Efficacy of Local Anesthesia for Radial Artery Puncture Pain: A Systematic Review and Network Meta-Analysis

We performed a systematic review and network meta-analysis (NMA) to assist clinicians in determining the optimal patient-specific method of analgesia during radial artery puncture by comparing radial artery puncture procedural pain. We included randomized controlled trials that assessed the prophylactic efficacy of local anesthesia for radial artery puncture-associated pain. We searched the Medical Literature Analysis and Retrieval System Online in January 2023, the Cochrane Central Register of Controlled Trials in January 2023, the Excerpta Medica Database in December 2022, the World Health Organization International Clinical Trials Platform Search Portal in January 2023, and ClinicalTrials.gov in January 2023. We synthesized the pain scores (0-100 scale) using the frequentist random-effects NMA model. We evaluated the confidence in each outcome using the CINeMA tool (https://cinema.ispm.unibe.ch/). We conducted an NMA of 1,619 patients across 14 studies on pain scores during radial artery puncture-related procedures for 12 interventions. Compared with placebo, mepivacaine infiltration and lidocaine spray probably reduce pain (mean difference (MD): -47.67, 95% confidence interval (CI): -61.45 to -33.89, confidence rating (CR): moderate; MD: -27.38, 95% CI: -37.53 to -17.22, CR: moderate). Of the 32 studies included, none reported systemic adverse events, such as anaphylaxis or local anesthetic systemic toxicity, or severe local adverse events. In conclusion, mepivacaine infiltration and lidocaine spray probably reduce the pain associated with radial artery puncture more than other local anesthesia.

Efficacy and safety of vapocoolant spray for vascular puncture in children and adults: A systematic review and meta-analysis

OBJECTIVE

The aim was to evaluate the effectiveness and safety of the vapocoolants for vascular puncture in children and adults.

METHOD

The search was carried out in PubMed, Web of Science, Embase and The Cochrane Library, from inception to March 2022. Randomized controlled trials comparing vapocoolants to control conditions for participants received intravenous cannulation or arterial puncture were included. Two reviewers independently performed selection of studies, data extraction, and assessment of risk of bias. The analysis was performed using fixed or random-effects model with mean differences or standardized mean difference and risk ratios.

RESULTS

A total of 25 studies involving 3143 participants were included. Compared with control conditions, vapocoolants may not decrease the pain of patients with arterial puncture (SMD = -0.36, 95% CI = -0.92 to -0.19, P = 0.20), but may more effectively relieve pain for adults received vein puncture (SMD = -0.65, 95% CI = -0.85 to -0.45, P < 0.00001). The application of vapocoolant increased the procedural difficulty of medical personnel (RR = 2.49, 95% CI = 1.62 to 3.84, P<0.000 1) and participants were more willing to use the spray in the future (RR = 1.88, 95% CI = 1.34 to 2.64, P = 0.0002). There was no significant difference for the first attempt success rate of the procedure and the occurrence of adverse events.

CONCLUSIONS

Vapocoolant spray may relieve pain in adults received vein puncture and cannot cause severe side effects, but is ineffective in children. It also had no effect on patients with arterial puncture. In addition, the application of spray increases procedural difficulties for medical professionals, but does not decrease first attempt success rate, and many patients would like to use the spray again for pain relief in the future. Thus, more rigorous and large-scale studies are needed to determine its effectiveness in vascular access.

Efficacy and Safety of Lidocaine Patch in the Management of Acute Postoperative Wound Pain: A Comprehensive Systematic Review and Meta-analysis of Randomized Controlled Trials

OBJECTIVE

This study sought to quantify the pooled effects of lidocaine patch (LP) on postoperative pain and side-effects through a comprehensive review and meta-analysis.

APPROACH

The study followed PRISMA, AMSTAR and the Cochrane Collaboration. Randomized controlled trials s comparing LP with placebo were retrieved from five electronic databases. Primary outcome in the study was cumulative intravenous morphine equivalent consumption (mg) within 24 hours postoperatively.

RESULTS

Twelve trials comprising 617 patients were included in the final analysis. Primary result indicated that the analgesic effects LP were only statistical but not clinically significant of postoperative intravenous morphine consumption within 24 hours (mean difference, -4.61 mg; 95% CI, -8.09, -1.14). Interestingly, the results of subgroup and meta-regression analysis indicated that preoperative administration of LP had potential advantages in postoperative wound pain management. It is also worthwhile to mention that LP provided a clinically important benefit in rest pain scores within 24-hour postoperatively. Apart from these, other secondary outcome analysis did not uncover any particularly significant analgesic or safety advantages to LP. Finally, LP also does not increase the risk of any local anesthetic-related side effects.

INNOVATION

This systematic review and meta-analysis provides moderate-to-high quality evidence undermining the role of LP for management of acute postoperative wound pain following surgical procedures and the justification for the associated extra costs.

