulation was scored at half or less that of the mask discomfort.

CONCLUSIONS

Care must be taken when developing a plan for anesthesia induction in children requiring multiple procedures. Children may develop an aversion to the odor or feel of the mask, or have a true phobia (irrational fear) of the mask. Those children with a phobia might also have other underlying anxieties.

Vasovagal syncope evoked by needle phobia when inserting a contact lens*

PURPOSE

To report a patient who fell unconscious because of vasovagal syncope evoked by needle phobia when he tried to wear contact lenses.

CASE REPORTS

A 16-year-old healthy boy had sometimes experienced dizziness when looking at the tips of pens. When he put his finger and the lens close to his eye to insert a soft contact lens, he felt sick and dizzy and fell unconscious.

CONCLUSION

Our experience suggests that patients with needle phobia may develop vasovagal syncope by concentrating on a fingertip when inserting a contact lens. We need to be aware of unconsciousness because of phobia when trying to insert contact lenses.

Topical vapocoolant quickly and effectively reduces vaccine-associated pain: results of a randomized, single-blinded, placebo-controlled study

BACKGROUND

Comprehensive international travel preparation often requires several vaccines. Up to 90% of adults have some fear of injections, mostly due to injection-related pain. Pediatric studies with routine vaccines have shown topical anesthetic EMLA cream (lidocaine and prilocaine, Astra Pharmaceuticals, Inc.) and the topical vapocoolant Fluori-Methane (dichlorodifluoromethane and trichlorodifluoromethane, Gebauer Co.) to be equally effective in reducing pain from vaccinations. EMLA cream is expensive and requires a 60-min application, while Fluori-Methane (FM) is immediate in onset of action and inexpensive. Skin anesthesia begins at 10 degrees C. Fluori-Methane can briefly cool the skin to 0 degrees C.

METHODS

We studied the effectiveness of topical vapocoolant on adult clients at our international travel clinic in a randomized, controlled trial of topical FM vs. cold (4 degrees C) saline placebo. Using a preset randomization table, participants served as their own controls, receiving placebo/control or active agent (participant blinded) in one arm (left or right), and a similar number of vaccines in the untreated arm. Vaccines were administered according to a set protocol per arm to minimize the risk of bias. Pain was measured using a modified McGill present pain intensity (PPI) pain index. Subjects rated their pain immediately and at 5 min on a six-level scale, noting treated and untreated arms separately. A questionnaire was completed on intervention preferences. Sample size was predetermined to achieve 90% statistical power estimating 25% efficacy (minimum n=172).

RESULTS

One hundred and eighty-five participants were enrolled; 93 FM and 92 cold saline placebo. FM-treated arms had a significant reduction in immediate pain compared to untreated arms (pain scale mean 2.2 vs. 3.1; p<.0001), and compared to placebo (mean 2.2 vs. 2.8; p<.01). Delayed pain at 5 min was not affected by FM or control (mean 1.9 vs. 2.0) compared to no intervention (pain scale 1.9). The intervention preference questionnaire indicated that participants did not find FM therapy uncomfortable. They would choose FM therapy in the future, over a cream, especially if a wait was involved.

CONCLUSION

The topical vapocoolant Fluori-Methane is an effective, quick, preferred, inexpensive agent for reducing vaccine-associated injection pain for international travel clients.

Perioperative bradycardia and asystole: relationship to vasovagal syncope and the Bezold-Jarisch reflex

Reflex cardiovascular depression with vasodilation and bradycardia has been variously termed vasovagal syncope, the Bezold-Jarisch reflex and neurocardiogenic syncope. The circulatory response changes from the normal maintenance of arterial pressure, to parasympathetic activation and sympathetic inhibition, causing hypotension. This change is triggered by reduced cardiac venous return as well as through affective mechanisms such as pain or fear. It is probably mediated in part via afferent nerves from the heart, but also by various non-cardiac baroreceptors which may become paradoxically active. This response may occur during regional anaesthesia, haemorrhage or supine inferior vena cava compression in pregnancy; these factors are additive when combined. In these circumstances hypotension may be more severe than that caused by bradycardia alone, because of unappreciated vasodilation. Treatment includes the restoration of venous return and correction of absolute blood volume deficits. Ephedrine is the most logical choice of single drug to correct the changes because of its combined action on the heart and peripheral blood vessels. Epinephrine must be used early in established cardiac arrest, especially after high regional anaesthesia.