Isaac Wiebe Medical Student C W Wiebe Medical Centre June & July 2015

Transcription

1 Isaac Wiebe Medical Student C W Wiebe Medical Centre June & July 2015

2 Needlestick procedures Many interventions rely on needlestick procedures Venipuncture, intravenous cannulation, vaccination, lumbar puncture, laceration repair Source of pain or discomfort Good practice includes minimizing this discomfort Pharmalogical and non-pharmalogical methods exist to reduce pain before the needlestick

3 Anesthesia Topical LET, EMLA, LMX, Tetracaine gel, Vapocoolant spray Needle-free Injection Iontophoresis Electrical stimulation Oral sucrose

4 Distractors and patient positioning Vigorous Rub Rapid method Positive reinforcement

5 Distractors can alleviate patient anxiety Videos, games, an object to look at Eg. 3 year old girl excisional biopsy and Lego Duplo game Eg. 7 year old boy frenotomy

6 A vigorous rub seconds prior to any skin puncture Can help to desensitize the area slightly Stimulating pressure and touch sensors can decrease pain perception

7 Equipment ready, mixed or laid out conveniently Non aspiration for blood

8 Teddy bears, prizes, stickers, balloons Candy? Check with parents Words of encouragement

9 LET 4% lidocaine 1 % tetracaine 0.5% epinephrine Use: anesthesia for suturing simple face or scalp lacerations C/I: digits, ears, nose Study showed ~46% pts received adequate anesthesia with LET alone Supplemental lidocaine for the rest

10 EMLA Eutectic Mixture of Local Anesthetics 5% emulsion of lidocaine(2.5%) and prilocaine (2.5%) Useful for any painful procedure on intact normal skin 1-2 hours until full effect 3 to 5 mm depth penetration ~1-2 hour duration, potentially up to 4 hours

11 Liposomal Lidocaine Aka LMX (formerly ELA-Max) LMX4 = 4% lidocaine, LMX5 = 5% lidocaine Venipuncture study in children: 30 min LMX4 = 60 min EMLA Use any procedure involving intact skin Children >1 month of age

12 Tetracaine gel (Eg. Ametop =4% tetracaine) min under dressing Duration 4-6 hours Causes skin erythema Children >1 month of age

13 Jet injection needle-free lidocaine delivery Compressed gas delivers liquid or powder lidocaine 5-8 mm beneath skin 1-3 min until anesthetic takes effect $ comparable to topical anesthetics Used on intact normal skin for any procedure One study showed jet injection to be more effective than topical anesthetic in reducing pain in ABG sampling S/E: mild erythema and petechiae

14 Vapocoolant Spray Eg. Pain Ease, Instant Ice Ethyl chloride (a flammable anesthetic) Cools skin surface Applied 15 seconds before a procedure Equal to EMLA or tetracaine gel Less effective than applying an ice cube to skin surface in intradermal procedures (not very painful to begin with)

15 Iontophoresis Electric current induces transdermal migration of lidocaine Reported to be uncomfortable, takes time, skin reactions

16 Transcutaneous electrical nerve stimulation Multiple theories suggested how TEN may reduce pain: blocking noxious input in the periphery or Reducing excitatory postsynaptic potentials or Stimulating A-delta fibres and blocking small unmyelinated C-fibres or Stimulating endorphin release to block pain Not shown to reduce pain associated with needlesticks

17 Considered a pharmacological method of pain relief appropriate for neonates 0.5 ml of 24% sucrose solution Shown to decrease pain during arterial puncture and venipuncture Endpoints: significantly less crying during and after procedure than non-sucrose group

18 Pharmacological Virtually no experience with topical anesthetics Injection Lidocaine with and without epinephrine Marcaine -intraoperative Non-Pharmacological Vigorous rub Distractors Positive reinforcement

19 1. Singer A J, Stark M J. Pretreatment of lacerations with lidocaine, epinephrine, and tetracaine at triage: A randomized double-blind trial. Academic Emergency Medicine 2000; 7(7): Singer A J, Stark M J. LET versus EMLA for pretreating lacerations: A randomized trial. Academic Emergency Medicine 2001; 8(3): Eichenfield L F, Funk A, Fallon-Friedlander S, Cunningham B B. A clinical study to evaluate the efficacy of ELA- Max (4% liposomal lidocaine) as compared with eutectic mixture of local anesthetics cream for pain reduction of venipuncture in children. Pediatrics 2002; 109(6): Zempsky W T, Robbins B, Richards P T, Leong M S, Schechter N L. A novel needle-free powder lidocaine delivery system for rapid local analgesia. Journal of Pediatrics 2008; 152(3): Lunoe M M, Drendel A L, Brousseau D C. Needle-free jet injection for administration of influenza vaccine: a randomised non-inferiority trial. Lancet 2004; 384(9944): Hajiseyedjavady H, Saeedi M, Eslami V, Shahsavarinia K, Farahmand S. Less painful arterial blood gas sampling using jet injection of 2% lidocaine: a randomized controlled clinical trial. Am J Emerg Med 2012; 30: Yoon W Y, Chung S P, Lee H S, Park Y S. Analgesic pretreatment for antibiotic skin test: vapocoolant spray vs ice cube. Am J Emerg Med 2008; 26: Coyne P J, MacMurren M, Izzo T, Kramer T. Transcutaneous electrical nerve stimulator for procedural pain associated with intravenous needlesticks. Journal of Intravenous Nursing 1995; 18(5): Milazzo W, Fielder J, Bittel A, Coil J, McClure M, Tobin P, Vande Kamp V. Oral sucrose to decrease pain associated with arterial puncture in infants 30 to 36 weeks' gestation: a randomized clinical trial. Advances in Neonatal Care 2011; 11(6):