- Email: [email protected]
What is the best topical anesthetic for nasogastric insertion? A comparison of lidocaine gel, lidocaine spray, and atomized cocaine
RESEARCH
What Is the Best Topical Anesthetic for Nasogastric Insertion? A Comparison of Lidocaine Gel, Lidocaine Spray, and Atomized Cocaine Authors: James Ducharme, MD, CM, FRCP(c), and Kim Matheson, BN, Saint John, New Brunswick, Canada Introduction: Nasogastric intubation has been shown to be a James Ducharme is Clinical Director, Department of Emergency Medicine, Saint John Regional Hospital, and Professor of Emergency Medicine, Dalhousie University, Saint John, New Brunswick, Canada. Kim Matheson is Research Coordinator, Department of Emergency Medicine, Saint John Regional Hospital, Saint John, New Brunswick, Canada. Reprints not available from the author. J Emerg Nurs 2003;29:427-30. Copyright © 2003 by the Emergency Nurses Association. 0099-1767/2003 $30.00 + 0 doi:10.1067/men.2003.146
painful procedure for patients. Previous studies have demonstrated the benefit of topical nasal anesthesia in decreasing the pain of this procedure. This study attempts to identify which of 3 topical anesthetic modalities would be preferred by patients. Methods: This study had a double-blind, double-dummy
randomized triple crossover design with 30 healthy volunteers as participants. Each participant had 3 nasogastric tubes inserted and acted as his or her own control for the 3 study medications: 1.5 mL 4% atomized lidocaine, 1.5 mL 4% atomized cocaine, and 5 mL 2% lidocaine gel. Participants scored pain of tube passage through the nostril as well as global discomfort. They were also asked to identify which agent they preferred. Results: In our 30 subjects, although no statistically significant
difference in nasal pain scores was found, “global discomfort” was less with the lidocaine gel (P = .017). Participants preferred the lidocaine gel over atomized cocaine (P < .00), but not to a statistically significant degree. Discussion: Two percent lidocaine gel appeared to provide the
best option for a topical anesthetic during nasogastric tube insertion.
October 2003 29:5
JOURNAL OF EMERGENCY NURSING
427
RESEARCH/Ducharme and Matheson
TABLE 1
Medications used Medication
A: 2% lidocaine gel B: 4% atomized lidocaine C: 4% atomized cocaine
T minus 11 min
T minus 10 min
T minus 5 min
2 sprays topical lidocaine to throat 2 sprays topical lidocaine to throat 2 sprays topical lidocaine to throat
1.5 mL atomized saline solution 1.5 mL atomized drug B 1.5 mL atomized drug C
5 mL drug A injected 5 mL placebo gel injected 5 mL placebo gel injected
he insertion of a nasogastric tube is considered a routine procedure in emergency medicine, although indications for its use have decreased during the past decade. Insertion of a nasogastric tube is no longer considered part of routine care for acute pancreatitis,1-3 and now patients with terminal cancer are often having their symptomatic bowel obstruction treated medically.4,5 Nevertheless, insertion of a nasogastric tube is still recommended for decompression of bowel obstruction, delivery of activated charcoal in acute intoxications, treatment of upper gastrointestinal bleeding, and treatment of intractable emesis associated with ileus. Singer et al6 surveyed patients and found that of all routine procedures performed in the emergency department, insertion of a nasogastric tube was considered the most painful.6 Three studies to date have looked at decreasing the discomfort of insertion of a nasogastric tube without placing the patient at risk for other more serious adverse effects. As with any painful procedure, the degree of anxiety of nasogastric tube insertion can be decreased with use of proper procedure and may be decreased with a caring approach.7 In an open study, Singer and Konia8 demonstrated that squirting of viscous lidocaine with a topical vasoconstrictor into the nasal passage accompanied by spraying of topical lidocaine into the throat decreased the pain and discomfort of nasogastric tube insertion considerably. A new mucosal atomizing device compared lidocaine with saline solution and again found lidocaine to be effective in decreasing procedural pain.9 When our department decided to develop and implement a policy of routine topical anesthesia prior to nasogastric tube insertion, we first compared topical agents to see for ourselves which agent was best.
