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April 23, 2010 Stephanie Padley, Jennifer Rivera, Jessica Tidmore and Kara Yannaccone College of Nursing, University of

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April 23, 2010 Stephanie Padley, Jennifer Rivera, Jessica Tidmore and Kara Yannaccone College of Nursing, University of

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    1. April 23, 2010 Stephanie Padley, Jennifer Rivera, Jessica Tidmore and Kara Yannaccone College 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.

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