A Needle-Free Jet-Injection System with Lidocaine for Peripheral Intravenous Cannula Insertion: A Randomized Controlled Trial with Cost-Effectiveness Analysis

Needleless or Noninvasive Delivery Technology

Injections of drugs or vaccines have become an indispensable part of living systems. Introduction to injections begins from the vaccination regimen at the neonatal stage and continues throughout the life span of an individual. Conventionally, injections are administered using hypodermic needles and syringes. These usually inject the liquid in the muscle, thus making intramuscular injections the most common form of administration. Although hypodermic syringes have been a clinician's tool in global vaccination efforts, they also have a set of undesirable characteristics. Pathogen transmission in case of HIV and HBV is one of the deadliest disadvantages of the needle-based injection system. Generation of plastic wastes in clinics, needlestick injury, and most importantly, pain associated with needle-based injections are a few more reasons of concern. In light of these issues, developing needle-free injection systems has excited researchers across the globe since the 1950s. Significant advancement has been reported in this field and various needle-free injection systems have been developed and are in clinical practice. This article briefly describes the history of needle-free injection systems and provides a detailed account of a few well-known methods of needle-less injections available.

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.

Needle-Free Jet Lidocaine Administration for Preinjection Anesthesia in Trigger Finger Injection: A Randomized Controlled Trial

PURPOSE

To evaluate the efficacy of needle-free jet lidocaine (J-tip) administration for pain reduction in trigger finger corticosteroid injection compared with simultaneous lidocaine injection with corticosteroid.

METHODS

A prospective randomized clinical trial was performed in which patients received either 0.25 mL of 2% lidocaine administered by J-tip just prior to 0.5 mL of corticosteroid injection by needle or 0.5 mL of 1% lidocaine and 0.5 mL of corticosteroid administered simultaneously through a needle for the treatment of trigger finger. Both the expected pain preinjection and the actual pain experienced postinjection were measured with a visual analog scale (VAS). Pain catastrophizing scale (PCS) scores were recorded before injection.

RESULTS

The use of the J-tip demonstrated a lower mean actual pain, 3.3 VAS, compared with the control group, 4.6 VAS. Both study groups anticipated more pain than they actually experienced. The PCS did not correlate to pre- or post-injection scores.

CONCLUSIONS

Needle-free jet administration of lidocaine reduces the pain associated with trigger finger injection. Patients anticipate more pain than they experience with trigger finger injection.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic I.

First do no harm: pain relief for the peripheral venous cannulation of adults, a systematic review and network meta-analysis

BACKGROUND

Peripheral venous cannulation is an everyday practice in hospitals, which many adults find painful. However, anaesthesia for cannulation is usually only offered to children. Inadequate pain relief is not only unpleasant for patients but may cause anxiety about further treatment and deter patients from seeking medical care in the future. The aim of this study is to discover the most effective local anaesthetic for adult peripheral venous cannulation and to find out how the pain of local anaesthetic application compares with that of unattenuated cannulation.

METHODS

These aims are addressed through a systematic review, network meta-analysis and random-effects meta-analysis. Searching covered 12 databases including MEDLINE and EMBASE from 1990 to August 2015. The main included study design was RCTs. The primary outcome measure is self-reported pain, measured on a 100 mm visual analogue scale.

RESULTS

The systematic review found 37 includable studies, 27 of which were suitable for network meta-analysis and two for random-effects meta-analysis. The results of the network meta-analysis indicate that none of the 17 anaesthetic considered had a very high probability of being the most effective when compared to each other; 2 % lidocaine had the highest probability (44 %). When the anaesthetics were compared to no treatment, the network meta-analysis showed that again 2 % lidocaine was estimated to be the most effective (mean difference -25.42 (95 % CI -32.25, -18.57). Other members of the 'caine' family were also estimated to be more effective than no treatment as were Ametop®, EMLA® and Rapydan® patch. The meta-analysis compared the pain of anaesthetic application with the unattenuated pain of cannulation. This found that all applications of local anaesthetic were less painful than cannulation without local anaesthetic. In particular a 1 % lidocaine injection was estimated to be -12.97 (95 % CI -15.71, -10.24) points (100 mm VAS) less painful than unattenuated cannulation.