T
Methods
428
JOURNAL OF EMERGENCY NURSING
We conducted a double-blind, double-dummy randomized triple crossover study with healthy volunteers. The principle investigator (JD) prepared all study medications and applied them as per study protocol, after participants had signed an informed consent (Table 1). The blinded research assistant inserted the nasogastric tube in the anesthetized nostril as per hospital policy for this procedure, ensuring that the tube had entered the esophagus before stopping. Each participant had 3 nasogastric tubes inserted and acted as his or her own control for the 3 study medications. There was a 1-hour washout period between each phase of the study. Each nostril was used once; for the last tube insertion, participants could select which nostril they preferred. The research assistant had the participants score the amount of pain of passage of the nasogastric tube through the nose as well as the global discomfort of the overall procedure, using 2 separate 100-mm Visual Analog Scales (VASs) (Figure 1). After passage of the third nasogastric tube, patients were asked to identify which of the 3 agents (A, B, or C) they preferred. The assistant also indicated which medication she believed provided the easiest passage for each patient, rating her choice prior to asking the participant to indicate his or her preferred agent. Persons were excluded from the study if they had known anatomic problems with their nose, allergies to the study medications, a history of illicit drug use, or were pregnant. Order of the topical anesthetics was randomized for the 30 adult participants using a computer-generated table. The study drugs were 1.5 mL of atomized 4% lidocaine, 1.5 mL of atomized 4% cocaine, and 5 mL of 2% lidocaine gel. All atomized agents, including the saline solution placebo, were applied with use of a single-use mucosal atomizer (Wolfe Tory Medical).9 The lidocaine and placebo
29:5 October 2003
RESEARCH/Ducharme and Matheson
Pain of NG Tube in Nostril
TABLE 2
Pain and discomfort scores* Measurement
Lidocaine gel Nostril pain Overall discomfort Atomized lidocaine Nostril pain Overall discomfort Atomized cocaine Nostril pain Overall discomfort
|
| Worst pain possible
Mean
SD
Median
No pain
19.3 18.6
24.9 19.6
10.5 12.5
|
|
23.9 27.1
26.4 23.0
12.2 23.7
No discomfort
Worst discomfort possible
30.5 32.6
29.6 24.8
18.3 22.5
One-way analysis of variance: P = .10 for median pain scores between groups. P = .017 for median global discomfort scores between groups (A vs B and C). *Discomfort was rated as least with lidocaine gel, higher with atomized lidocaine, and highest with atomized cocaine.
gels were injected with use of a 5-mL syringe fitted with a blunt tip adapter. All medications were applied with the subjects in an 80-degree sitting position. In addition, all subjects had 2 sprays of topical lidocaine applied to the back of the throat 1 minute prior to initiating the study protocols for any of the drugs. The lidocaine sprays were meant to act as a masking anesthetic to prevent the participant from identifying if the first medication was active or placebo. This study was approved by our institution’s review board. Analysis
All analyses were completed with blinding maintained for the statistician. A one-way analysis of variance was used to calculate differences in VAS scores between groups for both pain and discomfort. Interobserver agreement between assistant and patient for preferred medication was calculated with use of the κ statistic. Chi-square analysis was used to calculate differences in medications preferred by the patients.
Overall Discomfort of Procedure
FIGURE 1
Visual Analog Scales used. Subjects chose points along this line to indicate their discomfort, which were then measured in millimeters. NG, Nasogastric.
