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1. April 23, 2010Stephanie Padley, Jennifer Rivera, Jessica Tidmore and Kara YannacconeCollege of Nursing, University of Oklahoma Pediatric Procedural Pain
2. Identification of Problem Which topical analgesics are effectively used to decrease procedural pain in pediatric patients from newborn to 18 years of age?
3. Identification of Problem Prevalence
Needle sticks are the most common source of procedural pain in the world.
2.1% out of 18 million venipunctures use pain control each year
Consequences
Unrelieved pain
Anxiety
Uncooperative patients
4. Identification of Problem Problems with needle insertion in pediatric patients
Pain
Needle Phobia
Anxiety
Problems with medications
Not time efficient
Availability
Vasoconstriction
5. Interventions EMLA Cream – 2.5% lidocaine, 2.5% prilocaine
LMX-4/ELA-MAX – 4% liposomal lidocaine
Lidocaine
Buffered
J-tip
Tetracaine/Amethocaine gel – 4%
Midazolam- Benzodiazepine
Sweet-ease- 24% sucrose and H2O solution
Placebo
Distraction/Coaching
6. Terminology
Procedures
Port-a-cath
Peripheral IV
Peripherally inserted central catheter
Hickman/Broviac catheter
Standard Practices
Local hospitals
Cancer centers
7. Review of Literature EMLA vs. Amethocaine (2)
EMLA vs. Placebo
EMLA vs. ELA-MAX
Buffered Lidocaine vs. ELA-MAX
Tetracaine vs. Placebo
Lidocaine vs. Placebo
Midazolam vs. Placebo
Non-Pharmacological
8. Review of Literature Pros
Topic generates interest
Credible research
Reducing pain
Cons
Lack of evidence to make recommendations
Inadequate research on Port-a-Caths
Pain is subjective
9. Review of Literature Amethocaine is equally effective at reducing pain as EMLA, with half the application time.
ELA-MAX and Amethocaine:
30 minutes to onset
Fewer adverse effects
No vasoconstriction
No methemoglobinemia
10. Recommended Interventions Topical anesthesia is better than no intervention
Amethocaine over EMLA
ELA-MAX over EMLA
Further research for newer products
Further research for Port-a-Cath puncture
11. Suggestions for further study New questions
Reasoning behind non-adherence
Other problems needing further study
More current studies
Research about port-a-cath access
Research about ELA-MAX and Amethocaine in pediatrics
12. Suggestions for further study Other approaches to studying the problem
Systematic review of literature
Involvement of pediatric clinics
Tracking topical anesthetic use
13. Questions?
14.
But you can’t please all of the people, all of the time.
15. References Ballantyne, R. M., McNair, R. M., Ung, B. E., Gibbins, R. P., & Stevens, R. P. (2003). A Randomized Controled Trial Evaluating the Efficacy of Tetracaine Gel for Pain Relief from Peripherally Inserted Catheters in Infants. Advances in Neonatal Care , 297-307.
Bishai, Raafat, Freedman, Melvin, H., Koren, & Gideon. (1999). Amethocaine gel vs lidocaine - prilocaine cream for procedural pain in children. The American Pediatric Society and The Society of Pediatric Research, 45(4), 65A.
Chen, B. K., & Cunningham, M. B. (2001). Topical Anesthetics in Children: Agents and Techniques that Equally Comfort Patients, Parents and Clinicians. Current Opinion in Pediatrics , 324-330.
Cordoni, M. A., & Cordoni, M. L. (2001). Eutectic Mixture of Local Anesthetics Reduces Pain During Intravenous Catheter Insertion in the Pediatric Patient. The Clinical Journal of Pain , 115-118.
Eichenfeld, L., Funk, A., Fallon-Friedlander, S., & Cunningham, B. (2002). 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, 109(6), 1093-1099.
16. References Essink-Tjebbes, C., Hekster, Y., Liem, K., & van Dongen, R. (1999). Topical use of local anesthetics in neonates. Pharm World Sci, 21(4), 173-176.
Fetzer, P. M. (2002). Reducing Venipuncture and Intravenous Insertion Pain With Eutectic Mixture of Local Anesthetic. Nursing Research , 119-124.
Gilboy, S., & Hollywood, E. (2009). Helping to Alleviate Pain for Children Having Venepuncture. Pediatric Nursing , 14-19.
Jimenez, M. N., Bradford, B. H., Seidel, M. K., Sousa, M. M., & Lynn, M. A. (2006). A Comparison of a Needle-Free Injection System for Local Anesthesia Versus EMLA for Intravenous Catheter Insertion in the Pediatric Patient. International Anesthesia Research Society , 411-414.
Kleiber, C., Sorenson, M., Whiteside, K., Gronstal, B., & Tannous, R. (2002). Topical anesthetics for intravenous insertion in children: a randomized equivalency study. Pediatrics, 110(4), 758-761.
Koh, M. M., Harrison, M. D., Myers, R. B., Dembinski, R. B., Turner, M. R., & McGraw, M. T. (2004). A randomized, double-blind comparison study of EMLA and ELA-Max for topical anethesia in children undergoing intravenous insertion. Pediatric Anesthesia , 977-982.
17. References Lander, J. A., Weltman, B. J., & So, S. S. (2009). EMLA and Amethocaine for reduction of children's pain associated with needle insertion. The Cochrane Database of Systematic Reviews , 1-37.
Luhmann, J., Hurt, S., Shootman, M., & Kennedy, R. (2004). A Comparison of Buffered Lidocaine Versus ELA-Max Before Peripheral Intravenous Catheter Insertions in Children. Pediatrics: Official Journal of the American Academy of Pediatrics , 217-220.
Migdal, M., Chudzynska-Pomianowska, E., Vause, E., Henry, E., & Lazar, J. (2010). Rapid, Needle-Free Delivery of Lidocaine for Reducing the Pain of Venipuncture Among Pediatric Subjects. Pediatrics: Official Journal of the Academy of Pediatrics , 393-398.
Murat, M. P., Gall, M. P., & Yourniaire, M. B. (2003). Procedural Pain in Children: Evidence-Based Best Practice and Guidelines. Regional Anesthesia and Pain Medicine , 561-572.
Schultz, R. P., Strout, R. B., Jordan, R. B., & Worthing, R. B. (2002). Safety, Tolerability, and Efficacy of Iontophoresis With Lidocaine for Dermal Anesthesia in ED Pediatric Patients. Journal of Emergency Nursing , 289-296.
18. References Shavit, I, Hadash, A, Knaani-Levinz, H, Shachor-Meyouhas, Y, & Kassis, I. (2009). Lidocaine-based topical anesthetic with disinfectant (lidodin) verses emla for venipuncture. Clin J Pain, 25(7), 711-714.
Spanos, S., Booth, R., Koenig, H., Sikes, K., Gracely, E., & Kim, I. (2008). Jet injection of 1% buffered lidocaine versus topical ela-max for anesthesia before peripheral intravenous cathertization in children. Pediatric Emergency Care, 24(8), 511-515.
Young, M. M. (2005). Pediatric Procedural Pain. Annals of Emergency Medicine , 160-171.
Young, M. S., Schwartz, M. R., & Sheridan, S. M. (1996). EMLA Cream as a Topical Anesthetic Before Office Phlebotomy in Children. Southern Medical Journal , 1184-1187.