CONCLUSIONS

The pain of peripheral venous cannulation in adults can be successfully treated. The pain of application of any local anaesthetic is less than that of unattenuated cannulation. Local anaesthetic prior to cannulation should become normal practice and a marker of high quality care.

PROTOCOL REGISTRATION

The protocol for the larger study was registered with PROSPERO no. CRD42012002093 .

Safety and Efficacy of the "Easy Internal Jugular (IJ)": An Approach to Difficult Intravenous Access

BACKGROUND

The easy internal jugular (Easy IJ) technique involves placement of a single-lumen catheter in the internal jugular vein using ultrasound guidance. This technique is used in patients who do not have suitable peripheral or external jugular venous access. The efficacy and safety of this procedure are unknown.

OBJECTIVE

We aimed to estimate efficacy and safety parameters for the Easy IJ when used in emergency department (ED) settings.

METHODS

We conducted a prospective study of the Easy IJ in stable ED patients with severe intravenous access difficulty. The study was conducted simultaneously at two academic EDs and a community university-affiliated ED. Patients were selected for failure of alternative access, hemodynamic stability, and ability to increase the IJ diameter with the Valsalva maneuver. Emergency physicians prepped the skin and inserted an 18-gauge, 4.8-cm catheter using a limited sterile technique. We collected the following data: patient body mass index, age, procedure time, pain score, initial success, loss of patency, occurrence of pneumothorax, infection, or arterial puncture.

RESULTS

We recorded 83 attempts in 74 patients, with a median age of 44 years and a median body mass index of 27 kg/m². The initial success rate was 88%, with a mean procedure time of 4.4 min (95% confidence interval 3.8-4.9). The average pain score was 3.9 out of 10 (95% confidence interval 3.4-4.5). Ten of 73 successful lines (14%) lost patency. There were no cases of pneumothorax, arterial puncture, or line infection.

CONCLUSION

The Easy IJ was inserted successfully in 88% of cases, with a mean time of 4.4 min. Loss of patency, the only complication, occurred in 14% of cases.

Peripheral Intravenous Catheterisation in Obstetric Patients in the Hand or Forearm Vein: A Randomised Trial

A peripheral intravenous catheter is often inserted as part of care during labour. The catheter is inserted into the back of the hand or lower forearm vein in usual practice. There is no trial data to guide the care provider on which is the better insertion site in any clinical setting. 307 women admitted to the labour ward who required insertion of intravenous catheter were randomised to back of hand or lower forearm vein catheter insertion. Catheter insertion is by junior to mid-grade providers. We evaluated insertion success at the first attempt, pain during insertion and catheter replacement due to malfunction as main outcomes. After catheter removal, we recorded patient satisfaction with site, future site preference and insertion site swelling, bruising, tenderness, vein thrombosis and pain. Insertion of a catheter into back of hand vein is more likely to be successful at the first attempt. Insertion pain score, catheter replacement rate, patient satisfaction, patient fidelity to site in a future insertion and insertion site complications rate are not different between trial arms. In conclusion, both insertion sites are suitable; the back of the hand vein maybe easier to cannulate and seems to be preferred by our frontline providers.

A Randomized Clinical Trial of Jet-Injected Lidocaine to Reduce Venipuncture Pain for Young Children

STUDY OBJECTIVE

The J-Tip (National Medical Products Inc, Irvine, CA) uses air instead of a needle to push lidocaine into the skin. To our knowledge, no studies have investigated its use for venipuncture in young children. We determine whether the J-Tip decreased venipuncture pain in young children compared with vapocoolant spray.