anesthetic with regard to the overall discomfort score (Table 2). All median scores for both pain and discomfort were in the “mild” range (score <40 mm). Lidocaine gel was preferred by patients; 17 chose this gel, 9 chose atomized lidocaine, and 4 chose atomized cocaine as their medication of choice. There was a statistical preference of lidocaine gel over cocaine (P < .000), but not over atomized lidocaine. Only moderate agreement existed between the assistant and the patients when selecting one agent as the preferred medication at the end of the study (κ = .475). Patients were allowed to volunteer comments at any time, but none was solicited. Most patients complained of a disagreeable burning sensation when the 4% cocaine was applied with the atomizer. All participants found the topical lidocaine spray applied to the throat at the start of each procedure to be disagreeable and said they would have preferred not to receive that medication. Discussion
Thirty volunteer subjects rated all medications as equally effective when comparing pain of passage of the nasogastric tube through the nostril. As for overall discomfort, lidocaine gel was significantly better than either atomized
Without a doubt, many procedures performed on patients can be painful if care is not taken to prevent pain from occurring. Insertion of nasogastric tubes has been found to be the most painful of the common procedures performed in the emergency department.6 In the 2 comparative studies to date, the pain of nasogastric tube insertion with placebo was significantly greater than when topical anesthesia was used. When measured on a standard VAS scale, where 0 means no pain and 100 means the most pain possible, subjects rated insertion with placebo as 57.5 vs 28.6 with
October 2003 29:5
JOURNAL OF EMERGENCY NURSING
Results
429
RESEARCH/Ducharme and Matheson
medication and 64.5 with placebo vs 37.4 with medication.8,9 Based on these differences in pain levels, we believed it would be unethical to use placebos in our study. Patient reporting has long been recognized as the gold standard in pain scoring. In this study, we are again shown that the health care observer is not able to consistently identify which agent a patient prefers. The research assistant had to select the preferred medication prior to asking the patient to choose and attained only moderate agreement with the participants’ choices. With many routes possible for the application of topical anesthesia—atomized, wet nebulization, topical gel, dripped liquid—we chose 2 simple routes requiring minimal equipment, yet allowing a standardized approach. We compared 2 types of medication using the atomized format to see if the vasoconstrictor properties of cocaine would offer any additional benefit, although previous studies comparing lidocaine with cocaine have not shown one to be superior to the other in pain relief for nasal procedures.10,11 Nebulized lidocaine was not chosen, although it has been studied in fiber-optic bronchoscopy and intubation, because of the risk of eliminating the gag reflex, potentially placing a patient at risk for aspiration.12-14 As with many aspects of the treatment or prevention of pain, patient preference is not based solely on pain relief. Adverse effects often alter patient preferences. In this study no difference in pain levels existed between the 3 arms, with all methods scoring median pain scores less than 20 mm on the VAS. Overall discomfort, however, was less with the lidocaine gel. Passage of the nasogastric tube requires not only passing through the nostril, but also through the oropharynx. Many patients find the gagging and discomfort in the throat more bothersome than the pain of nasal passage. Scoring overall discomfort also allowed the participant to include subjective feelings that had not been considered by us or were not quantifiable. All 3 agents appeared to be effective in decreasing the pain of insertion. Our measured pain scores were even lower than those found in the medication arms of the 2 placebo-controlled studies. Our subjects preferred topical lidocaine gel over atomized cocaine, but not over atomized lidocaine. There was a strong trend for preference of the gel. The lack of difference in the scores for the atomized lidocaine may be a result of inadequate sample size. In our
430