CONCLUSION

Taken together, the current evidence does not support LP as part of a routine multimodal analgesia strategy to alleviate early postoperative acute pain. However, further studies should explore the clinical value of preoperative administration and the long-term effect of LP.

Management of procedural pain in the intensive care unit

Pain is a common experience for inpatients, and intensive care unit (ICU) patients undergo more pain than other departmental patients, with an incidence of 50% at rest and up to 80% during common care procedures. At present, the management of persistent pain in ICU patients has attracted considerable attention, and there are many related clinical studies and guidelines. However, the management of transient pain caused by certain ICU procedures has not received sufficient attention. We reviewed the different management strategies for procedural pain in the ICU and reached a conclusion. Pain management is a process of continuous quality improvement that requires multidisciplinary team cooperation, pain-related training of all relevant personnel, effective relief of all kinds of pain, and improvement of patients' quality of life. In clinical work, which involves complex and diverse patients, we should pay attention to the following points for procedural pain: (1) Consider not only the patient's persistent pain but also his or her procedural pain; (2) Conduct multimodal pain management; (3) Provide combined sedation on the basis of pain management; and (4) Perform individualized pain management. Until now, the pain management of procedural pain in the ICU has not attracted extensive attention. Therefore, we expect additional studies to solve the existing problems of procedural pain management in the ICU.

Effectiveness of lidocaine spray on radial arterial puncture pain: A randomized double-blind placebo controlled trial

OBJECTIVE

Radial arterial puncture is a painful procedure. The aim of this study was to evaluate the effect of lidocaine spray (10%) on pain associated with radial artery blood withdrawal for arterial blood gas analysis.

METHODS

This randomized, controlled, double-blind study was performed between December 2018 and September 2019. Before radial arterial puncture, 10% lidocaine or placebo spray was applied to each patient by the attending physician, who was blinded with regard to random assignment. The spray was administered six times on the site from a distance of 5 cm. After waiting for 5 min, a radial arterial puncture was performed routinely. The pain levels of patients during radial arterial puncture and 5 min after puncture were evaluated with the visual analog scale (VAS). The Wilcoxon test was used to compare pain scores during puncture.

RESULTS

The research was performed with 67 patients (34 patients in the lidocaine group, 33 patients in the placebo group) who were admitted to the emergency department and required ABG analysis. Forty-three patients were men, and 24 were women. The ages of the patients ranged between 19 and 86 years, and the mean (± standard deviation) age was 56.3 ± 16.6 years. Pain levels, as measured by VAS, were significantly lower in the lidocaine group (24.00 mm IQR:[14.75-33.75]) compared with the placebo group (33.00 mm IQR:[22.00-61.50]) during radial arterial puncture (p = 0.011).

CONCLUSIONS

The level of pain perceived during radial arterial puncture was significantly lower in those who were administered lidocaine spray. Lidocaine spray application can be used in pain management related to radial arterial puncture.

Interventions to reduce arterial puncture-related pain: A systematic review and meta-analysis

BACKGROUND

Arterial puncture-related pain remains unaddressed across several clinical settings. Analgesic techniques are not routinely employed before arterial puncture despite the recommendation that local anesthesia be used, except in emergencies. A comprehensive review of interventions aimed at reducing arterial puncture-related pain and their potential effectiveness is lacking, and the benefit of some interventions is uncertain.

OBJECTIVE

To describe interventions aimed at reducing arterial puncture-related pain and provide an estimate of their effectiveness.

DESIGN

Systematic review and meta-analysis (PROSPERO no. CRD42020212299).

DATA SOURCE(S)

PubMed, CINAHL EBSCO, EMBASE, the Cochrane Database of Systematic Reviews, and Scopus were searched from their inception to 7 October 2020. No temporal or language limits were applied.

METHODS

Published, quantitative studies on interventions aimed at reducing arterial puncture-related pain among adults were included. Screening, quality appraisal, and data extraction were undertaken independently by two reviewers. Random effects meta-analyses were performed to assess the association between interventions aimed at reducing arterial puncture-related pain and patients' perceived pain using difference in means (MD) with 95% confidence intervals (CIs). A funnel plot and Egger test were used to assess publication bias.

RESULTS

The titles and abstracts of the 2446 identified articles were screened, and 43 and 31 studies were finally included in the systematic review and meta-analysis, respectively. Interventions to reduce arterial puncture-related pain included: topical anesthetics (n = 16), cryotherapy (n = 9), local anesthetic infiltration (n = 5), narrower needle gage (n = 5), ultrasound-guided procedure (n = 3), topical anesthetics combined with local anesthetic infiltration (n = 1), iontophoresis using anesthetics (n = 1), engineered blood gas syringe (n = 1), jet injector (n = 1), and local massage (n = 1). Topical anesthetics [MD -0.58, 95% CI -1.00, -0.15], cryotherapy [MD -1.13, 95% CI -1.72, -0.53], and local anesthetic infiltration [MD -1.13, 95% CI -1.72, -0.53] reduced arterial puncture-related pain. No benefit was found for narrower needle gage [MD -0.07, 95% CI -0.86, 0.71] or ultrasound-guided procedure [MD -1.74, 95% CI -3.51, 0.03]. No publication bias was detected.