METHODS

Children aged 1 to 6 years were randomized into 3 groups: intervention (J-Tip), control (vapocoolant spray), and sham (vapocoolant spray and pop of an empty J-Tip). The procedure was videotaped and scored with the Face, Legs, Activity, Cry and Consolability (FLACC) tool at 3 points; baseline, before approach; device, at J-Tip deployment; and at venipuncture. The FLACC tool was scored 0 (none) to 10 (severe). Comparisons of pain scores over time were made with the generalized estimating equation. Venipuncture success and adverse effects were assessed and compared with χ(2).

RESULTS

Two hundred five children enrolled: intervention 96, control 53, and sham 56. There were no between-group differences in baseline characteristics. There was no mean change in pain scores from device to venipuncture in the intervention group (0.26; 95% confidence interval [CI] -0.31 to 0.82), but there was an increase in pain in the control (2.82; 95% CI 1.91 to 3.74) and sham (1.68; 95% CI 0.83 to 2.52) groups. This change was greater for the control and sham compared to the intervention group. There was no difference in venipuncture success between groups. No severe adverse events occurred. Minor adverse events were the same between groups.

CONCLUSION

Use of the J-Tip for children aged 1 to 6 years reduced venipuncture pain compared with vapocoolant spray or sham treatment.

Does Combined Use of the J-tip® and Buzzy® Device Decrease the Pain of Venipuncture in a Pediatric Population?

BACKGROUND

Both the J-tip® (a needle-free device for subcutaneous delivery of lidocaine) and the Buzzy® (a cooled, vibrating device to employ gate control to minimize procedural pain) have shown some efficacy in diminishing the pain of venipuncture.

PURPOSE

To develop an optimal protocol for pre-venipuncture/IV start pain management by investigating the impact of adding the use of Buzzy® prior to the use of the J-tip®.

PROCEDURES

Pediatric emergency department patients aged 1 month to 21 years were prospectively enrolled in Phase 1 (J-tip® only) then Phase 2 (Buzzy®+J-tip®) for analgesia prior to venipuncture or IV start. Age-appropriate pain scale scores were collected for the subsequent procedure, as well the administration of lidocaine via J-tip®.

MAIN FINDINGS

With the combined intervention (phase 2), 14.2% of patients had a pain scale score >3 with venipuncture and 16.1% had a pain scale score >3 with application of the J-tip® itself. With no intervention for pain relief, 71% of patients experienced a pain scale score >3 for venipuncture. With the J-tip® alone (phase 1), 21% had a pain scale score >3 with venipuncture and 22.3% had a pain scale score >3 with application of the J-tip® itself.

CONCLUSIONS

Patients receiving either intervention reported lower scores on pain scales during venipuncture or IV start than the no analgesia group. The combined intervention did not yield a significant decrease in scores on pain scale scores over the J-tip® alone.

Safety and Efficacy of Needle-free Powder Lidocaine Delivery System in Adult Patients Undergoing Venipuncture or Peripheral Venous Cannulation: A Randomized, Double-Blind, Placebo-controlled Trial

OBJECTIVES

The purpose of this study was to evaluate the efficacy, safety, and tolerability of a needle-free powder lidocaine delivery system compared with sham placebo in adults.

METHODS

Adult patients participated in this multicenter, randomized, double-blind, placebo-controlled, parallel-group study. Patients were randomly allocated to receive either the needle-free powder lidocaine delivery system or sham placebo 1 to 3 minutes before a required venipuncture or venous cannulation. The primary efficacy endpoint measured the analgesic effect of the active system using a pain visual analogue scale.

RESULTS

In 693 adults who completed the study, the needle-free powder lidocaine delivery system was associated with significantly less pain during venipuncture and venous cannulation compared with sham placebo, as demonstrated by a difference between groups in age-adjusted mean pain score (P=0.003). Secondary analyses demonstrating significant differences between groups included the proportion of patients who were pain free, the proportion of responders, and the difference between pain experienced during the current venous procedure compared with the recollection of pain experienced during a prior venous procedure. Use of the active system was not associated with any serious adverse events or any adverse events resulting in study discontinuation. All treatment-related adverse events were mild.