study, 2% lidocaine gel appeared to be the topical anesthetic agent of choice. There was a significant difference in overall discomfort with lidocaine gel. Also, there are no restrictions on its use, and it is simple to apply. On these bases, we developed a standard policy for the use of lidocaine gel prior to nasogastric tube insertion. REFERENCES 1. Sarr MG, Sanfey H, Cameron JL. Prospective, randomized trial of nasogastric suction in patients with acute pancreatitis. Surgery 1986;100:500-4. 2. Navarro S, Ros E, Aused R, Garcia PM, Pique JM, Vilar BJ. Comparison of fasting, nasogastric suction and cimetidine in the treatment of acute pancreatitis. Digestion 1984;30:224-30. 3. Levant JA, Secrist DM, Resin H, Sturdevant RA, Guth PH. Nasogastric suction in the treatment of alcoholic pancreatitis. A controlled study. JAMA 1974;229:51-2. 4. Ripamonti C, Mercadante S, Groff L, Zecca E, DeConno F, Casuccio A. Role of octreotide, scopolamine butylbromide, and hydration in symptom control of patients with inoperable bowel obstruction and nasogastric tubes: a prospective randomized trial. J Pain Symptom Manage 2000;19:23-34. 5. Mangili G, Franchi M, Mariani A, Zanaboni F, Rabaiotti E, Frigerio L. Octreotide in the management of bowel obstruction in terminal ovarian cancer. Gynecol Oncol 1996;61:345-8. 6. Singer AJ, Richman PB, Kowalska A, Thode HC Jr. Comparison of patient and practitioner assessments of pain from commonly performed emergency department procedures. Ann Emerg Med 1999;33:652-8. 7. Penrod J, Morse JM, Wilson S. Comforting strategies used during nasogastric tube insertion. J Clin Nurs 1999;8:31-8. 8. Singer AJ, Konia N. Comparison of topical anesthetics and vasoconstrictors vs lubricants prior to nasogastric intubation: a randomized, controlled trial. Acad Emerg Med 1999;6:184-90. 9. Wolfe TR, Fosnocht DE, Linscott MS. Atomized lidocaine as topical anesthesia for nasogastric tube placement: a randomized, double-blind, placebo-controlled trial. Ann Emerg Med 2000; 35:421-5. 10. Noorily AD, Noorily SH, Otto RA. Cocaine, lidocaine, tetracaine: which is best for topical nasal anesthesia? Anesth Analg 1995;81:724-7. 11. Tarver CP, Noorily AD, Sakai CS. A comparison of cocaine vs. lidocaine with oxymetazoline for use in nasal procedures. Otolaryngol Head Neck Surg 1993;109:653-9. 12. Graham DR, Hay JG, Clague J, Nisar M, Earis JE. Comparison of three different methods used to achieve local anesthesia for fiberoptic bronchoscopy. Chest 1992;102:704-7. 13. Gjonaj ST, Lowenthal DB, Dozor AJ. Nebulized lidocaine administered to infants and children undergoing flexible bronchoscopy. Chest 1997;112:1665-9. 14. Kenny JF, Molloy K, Pollack M, Ortiz MT. Nebulized lidocaine as an adjunct to endotracheal intubation in the prehospital setting. Prehosp Disaster Med 1996;11:312-3.
JOURNAL OF EMERGENCY NURSING
29:5 October 2003
What Is the Best Topical Anesthetic for Nasogastric Insertion? A Comparison of Lidocaine Gel, Lidocaine Spray, and Atomized Cocaine Authors: James Ducharme, MD, CM, FRCP(c), and Kim Matheson, BN, Saint John, New Brunswick, Canada Introduction: Nasogastric intubation has been shown to be a James Ducharme is Clinical Director, Department of Emergency Medicine, Saint John Regional Hospital, and Professor of Emergency Medicine, Dalhousie University, Saint John, New Brunswick, Canada. Kim Matheson is Research Coordinator, Department of Emergency Medicine, Saint John Regional Hospital, Saint John, New Brunswick, Canada. Reprints not available from the author. J Emerg Nurs 2003;29:427-30. Copyright © 2003 by the Emergency Nurses Association. 0099-1767/2003 $30.00 + 0 doi:10.1067/men.2003.146
painful procedure for patients. Previous studies have demonstrated the benefit of topical nasal anesthesia in decreasing the pain of this procedure. This study attempts to identify which of 3 topical anesthetic modalities would be preferred by patients. Methods: This study had a double-blind, double-dummy
randomized triple crossover design with 30 healthy volunteers as participants. Each participant had 3 nasogastric tubes inserted and acted as his or her own control for the 3 study medications: 1.5 mL 4% atomized lidocaine, 1.5 mL 4% atomized cocaine, and 5 mL 2% lidocaine gel. Participants scored pain of tube passage through the nostril as well as global discomfort. They were also asked to identify which agent they preferred. Results: In our 30 subjects, although no statistically significant
difference in nasal pain scores was found, “global discomfort” was less with the lidocaine gel (P = .017). Participants preferred the lidocaine gel over atomized cocaine (P < .00), but not to a statistically significant degree. Discussion: Two percent lidocaine gel appeared to provide the
best option for a topical anesthetic during nasogastric tube insertion.
