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The Effect of Vapocoolant Spray on Pain in Adults Undergoing Peripheral Intravenous Line Placement in the Emergency Department: Preliminary Results of a Randomized, Blinded, Placebo-Controlled Trial
Research Forum Abstracts shorter for APT subjects (median 39 minutes, IQR 23-71) as compared to control cases (52, IQR 32-116). Regression adjusting for initial NRS (the only confounder identified) confirmed the finding that as compared to control subjects, APT subjects received initial analgesia faster (21 minutes, 95% CI 4-39 minutes, p ¼ 0.17). Conclusions: Deployment of APT in the study ED was associated with a 5-fold increase in analgesia administration rates, as well as a 21-minute faster time to initial analgesia.
254
The Effect of Vapocoolant Spray on Pain in Adults Undergoing Peripheral Intravenous Line Placement in the Emergency Department: Preliminary Results of a Randomized, Blinded, Placebo-Controlled Trial
Mace S/The Cleveland Clinic, Cleveland, OH
Study Objectives: Painful diagnostic or therapeutic procedures including peripheral intravenous line placement are commonly performed in the emergency department (ED). Prior investigation has documented that practitioners frequently provide inadequate anesthesia for patients with painful medical conditions and often fail to use anesthetics before performing painful procedures. Topical anesthetics have been recommended as a method to decrease a patient’s procedural pain. This study determines if topical vapocoolant spray is effective and safe in adults undergoing placement of a peripheral intravenous line in the ED Methods: Prospective blinded randomized controlled efficacy and safety trial of vapocoolant spray on pain in adults undergoing placement of a peripheral intravenous line in the ED at a large urban tertiary care referral hospital. Adults 21 years randomized to normal saline (NS) placebo spray or vapocoolant spray (1,1,1,3,3 pentafluoropropane and 1,1,1,2 tetrafluoroethane) (Gebauer Pain-Ease®) prior to undergoing placement of a peripheral intravenous line. Numeric rating scales (NRS 1 to 10) were obtained after the spray was given and after placement of the peripheral intravenous line. Inspection/assessment including a checklist for pallor, redness, etc., and photographs of the peripheral intravenous line site were done pre and post application of the spray. Vital signs were obtained after the spray was given and after the peripheral intravenous line was placed. Side effects were documented. Results: Twenty-nine adults were evaluated: N¼ 14 for the NS placebo spray and N¼15 for the vapocoolant (V) spray. Demographics were not significantly different for the saline (S) or vapocoolant (V) groups. Resultswere saline vs. vapocoolant: mean age (years) 48.3 (S) vs. 49.1 (V), males 4 (S) vs. 6 (V), African-American 5 (S) vs. 10 (V), Caucasian 6 (S) vs. 5 (V). Mean NRS after placement of an intravenous line for saline spray was 4.78 (SD 3.26) [95% CI: 2.90, 6.67] and for vapocoolant spray was 1.87 (SD 1.64) [95% CI: 0.96, 2.27], which was significantly different at p < 0.005. Assessment including before and after photographs revealed no pallor, redness, or other abnormalities of the skin at the site of the spray application/venipuncture. There were no significant differences in vital signs between saline and vapocoolant before and after the spray or the peripheral intravenous line placement. There were no documented side effects. The preliminary findings of this study are reported. This study is ongoing and we are continuing to enroll patients. Conclusions: Vapocoolant is effective and safe for the treatment of the acute pain of peripheral intravenous line placement in ED patients with a significant decrease of 2.91 in the mean NRS compared with NS (4.78 saline to 1.87 vapocoolant) and was well tolerated with very few minor side effects that resolved quickly. There were no visible abnormalities at the site post application of the spray. Following application of the spray and prior to the peripheral intravenous line placement, there was no significant difference in mean NRS between the saline or vapocoolant spray with a mean NRS < 1 for either spray, indicating that appropriate application of the vapocoolant spray was not painful or uncomfortable.