DISCUSSION

This clinical trial demonstrated that use of a needle-free powder lidocaine delivery system resulted in a significant reduction of pain during venipuncture and peripheral intravenous cannulation in adults. Both the predefined primary endpoint and all 3 secondary endpoints were met. The needle-free powder lidocaine delivery system may be an option for analgesia during venous access procedures in adults.

Transdermal analgesia with local anesthetics in children: review, update and future directions

Topical local anesthetics in one form or another have been used for the past 20 years to alleviate the skin pain associated with needle puncture and venous cannulation in children. Although the application of topical anesthetic creams is painless compared with traditional local anesthetic infiltration of the skin and subcutaneous tissues prior to venipuncture and minor skin procedures, they remain underutilized, primarily due to their slow analgesic onset and inconsistent effectiveness. For a topical local anesthetic to be of practical use in busy clinical settings, it must be easy to apply, have minimal side effects, not require cumbersome equipment and be reasonably cost effective. Until recently, limitations in one or all of these areas have dissuaded pediatric practitioners from their routine use. However, recent advances in transdermal delivery technologies, have led to the emergence of a number of new delivery approaches that accelerate the onset time to 20 min or less and provide more consistent and deeper sensory skin analgesia. Although still in the early stages of investigation, technologies that promote the flux of drugs of all sizes through the skin by creating transient microchannels show great promise in circumventing the skin barrier and promoting the transdermal delivery of not only local anesthetics but also other drugs. Ultimately, the rationale to change clinical practice and use a new transdermal delivery system will depend upon the cost, ease of use, frequency of adverse events and the benefits to the patient relative to an alternative method.

Efficacy of a near-infrared light device in pediatric intravenous cannulation: a randomized controlled trial

OBJECTIVES

To determine whether the use of a near-infrared light venipuncture aid (VeinViewer; Luminetx Corporation, Memphis, Tenn) would improve the rate of successful first-attempt placement of intravenous (IV) catheters in a high-volume pediatric emergency department (ED).

METHODS

Patients younger than 20 years with standard clinical indications for IV access were randomized to have IV placement by ED nurses (in 3 groups stratified by 5-year blocks of nursing experience) using traditional methods (standard group) or with the aid of the near-infrared light source (device group). If a vein could not be cannulated after 3 attempts, patients crossed over from one study arm to the other, and study nurses attempted placement with the alternative technique. The primary end point was first-attempt success rate for IV catheter placement. After completion of patient enrollment, a questionnaire was completed by study nurses as a qualitative assessment of the device.

RESULTS

A total of 123 patients (median age, 3 years) were included in the study: 62 in the standard group and 61 in the device group. There was no significant difference in first-attempt success rate between the standard (79.0%, 95% confidence interval [CI], 66.8%-88.3%) and device (72.1%, 95% CI, 59.2%-82.9%) groups. Of the 19 study nurses, 14 completed the questionnaire of whom 70% expressed neutral or unfavorable assessments of the device in nondehydrated patients without chronic underlying medical conditions and 90% found the device a helpful tool for patients in whom IV access was difficult.

CONCLUSIONS

First-attempt success rate for IV placement was nonsignificantly higher without than with the assistance of a near-infrared light device in a high-volume pediatric ED. Nurses placing IVs did report several benefits to use of the device with specific patient groups, and future research should be conducted to demonstrate the role of the device in these patients.

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.

The effect of needle bevel position on pain for subcutaneous lidocaine injection

It is a common practice for medical practitioners to use subcutaneous infiltration of lidocaine to alleviate the pain of intravenous cannulation or line insertion. Although previous studies have assessed several factors affecting the pain associated with local anesthetic infiltration, there is a paucity of data on the effects of needle bevel position. In this prospective, randomized, controlled trial, we compared the effect of two different needle bevel positions (bevel up versus bevel down) and the pain associated with the subcutaneous injection of 1% lidocaine in 50 adult volunteers. Significantly higher pain scores were observed when the needle was placed bevel down compared with bevel up (P = .02). No significant differences in pain scores were noted between the groups for age and gender.