October 2003 29:5
JOURNAL OF EMERGENCY NURSING
427
RESEARCH/Ducharme and Matheson
TABLE 1
Medications used Medication
A: 2% lidocaine gel B: 4% atomized lidocaine C: 4% atomized cocaine
T minus 11 min
T minus 10 min
T minus 5 min
2 sprays topical lidocaine to throat 2 sprays topical lidocaine to throat 2 sprays topical lidocaine to throat
1.5 mL atomized saline solution 1.5 mL atomized drug B 1.5 mL atomized drug C
5 mL drug A injected 5 mL placebo gel injected 5 mL placebo gel injected
he insertion of a nasogastric tube is considered a routine procedure in emergency medicine, although indications for its use have decreased during the past decade. Insertion of a nasogastric tube is no longer considered part of routine care for acute pancreatitis,1-3 and now patients with terminal cancer are often having their symptomatic bowel obstruction treated medically.4,5 Nevertheless, insertion of a nasogastric tube is still recommended for decompression of bowel obstruction, delivery of activated charcoal in acute intoxications, treatment of upper gastrointestinal bleeding, and treatment of intractable emesis associated with ileus. Singer et al6 surveyed patients and found that of all routine procedures performed in the emergency department, insertion of a nasogastric tube was considered the most painful.6 Three studies to date have looked at decreasing the discomfort of insertion of a nasogastric tube without placing the patient at risk for other more serious adverse effects. As with any painful procedure, the degree of anxiety of nasogastric tube insertion can be decreased with use of proper procedure and may be decreased with a caring approach.7 In an open study, Singer and Konia8 demonstrated that squirting of viscous lidocaine with a topical vasoconstrictor into the nasal passage accompanied by spraying of topical lidocaine into the throat decreased the pain and discomfort of nasogastric tube insertion considerably. A new mucosal atomizing device compared lidocaine with saline solution and again found lidocaine to be effective in decreasing procedural pain.9 When our department decided to develop and implement a policy of routine topical anesthesia prior to nasogastric tube insertion, we first compared topical agents to see for ourselves which agent was best.
T
Methods
428
JOURNAL OF EMERGENCY NURSING
We conducted a double-blind, double-dummy randomized triple crossover study with healthy volunteers. The principle investigator (JD) prepared all study medications and applied them as per study protocol, after participants had signed an informed consent (Table 1). The blinded research assistant inserted the nasogastric tube in the anesthetized nostril as per hospital policy for this procedure, ensuring that the tube had entered the esophagus before stopping. Each participant had 3 nasogastric tubes inserted and acted as his or her own control for the 3 study medications. There was a 1-hour washout period between each phase of the study. Each nostril was used once; for the last tube insertion, participants could select which nostril they preferred. The research assistant had the participants score the amount of pain of passage of the nasogastric tube through the nose as well as the global discomfort of the overall procedure, using 2 separate 100-mm Visual Analog Scales (VASs) (Figure 1). After passage of the third nasogastric tube, patients were asked to identify which of the 3 agents (A, B, or C) they preferred. The assistant also indicated which medication she believed provided the easiest passage for each patient, rating her choice prior to asking the participant to indicate his or her preferred agent. Persons were excluded from the study if they had known anatomic problems with their nose, allergies to the study medications, a history of illicit drug use, or were pregnant. Order of the topical anesthetics was randomized for the 30 adult participants using a computer-generated table. The study drugs were 1.5 mL of atomized 4% lidocaine, 1.5 mL of atomized 4% cocaine, and 5 mL of 2% lidocaine gel. All atomized agents, including the saline solution placebo, were applied with use of a single-use mucosal atomizer (Wolfe Tory Medical).9 The lidocaine and placebo
29:5 October 2003
RESEARCH/Ducharme and Matheson
Pain of NG Tube in Nostril
TABLE 2
Pain and discomfort scores* Measurement
Lidocaine gel Nostril pain Overall discomfort Atomized lidocaine Nostril pain Overall discomfort Atomized cocaine Nostril pain Overall discomfort
|
| Worst pain possible
Mean
SD
Median
No pain
19.3 18.6
24.9 19.6
10.5 12.5
|
|
23.9 27.1
26.4 23.0
12.2 23.7
No discomfort
Worst discomfort possible
30.5 32.6
29.6 24.8
18.3 22.5
One-way analysis of variance: P = .10 for median pain scores between groups. P = .017 for median global discomfort scores between groups (A vs B and C). *Discomfort was rated as least with lidocaine gel, higher with atomized lidocaine, and highest with atomized cocaine.