255
Pain, Expectations of Pain Relief, and Opioid Misuse Among Emergency Department Patients
Lopez JJ, Straube ST, Baird J, Mello MJ, Beaudoin FL/Alpert Medical School, Providence, RI
Study Objectives: To determine differences in patient-reported pain, and expectations of pain relief between patient self-reporting opioid misuse and those who do not. Methods: This was a prospective observational study of a consecutive sample of discharged emergency department (ED) patients, recruited during 8-hour shifts from 7am to 12am over an 8-week period. Eligible patients were aged 18-55 and
Volume 62, no. 4s : October 2013
discharged with a prescription opioid. Participants were identified via screening of the electronic medical record (EMR) and approached by one of two medical student coinvestigators. Consented participants completed a baseline assessment of pain and expectations of pain relief (modified Brief Pain Inventory (m-BPI)) in the ED, and were contacted 3 and 30 days later for follow-up. Follow-up surveys included questions about opioid use behaviors, the Current Opioid Misuse Measure (COMM), and repeated m-BPI were administered by Internet (SurveyMonkey Pro) or telephone when internet was unavailable. M-BPI scores were broken down into the: 1) Composite actual pain experience (range 0-30) and 1) Expected future pain experience scores (range 0-30) were calculated. Patients were classified as misusers based on a definition of misuse derived from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) section on drug abuse. Opioid misuse was constituted by self-reported: 1) self-escalation of dose (frequency or amount), 2) use for a reason besides pain, 3) taking another’s pain medication, or 4) use with or illicit drugs. Results: Seventy-six of 103 enrollees (74%) responded to the day 3 survey, and 64 of 103 responded to the day 30 survey (62%). Twenty-two of day 3 responders were identified as misusers (29%), and 23 at day 30 (36%); 11 were identified as misusers at both follow-ups. Those who were classified as misusers on day 3 had significantly greater actual pain and expected pain compared to non-misusers (3-day actual pain: misusers M ¼12.39, SD¼8.83; non-misusers M ¼ 6.97 SD¼ 7.67; t(74) ¼2.35, p ¼.03; 3-day expected future pain: misusers M ¼15.80, SD¼7.79; non-misusers M ¼ 9.25 SD¼ 6.95; t(74) ¼3.48, p ¼.001). These differences were also found amongst 30-day misusers (30-day actual pain: misusers M ¼12.82, SD¼9.98; non-misusers M ¼ 8.10 SD¼ 8.12; t(74) ¼2.06, p ¼.04. 30-day expected future pain: misusers M ¼11.39, SD¼9.77; non-misusers M ¼ 7.00 SD¼ 7.61; t(74) ¼2.00, p ¼.05). Conclusions: Misusers were more likely to report greater actual current pain and have a greater expectation of future pain, a relationship that extended beyond the initial ED presentation. This may be due to unrealistic expectations of pain management, poor initial pain control, or other phenomenon such as tolerance, dependence, and opioid induced-hyperalgesia. It is also possible that misusers exaggerate their current pain in order to receive additional opioids. Our study is limited in that we did not control for underlying chronic pain or long-term opioid use. However, this study highlights the complex dynamic between pain and opioid misuse and suggests that pain, as well as expectations of pain relief, might be targeted as a modifiable risk factor for opioid misuse.
256
Arterial Puncture Using Insulin Needle is Less Painful than Standard Needle: A Randomised Crossover Trial
Yau YW, Ibrahim I, Kuan WS, Chan YH/National University Hospital Systems, Singapore, Singapore
Study Objective: Radial arterial punctures are often performed in the emergency department to assess ill patients. However, these punctures are painful and can create anxiety in patients. In our hospital, physicians conventionally use the standard 23G needle attached to a syringe to obtain radial arterial blood. Smaller gauge, shorter and sharper needle has been shown to produce less pain. The common insulin syringe with its attached short 29G needle fits this description. The main objective of this study was to compare the degree of pain experienced during radial arterial punctures performed using the 29G common insulin syringe to that of the standard 23G needle. Methods: Healthy volunteers were recruited to receive bilateral radial arterial punctures. They were assigned to receive either the insulin or the standard needle on the right or the left hand as the first puncture using block of 4 randomization. Allocation concealment was achieved