Jet injector compared with oral midazolam for preoperative sedation in children

Preliminary pharmacokinetics and patient experience of jet-injected dexmedetomidine in healthy adults

Jet injection is a drug delivery system without a needle. A compressed liquid drug formulation pierces the skin, depositing the drug into the subcutaneous or intramuscular tissues. We investigated the pharmacokinetics and patient experience of dexmedetomidine administered using jet injection in six healthy adult study participants. This needleless jet injection device was used to administer dexmedetomidine 0.5 μg/kg to the subcutaneous tissues overlying the deltoid muscle. Serum concentrations of dexmedetomidine were assayed at approximately 5 minutes, 15 minutes, 30 minutes, 1 hour and 4 hours after administration. Pharmacokinetic interrogation of concentration time profiles estimated an absorption half time for jet-injected dexmedetomidine of 21 minutes (coefficient of variation 69.4%) with a relative bioavailability assumed unity. In our samples the measured median peak (range) concentration was 0.164 μg/l (0.011-0.325 μg/l), observed in the sample taken at a median (range) of 13.5 minutes (11-30 minutes). The Richmond agitation sedation scale was used to assess the sedative effect, and scored 0 (alert and calm) or -1 (drowsy) in all participants. Five of the six participants stated they would prefer jet injection to needle injection in the future and one had no preference. The findings suggest that the use of a larger dose (>2 μg/kg) would be required to achieve the clinically relevant target concentration of 1 μg/l necessary to achieve deeper sedation (Richmond agitation sedation scale ≤3).

Development and content validation of the Pediatric Oral Medicines Acceptability Questionnaires (P-OMAQ): patient-reported and caregiver-reported outcome measures

BACKGROUND

Evolving regulatory guidelines recommend routine assessment of the acceptability of pediatric oral medicines throughout clinical development processes. However, such assessment is problematic owing to a lack of standard methods or criteria that define acceptability for children and their caregivers. This research aimed to identify the attributes of acceptability for targeted oral formulation types that are important to children, and to develop content-valid patient- and caregiver-reported outcome acceptability measures for use in the context of clinical drug development.

METHODS

A concept-focused literature review and two advisory panel meetings involving researchers, clinicians, and measurement scientists were conducted to identify acceptability attributes that may be relevant to children taking targeted oral medicine formulations. The Pediatric Oral Medicines Acceptability Questionnaires (P-OMAQs), including patient (P-OMAQ-P) and caregiver (P-OMAQ-C) versions, were drafted to assess these attributes. Qualitative concept elicitation (CE) and cognitive debriefing (CD) patient and caregiver interviews were conducted to confirm key acceptability attribute concepts for measurement and to evaluate patient and caregiver ability to understand and respond to the questions.

RESULTS

A full-text review of 40 articles identified 24 acceptability attributes that were categorized into 10 overarching domains and organized into a preliminary conceptual model. Feedback from the advisory panel refined the preliminary model. In total, 14 attributes were reported during the CE phase of the interviews (n = 23 pediatric patients, n = 13 caregivers); six attributes were included in the final model. The draft P-OMAQ was refined over four waves of CD interviews (n = 31 pediatric patients, n = 48 caregivers). The final version of the P-OMAQ-P is a 12-item questionnaire designed for young people aged 8-17 years. The P-OMAQ-C is a 19-item questionnaire designed for adult caregivers of young people aged 6 months to 17 years. There are two versions of each questionnaire: one with a 24-h recall period and one with a 7-day recall period. All items are answered on a 5-point numerical rating scale.

CONCLUSIONS

This research supports the content validity of the patient and caregiver versions of the P-OMAQ. Both questionnaires appropriately assess the acceptability of oral medicine formulations from the perspective of pediatric patients and their caregivers.