gels were injected with use of a 5-mL syringe fitted with a blunt tip adapter. All medications were applied with the subjects in an 80-degree sitting position. In addition, all subjects had 2 sprays of topical lidocaine applied to the back of the throat 1 minute prior to initiating the study protocols for any of the drugs. The lidocaine sprays were meant to act as a masking anesthetic to prevent the participant from identifying if the first medication was active or placebo. This study was approved by our institution’s review board. Analysis
All analyses were completed with blinding maintained for the statistician. A one-way analysis of variance was used to calculate differences in VAS scores between groups for both pain and discomfort. Interobserver agreement between assistant and patient for preferred medication was calculated with use of the κ statistic. Chi-square analysis was used to calculate differences in medications preferred by the patients.
Overall Discomfort of Procedure
FIGURE 1
Visual Analog Scales used. Subjects chose points along this line to indicate their discomfort, which were then measured in millimeters. NG, Nasogastric.
anesthetic with regard to the overall discomfort score (Table 2). All median scores for both pain and discomfort were in the “mild” range (score <40 mm). Lidocaine gel was preferred by patients; 17 chose this gel, 9 chose atomized lidocaine, and 4 chose atomized cocaine as their medication of choice. There was a statistical preference of lidocaine gel over cocaine (P < .000), but not over atomized lidocaine. Only moderate agreement existed between the assistant and the patients when selecting one agent as the preferred medication at the end of the study (κ = .475). Patients were allowed to volunteer comments at any time, but none was solicited. Most patients complained of a disagreeable burning sensation when the 4% cocaine was applied with the atomizer. All participants found the topical lidocaine spray applied to the throat at the start of each procedure to be disagreeable and said they would have preferred not to receive that medication. Discussion
Thirty volunteer subjects rated all medications as equally effective when comparing pain of passage of the nasogastric tube through the nostril. As for overall discomfort, lidocaine gel was significantly better than either atomized
Without a doubt, many procedures performed on patients can be painful if care is not taken to prevent pain from occurring. Insertion of nasogastric tubes has been found to be the most painful of the common procedures performed in the emergency department.6 In the 2 comparative studies to date, the pain of nasogastric tube insertion with placebo was significantly greater than when topical anesthesia was used. When measured on a standard VAS scale, where 0 means no pain and 100 means the most pain possible, subjects rated insertion with placebo as 57.5 vs 28.6 with
October 2003 29:5
JOURNAL OF EMERGENCY NURSING
Results
429
RESEARCH/Ducharme and Matheson
medication and 64.5 with placebo vs 37.4 with medication.8,9 Based on these differences in pain levels, we believed it would be unethical to use placebos in our study. Patient reporting has long been recognized as the gold standard in pain scoring. In this study, we are again shown that the health care observer is not able to consistently identify which agent a patient prefers. The research assistant had to select the preferred medication prior to asking the patient to choose and attained only moderate agreement with the participants’ choices. With many routes possible for the application of topical anesthesia—atomized, wet nebulization, topical gel, dripped liquid—we chose 2 simple routes requiring minimal equipment, yet allowing a standardized approach. We compared 2 types of medication using the atomized format to see if the vasoconstrictor properties of cocaine would offer any additional benefit, although previous studies comparing lidocaine with cocaine have not shown one to be superior to the other in pain relief for nasal procedures.10,11 Nebulized lidocaine was not chosen, although it has been studied in fiber-optic bronchoscopy and