using opaque sealed envelopes. For each volunteer, a single doctor performed both punctures. The primary outcome was the pain score measured on a 100mm visual analog scale (VAS) and the secondary outcomes were immediate complications following the procedure and failure to obtain at least 0.5ml of blood in a single puncture. Both the volunteers and outcome assessors were blinded to the type of needles used. Results: Fifty healthy volunteers (44% males) were recruited in the study. The mean age is 32.2 years. One patient withdrew from the study after the first puncture (standard needle) but is included in the analysis. The mean VAS score ( SD) using the insulin needle was lower than the standard needle, 22.6 (21.9) mm versus 38.5 (23.7) mm; p<0.0001. There was no difference in pain score between the two needles in relation to which hand was used (p¼0.67) or whether the puncture was the first or the second (p¼0.42). Bruising was immediately observed in 24% of punctures
Annals of Emergency Medicine S93
254
The Effect of Vapocoolant Spray on Pain in Adults Undergoing Peripheral Intravenous Line Placement in the Emergency Department: Preliminary Results of a Randomized, Blinded, Placebo-Controlled Trial
Mace S/The Cleveland Clinic, Cleveland, OH
Study Objectives: Painful diagnostic or therapeutic procedures including peripheral intravenous line placement are commonly performed in the emergency department (ED). Prior investigation has documented that practitioners frequently provide inadequate anesthesia for patients with painful medical conditions and often fail to use anesthetics before performing painful procedures. Topical anesthetics have been recommended as a method to decrease a patient’s procedural pain. This study determines if topical vapocoolant spray is effective and safe in adults undergoing placement of a peripheral intravenous line in the ED Methods: Prospective blinded randomized controlled efficacy and safety trial of vapocoolant spray on pain in adults undergoing placement of a peripheral intravenous line in the ED at a large urban tertiary care referral hospital. Adults 21 years randomized to normal saline (NS) placebo spray or vapocoolant spray (1,1,1,3,3 pentafluoropropane and 1,1,1,2 tetrafluoroethane) (Gebauer Pain-Ease®) prior to undergoing placement of a peripheral intravenous line. Numeric rating scales (NRS 1 to 10) were obtained after the spray was given and after placement of the peripheral intravenous line. Inspection/assessment including a checklist for pallor, redness, etc., and photographs of the peripheral intravenous line site were done pre and post application of the spray. Vital signs were obtained after the spray was given and after the peripheral intravenous line was placed. Side effects were documented. Results: Twenty-nine adults were evaluated: N¼ 14 for the NS placebo spray and N¼15 for the vapocoolant (V) spray. Demographics were not significantly different for the saline (S) or vapocoolant (V) groups. Resultswere saline vs. vapocoolant: mean age (years) 48.3 (S) vs. 49.1 (V), males 4 (S) vs. 6 (V), African-American 5 (S) vs. 10 (V), Caucasian 6 (S) vs. 5 (V). Mean NRS after placement of an intravenous line for saline spray was 4.78 (SD 3.26) [95% CI: 2.90, 6.67] and for vapocoolant spray was 1.87 (SD 1.64) [95% CI: 0.96, 2.27], which was significantly different at p < 0.005. Assessment including before and after photographs revealed no pallor, redness, or other abnormalities of the skin at the site of the spray application/venipuncture. There were no significant differences in vital signs between saline and vapocoolant before and after the spray or the peripheral intravenous line placement. There were no documented side effects. The preliminary findings of this study are reported. This study is ongoing and we are continuing to enroll patients. Conclusions: Vapocoolant is effective and safe for the treatment of the acute pain of peripheral intravenous line placement in ED patients with a significant decrease of 2.91 in the mean NRS compared with NS (4.78 saline to 1.87 vapocoolant) and was well tolerated with very few minor side effects that resolved quickly. There were no visible abnormalities at the site post application of the spray. Following application of the spray and prior to the peripheral intravenous line placement, there was no significant difference in mean NRS between the saline or vapocoolant spray with a mean NRS < 1 for either spray, indicating that appropriate application of the vapocoolant spray was not painful or uncomfortable.