A Needle-Free Injection System (INJEX™) with lidocaine for epidural needle insertion: A randomized controlled trial

Objectives:

Local anesthetic infiltration is also a process of a painful process itself. INJEX™ technology, known as “Needle-free” drug delivery system, was designed for reducing the pain associated with cutaneous procedures. We conducted a prospective, randomized trial to evaluate the application of lidocaine with INJEX™ system and 27-gauge needle.

Methods:

A total of 60 consecutive patients were allocated to receive either INJEX group or 27-gauge needle group. Local anesthetic infiltration was applied two minutes before epidural needle insertion.

Results:

Mean VAS, at the time of local anesthetic injection was 0 for group I and 2 for group II. When the effect of epidural needle insertion was compared, the mean VAS score was one versus two for Group-I versus Group-II, respectively. Lidocaine applied with the INJEX™ system before epidural needle insertion significantly reduced the intensity of pain during that procedure and was least effective the lidocaine applied with the 27-gauge needle and patients felt less pain during at the time of local anesthetic injection in Group-I.

Conclusion:

Needle-free delivery of lidocaine is an effective, easy to-use and noninvasive method of providing local anesthesia for the epidural needle insertion.

Perioperative effects of oral midazolam premedication in children undergoing skin laser treatment: a double-blinded randomized placebo-controlled trial

PURPOSE: To investigate and compare the efficacy of oral midazolam with two different dosages in orange juice on perioperative hemodynamics and behavioral changes in children who underwent skin laser treatment in an academic educational Hospital. METHODS: Ninety children, candidates for skin laser treatment were randomly assigned to 1 of 3 groups of 30 each: the placebo group received 0.1 ml/kg orange flavored juice, group 2 and 3 receiving 0.5 and 1 mg/kg of injectable midazolam mixed with an equal volume of orange juice, respectively. The main outcome measures included the mask acceptance, patients' behavioral scales and postoperative events. RESULTS: There were no significant differences in heart rate, respiratory rate, and systolic blood pressure among the three groups. However, arterial oxygen saturation was significantly reduced in those given 1 mg.kg-1 midazolam. The median scores of anxiety, separation from parent, preparing an intravenous line, acceptance of the oxygen mask, good sedation, crying reduction and consciousness level were better in midazolam group. Postoperative agitation and re-crying were also more frequent in placebo receivers. Those given 1 mg.kg-1 midazolam were significantly more optimal for sedation, crying, consciousness, preparing an intravenous line, and postoperative re-crying compared with 0.5 mg.kg-1 midazolam receivers. CONCLUSION: As a preanaesthetic medication, the 1 mg.kg-1 dose of orally given midazolam especially in a volume of orange juice and can optimize the children's behavior during skin laser treatment with no serious adverse effects, enhancing their parents' satisfactions about the sedative protocol.

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 comparison of a needle-free injection system for local anesthesia versus EMLA for intravenous catheter insertion in the pediatric patient

Placement of IV catheters is a painful and stressful procedure for children. J-Tip is a needle-less Food and Drug Administration approved injection system that can be used for delivery of local anesthetic before IV cannulation. In this study, we compared the effectiveness of J-Tip versus eutectic mixture of local anesthetics (EMLA) to facilitate IV cannulation and provide adequate analgesia before IV placement. Children 7-19 years of age (n = 116) were randomized to receive 0.25 mL of 1% buffered lidocaine with J-Tip (n = 57) or 2.5 g of EMLA (n = 59) before IV cannulation. Measurements of success of cannulation (number of attempts for IV placement) and pain (0-10 visual analog scale) at application of local anesthetic and at cannulation were performed. There was a significant (P = 0.0001) difference in pain ratings during IV cannulation between EMLA (median = 3) and the J-Tip (median = 0). Eighty-four percent of patients reported no pain at the time of J-Tip lidocaine application compared to 61% in the EMLA group at the time of dressing removal (P = 0.004). We did not find differences in the number of attempts for IV cannulation. J-Tip application of 1% buffered lidocaine before IV cannulation is not painful and has better anesthetic effectiveness compared with EMLA.