CONCLUSIONS

Local anesthetic infiltration provided the greatest pain reduction and should be considered standard practice. Cryotherapy may be a safe, convenient alternative to local anesthetic infiltration. Topical anesthetics had limited benefit, and their lengthy time of onset makes them unsuitable for critical or emergency situations, though they may represent an option when comorbid conditions make cooling impossible. Caution must be used when interpreting these results, given the high risk of bias in the methods of included studies and the heterogeneity across the studies.

Vapocoolant Spray Versus Lidocaine Infiltration for Radial Artery Cannulation: A Prospective, Randomized, Controlled Clinical Trial

OBJECTIVES

Local infiltration with lidocaine is a frequently used measure to prevent pain during arterial cannulation. Its administration is associated with pain. Vapocoolants like ethyl chloride or alkanes also affect rapid-onset anesthesia. However, their administration causes less discomfort compared with administration of lidocaine. The effectiveness of vapocoolants in mitigating discomfort associated with arterial cannulation never has been studied. The authors therefore compared vapocoolant with lidocaine for reducing discomfort caused by arterial cannulation.

DESIGN

Prospective, randomized, controlled study.

SETTING

University hospital, single center.

PARTICIPANTS

One hundred sixty adult patients requiring arterial cannulation before induction of general anesthesia for cardiac surgery or carotid endarterectomy.

INTERVENTIONS

Patients received either lidocaine infiltration or vapocoolant spray prior to arterial cannulation. Overall discomfort resulting from the whole procedure (applying local/topical anesthesia followed by arterial puncture) was rated on a 0 to 10 numerical rating scale. Puncture failure rate and time required for the intervention also were recorded.

MEASUREMENTS AND MAIN RESULTS

One hundred forty-three patients were included in the per-protocol analysis. Mean pain scores in the vapocoolant group were 3.4 (±1.58) compared with 4.5 (±2.29) in the lidocaine group (difference 1.1±0.33; p = 0.032; Mann-Whitney U-test). The higher puncture failure rate in the lidocaine group (n = 11 v 4) was not significant (p = 0.06; Fisher's exact test). The time required for the intervention was longer in the lidocaine group (138±44 s v 128±44 s; p = 0.019; Mann-Whitney U-test).

CONCLUSIONS

Vapocoolant spray is an alternative to lidocaine infiltration to mitigate discomfort associated with arterial cannulation.

Topical anesthesia

Topical anesthetics are being widely used in numerous medical and surgical sub-specialties such as anesthesia, ophthalmology, otorhinolaryngology, dentistry, urology, and aesthetic surgery. They cause superficial loss of pain sensation after direct application. Their delivery and effectiveness can be enhanced by using free bases; by increasing the drug concentration, lowering the melting point; by using physical and chemical permeation enhancers and lipid delivery vesicles. Various topical anesthetic agents available for use are eutectic mixture of local anesthetics, ELA-max, lidocaine, epinephrine, tetracaine, bupivanor, 4% tetracaine, benzocaine, proparacaine, Betacaine-LA, topicaine, lidoderm, S-caine patch™ and local anesthetic peel. While using them, careful attention must be paid to their pharmacology, area and duration of application, age and weight of the patients and possible side-effects.

Topical local anesthesia: focus on lidocaine-tetracaine combination

In recent years, the popularity of aesthetic and cosmetic procedures, often performed in outpatient settings, has strongly renewed interest in topical anesthetics. A number of different options are widely used, alone or in combination, in order to minimize the pain related to surgery. Moreover, interest in local anesthetics in the treatment of some painful degenerative conditions such as myofascial trigger point pain, shoulder impingement syndrome, or patellar tendinopathy is increasing. Numerous clinical trials have shown that lidocaine–tetracaine combination, recently approved for adults aged 18 or older, is effective and safe in managing pain. The present paper gives an overview of the recent literature regarding the efficacy and safety of lidocaine–tetracaine combination use.

Using skin for drug delivery and diagnosis in the critically ill

Skin offers easy access, convenience and non-invasiveness for drug delivery and diagnosis. In principle, these advantages of skin appear to be attractive for critically ill patients given potential difficulties that may be associated with oral and parenteral access in these patients. However, the profound changes in skin physiology that can be seen in these patients provide a challenge to reliably deliver drugs or provide diagnostic information. Drug delivery through skin may be used to manage burn injury, wounds, infection, trauma and the multisystem complications that rise from these conditions. Local anaesthetics and analgesics can be delivered through skin and may have wide application in critically ill patients. To ensure accurate information, diagnostic tools require validation in the critically ill patient population as information from other patient populations may not be applicable.