255
Pain, Expectations of Pain Relief, and Opioid Misuse Among Emergency Department Patients
Lopez JJ, Straube ST, Baird J, Mello MJ, Beaudoin FL/Alpert Medical School, Providence, RI
Study Objectives: To determine differences in patient-reported pain, and expectations of pain relief between patient self-reporting opioid misuse and those who do not. Methods: This was a prospective observational study of a consecutive sample of discharged emergency department (ED) patients, recruited during 8-hour shifts from 7am to 12am over an 8-week period. Eligible patients were aged 18-55 and
Volume 62, no. 4s : October 2013
discharged with a prescription opioid. Participants were identified via screening of the electronic medical record (EMR) and approached by one of two medical student coinvestigators. Consented participants completed a baseline assessment of pain and expectations of pain relief (modified Brief Pain Inventory (m-BPI)) in the ED, and were contacted 3 and 30 days later for follow-up. Follow-up surveys included questions about opioid use behaviors, the Current Opioid Misuse Measure (COMM), and repeated m-BPI were administered by Internet (SurveyMonkey Pro) or telephone when internet was unavailable. M-BPI scores were broken down into the: 1) Composite actual pain experience (range 0-30) and 1) Expected future pain experience scores (range 0-30) were calculated. Patients were classified as misusers based on a definition of misuse derived from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) section on drug abuse. Opioid misuse was constituted by self-reported: 1) self-escalation of dose (frequency or amount), 2) use for a reason besides pain, 3) taking another’s pain medication, or 4) use with or illicit drugs. Results: Seventy-six of 103 enrollees (74%) responded to the day 3 survey, and 64 of 103 responded to the day 30 survey (62%). Twenty-two of day 3 responders were identified as misusers (29%), and 23 at day 30 (36%); 11 were identified as misusers at both follow-ups. Those who were classified as misusers on day 3 had significantly greater actual pain and expected pain compared to non-misusers (3-day actual pain: misusers M ¼12.39, SD¼8.83; non-misusers M ¼ 6.97 SD¼ 7.67; t(74) ¼2.35, p ¼.03; 3-day expected future pain: misusers M ¼15.80, SD¼7.79; non-misusers M ¼ 9.25 SD¼ 6.95; t(74) ¼3.48, p ¼.001). These differences were also found amongst 30-day misusers (30-day actual pain: misusers M ¼12.82, SD¼9.98; non-misusers M ¼ 8.10 SD¼ 8.12; t(74) ¼2.06, p ¼.04. 30-day expected future pain: misusers M ¼11.39, SD¼9.77; non-misusers M ¼ 7.00 SD¼ 7.61; t(74) ¼2.00, p ¼.05). Conclusions: Misusers were more likely to report greater actual current pain and have a greater expectation of future pain, a relationship that extended beyond the initial ED presentation. This may be due to unrealistic expectations of pain management, poor initial pain control, or other phenomenon such as tolerance, dependence, and opioid induced-hyperalgesia. It is also possible that misusers exaggerate their current pain in order to receive additional opioids. Our study is limited in that we did not control for underlying chronic pain or long-term opioid use. However, this study highlights the complex dynamic between pain and opioid misuse and suggests that pain, as well as expectations of pain relief, might be targeted as a modifiable risk factor for opioid misuse.
256
Arterial Puncture Using Insulin Needle is Less Painful than Standard Needle: A Randomised Crossover Trial
Yau YW, Ibrahim I, Kuan WS, Chan YH/National University Hospital Systems, Singapore, Singapore
Study Objective: Radial arterial punctures are often performed in the emergency department to assess ill patients. However, these punctures are painful and can create anxiety in patients. In our hospital, physicians conventionally use the standard 23G needle attached to a syringe to obtain radial arterial blood. Smaller gauge, shorter and sharper needle has been shown to produce less pain. The common insulin syringe with its attached short 29G needle fits this description. The main objective of this study was to compare the degree of pain experienced during radial arterial punctures performed using the 29G common insulin syringe to that of the standard 23G needle. Methods: Healthy volunteers were recruited to receive bilateral radial arterial punctures. They were assigned to receive either the insulin or the standard needle on the right or the left hand as the first puncture using block of 4 randomization. Allocation concealment was achieved using opaque sealed envelopes. For each volunteer, a single doctor performed both punctures. The primary outcome was the pain score measured on a 100mm visual analog scale (VAS) and the secondary outcomes were immediate complications following the procedure and failure to obtain at least 0.5ml of blood in a single puncture. Both the volunteers and outcome assessors were blinded to the type of needles used. Results: Fifty healthy volunteers (44% males) were recruited in the study. The mean age is 32.2 years. One patient withdrew from the study after the first puncture (standard needle) but is included in the analysis. The mean VAS score ( SD) using the insulin needle was lower than the standard needle, 22.6 (21.9) mm versus 38.5 (23.7) mm; p<0.0001. There was no difference in pain score between the two needles in relation to which hand was used (p¼0.67) or whether the puncture was the first or the second (p¼0.42). Bruising was immediately observed in 24% of punctures
Annals of Emergency Medicine S93