A randomized, double-blind controlled study of jet lidocaine compared to jet placebo for pain relief in children undergoing needle insertion in the emergency department

OBJECTIVES

The objectives were to determine whether pretreatment with needleless jet-delivered lidocaine decreases self-reported pain in children undergoing needle insertion in the emergency department (ED) and to explore whether pretreatment with a jet device decreases self-reported pain in children undergoing needle insertion in the ED.

METHODS

This study examined needle insertion pain in children 5-18 years of age. In the first phase of this study, children received either pretreatment with jet-delivered lidocaine (0.2 mL of buffered 1% lidocaine; n = 75) or pretreatment with jet-delivered placebo (0.2 mL of preservative-free normal saline; n = 75) 60 seconds before undergoing needle insertion. This phase of the study had a randomized, double-blind, placebo-controlled design. In the second phase, an unblinded, nonconcurrent, nonintervention control group (n = 47) was examined to describe any effect of using the jet device. Patients reported pain upon administration of the jet device and at needle insertion using a 100-mm color analog scale (CAS). Patients also reported their satisfaction with this device. The physicians and nurses performing needle insertions were asked to rate their ability to visualize the vein and their satisfaction with the device.

RESULTS

The mean (+/-standard deviation [SD]) needle insertion pain score for jet lidocaine, 28 (+/-7) mm, was similar to the mean needle insertion pain score for jet placebo, 34 (+/-7) mm. The mean needle insertion pain score for both the jet lidocaine and the jet placebo groups were lower than the needle insertion pain scores for the no device group, 52 (+/-8) mm. The majority of patients receiving the jet device reported that they would request this device for future needle insertions. Providers' ratings of their ability to visualize veins and the patient cooperation were similar in all three groups.

CONCLUSIONS

Jet-delivered lidocaine is no more effective than jet-delivered placebo in providing local anesthesia for needle insertion. Jet lidocaine and jet placebo may provide superior analgesia compared to no local anesthetic pretreatment.

Pharmacologic approaches for reducing venous access pain in children

A variety of pharmacologic options are available to clinicians who want to provide effective and safe topical local anesthesia to children undergoing venous access procedures. These options can be distinguished on the basis of how they deliver active drug through the impermeable outer layer of skin, the stratum corneum, to pain receptors located in the dermis and epidermis. Three general methodologies are typically used to bypass the stratum corneum: direct injection of local anesthetics, usually via a small-gauge hypodermic syringe; passive diffusion from topical creams or gels; and active needle-free drug strategies that enhance the rate of drug passage into the dermis and epidermis. Examples of the latter mechanisms include heat-enhanced diffusion, iontophoresis, sonophoresis, laser-assisted transdermal passage, and pressurized gas delivery of powdered drug particles. Pharmacologic options in this setting can also be distinguished on the basis of the time to onset of full anesthetic effect. Several available agents induce significant local anesthesia within 1 to 3 minutes of administration, or faster, allowing easy integration into the skin preparation and subsequent venous access procedure. In combination with nonpharmacologic approaches, these agents can be used to dramatically lessen this significant source of pediatric pain.

Skin surgery in children: local anaesthesia and sedation techniques

In the past, procedural pain control in young children was undertreated as it was incorrectly alleged that their neuronal pain pathways were undeveloped. However, it is now recognised that even neonates are able to experience pain. Moreover, intensely painful physical experiences in childhood can have persisting physiological and psychological consequences. Therefore, the management of acute pain is essential. In this paper, the authors provide an in-depth discussion regarding the anaesthetic options for paediatric patients undergoing dermatological surgery.

Procedural sedation and analgesia research: state of the art

The authors review the current state of procedural sedation and analgesia research and clinical practice in adults and children, discuss the limitations in research methodology, and propose future areas of investigation.

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.