intubation, because of the risk of eliminating the gag reflex, potentially placing a patient at risk for aspiration.12-14 As with many aspects of the treatment or prevention of pain, patient preference is not based solely on pain relief. Adverse effects often alter patient preferences. In this study no difference in pain levels existed between the 3 arms, with all methods scoring median pain scores less than 20 mm on the VAS. Overall discomfort, however, was less with the lidocaine gel. Passage of the nasogastric tube requires not only passing through the nostril, but also through the oropharynx. Many patients find the gagging and discomfort in the throat more bothersome than the pain of nasal passage. Scoring overall discomfort also allowed the participant to include subjective feelings that had not been considered by us or were not quantifiable. All 3 agents appeared to be effective in decreasing the pain of insertion. Our measured pain scores were even lower than those found in the medication arms of the 2 placebo-controlled studies. Our subjects preferred topical lidocaine gel over atomized cocaine, but not over atomized lidocaine. There was a strong trend for preference of the gel. The lack of difference in the scores for the atomized lidocaine may be a result of inadequate sample size. In our
430
study, 2% lidocaine gel appeared to be the topical anesthetic agent of choice. There was a significant difference in overall discomfort with lidocaine gel. Also, there are no restrictions on its use, and it is simple to apply. On these bases, we developed a standard policy for the use of lidocaine gel prior to nasogastric tube insertion. REFERENCES 1. Sarr MG, Sanfey H, Cameron JL. Prospective, randomized trial of nasogastric suction in patients with acute pancreatitis. Surgery 1986;100:500-4. 2. Navarro S, Ros E, Aused R, Garcia PM, Pique JM, Vilar BJ. Comparison of fasting, nasogastric suction and cimetidine in the treatment of acute pancreatitis. Digestion 1984;30:224-30. 3. Levant JA, Secrist DM, Resin H, Sturdevant RA, Guth PH. Nasogastric suction in the treatment of alcoholic pancreatitis. A controlled study. JAMA 1974;229:51-2. 4. Ripamonti C, Mercadante S, Groff L, Zecca E, DeConno F, Casuccio A. Role of octreotide, scopolamine butylbromide, and hydration in symptom control of patients with inoperable bowel obstruction and nasogastric tubes: a prospective randomized trial. J Pain Symptom Manage 2000;19:23-34. 5. Mangili G, Franchi M, Mariani A, Zanaboni F, Rabaiotti E, Frigerio L. Octreotide in the management of bowel obstruction in terminal ovarian cancer. Gynecol Oncol 1996;61:345-8. 6. Singer AJ, Richman PB, Kowalska A, Thode HC Jr. Comparison of patient and practitioner assessments of pain from commonly performed emergency department procedures. Ann Emerg Med 1999;33:652-8. 7. Penrod J, Morse JM, Wilson S. Comforting strategies used during nasogastric tube insertion. J Clin Nurs 1999;8:31-8. 8. Singer AJ, Konia N. Comparison of topical anesthetics and vasoconstrictors vs lubricants prior to nasogastric intubation: a randomized, controlled trial. Acad Emerg Med 1999;6:184-90. 9. Wolfe TR, Fosnocht DE, Linscott MS. Atomized lidocaine as topical anesthesia for nasogastric tube placement: a randomized, double-blind, placebo-controlled trial. Ann Emerg Med 2000; 35:421-5. 10. Noorily AD, Noorily SH, Otto RA. Cocaine, lidocaine, tetracaine: which is best for topical nasal anesthesia? Anesth Analg 1995;81:724-7. 11. Tarver CP, Noorily AD, Sakai CS. A comparison of cocaine vs. lidocaine with oxymetazoline for use in nasal procedures. Otolaryngol Head Neck Surg 1993;109:653-9. 12. Graham DR, Hay JG, Clague J, Nisar M, Earis JE. Comparison of three different methods used to achieve local anesthesia for fiberoptic bronchoscopy. Chest 1992;102:704-7. 13. Gjonaj ST, Lowenthal DB, Dozor AJ. Nebulized lidocaine administered to infants and children undergoing flexible bronchoscopy. Chest 1997;112:1665-9. 14. Kenny JF, Molloy K, Pollack M, Ortiz MT. Nebulized lidocaine as an adjunct to endotracheal intubation in the prehospital setting. Prehosp Disaster Med 1996;11:312-3.
JOURNAL OF EMERGENCY NURSING
29:5 October 2003