Less painful arterial blood gas sampling using jet injection of 2% lidocaine: a randomized controlled clinical trial

doi:10.1016/j.ajem.2011.07.011

The American Journal of Emergency Medicine

Volume 30, Issue 7, September 2012, Pages 1100-1104

https://doi.org/10.1016/j.ajem.2011.07.011 Get rights and content

Abstract

Objective

The aim of this study was to compare pain levels from arterial blood gas (ABG) sampling performed with or without application of lidocaine via jet injector.

Background

Pain is still a primary concern in the emergency department. Arterial blood gas sampling is a very painful procedure. No better technique for decreasing the pain of the ABG procedure has been presented. An ideal local anesthesia procedure for ABG sampling should be rapid, easily learned, inexpensive, and free of needlestick risk.

Materials and Methods

We evaluated the effectiveness of a lidocaine jet injection technique in achieving satisfactory pain control in patients undergoing ABG sampling. Forty-two patients were randomized to 2 groups: group A, which received lidocaine by jet injection (0.2 mL of lidocaine 2%), and group B, a control group that received a topical application of 1 mL of lidocaine gel 2% 2 minutes before the ABG sampling. Pain was assessed on a 10-cm visual analog scale (0, absence of pain; 10, greatest imaginable pain).

Results

The pain visual analog scale score during ABG sampling was considerably lower in group A compared with group B (1.29 ± 0.90 vs 4.19 ± 1.43; P < .001). The number of attempts required for ABG sampling was significantly lower in group A compared with group B (1.29 ± 0.46 vs 2.1 ± 0.12; P = .009). All residents reported ease of use with the lidocaine jet injection procedure (P < .05).

Conclusion

Lidocaine jet injection provides beneficial and rapid anesthesia, resulting in less pain and a greater rate of successful ABG sampling. Therefore, it is recommended for use before ABG sampling to decrease the patient's pain and the number of unsuccessful attempts and to enhance the patient's satisfaction.

Introduction

Although performing painful procedures is routine and unavoidable in an emergency department (ED) and many investigators have tried to find a solution to decrease the pain of patients in the ED, pain is still a main concern in the ED. In most situations and procedures, pain is not relieved systematically and satisfactorily [1], [2]. Two thirds of the trauma patients have moderate to severe pain at discharge [3]. Pain management is difficult, time-consuming, and expensive [4], [5]. One of the most routine painful procedures in the ED is venous or arterial cannulation. Arterial blood gas (ABG) sampling is a painful procedure because of high rates of failure involving several unsuccessful attempts before successful blood sampling. Another factor in the level of pain involved is the anatomical locations for ABG sampling in highly innervated places such as the wrist, elbow, or thigh. In most modern EDs, there is no protocol for local anesthetic medications before needle insertion, especially in adult patients. Therefore, it is understandable that we do not see any pain management attempts before ABG sampling even when there is a need for multiple attempts to perform the correct ABG sampling.

There are some limitations for choosing a method of pain control before cannulation. It should be fast, accurate, inexpensive and easily learned and nonpainful itself; however, no such advantageous technique has yet been presented for decreasing ABG pain. Some studies have reported the efficiency of the needle-free jet injector device in vaccinations, venous catheterization, and other administrations [6], [7], [8], [9]. Furthermore, jet injectors are widely used in local anesthesia for minor procedures and biopsies [10], digital blocks [11], and fine needle aspirations [12]. The jet injector can be called a safe device because it does not contain any sharp components. Therefore, there is no threat of needlestick injury or any difficulty in discarding them. Moreover, because the jet injector has a disposable syringe, there is no concern about transmitting infection.

Studies have shown that injection of lidocaine via jet injector would provide more effective anesthesia compared with placebo injection via jet injector during needle insertion for peripheral intravenous cannula insertion [8], [13], [14]. Studies also have shown that anesthesia using a jet injector with lidocaine compared with other topical anesthetics such as ELA-Max (since renamed LMX; Ferndale Laboratories, Ferndale, Michigan) [15] or eutectic mixture of local anesthesia (EMLA) [16] has a better or at least equal anesthesia effect for intravenous cannula insertion. No study has reported on the use of jet-injected lidocaine in patients undergoing ABG sampling. This study aimed to compare the pain level during ABG sampling in patients experiencing lidocaine injection using the jet injection device with that of patients receiving lidocaine gel before ABG sampling.

Section snippets

Study design

The study was conducted between June 2010 and January 2011 in the Imam-Reza Hospital in Tabriz, Iran, with local research ethics committee approval and informed consent from the patients.

In our study, to ensure that the procedure was performed accurately, experienced postgraduate year–3 ED residents performed the ABG procedures and pain scoring. All scores were recorded separately and without having access to other scores. Pain score was measured at the end of the procedure by asking the

Results

There was no significant difference between the mean ages in groups A and B (58.62 ± 19.15 vs 50.90 ± 20.66 years; P = .217, Mann-Whitney U test). There was also no significant difference between the sex ratios in groups A and B (15 male and 6 female vs 10 male and 11 female; P = .208, Fisher exact tests; Table 1). Visual Analog Scale score during ABG sampling was considerably lower in group A compared with group B (1.29 ± 0.90 vs 4.19 ± 1.43; P < .001, Mann-Whitney U test). The number of

Discussion

This is the first study conducted analyzing the use of lidocaine needleless injection before ABG sampling; however, studies on other procedures such as intravenous cannulation using jet injection have reported the useful role of the lidocaine jet injector for controlling pain [6], [8], [9], [15], [16].

Our study showed that using the lidocaine jet injector device before ABG sampling reduces pain remarkably. It also showed that use of the jet injector significantly reduced the average number of

Conclusion

This is the first study, as far as we know, demonstrating that the needle-free injection of lidocaine is an effective, useful, and noninvasive method for making ABG sampling easier. This study demonstrates that jet injection of 2% lidocaine provides beneficial and rapid anesthesia, which results in less pain and fewer procedure failures. Lidocaine jet injection is recommended for use before ABG sampling to decrease patient pain and the number of sampling attempts and to improve the patient's

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Cited by (17)

Interventions to reduce arterial puncture-related pain: A systematic review and meta-analysis
2022, International Journal of Nursing Studies
Citation Excerpt :
One (García García et al., 2005) study did not specify the tool used (Table 1). Included studies assessed different strategies to reduce arterial puncture-related pain, including topical anesthetics (n = 16) (Aguilar et al., 2007, Cortés-Télles et al., 2012, García García et al., 2005, Giner et al., 2000, Joly et al., 1998, Kim et al., 2007, Latsios et al., 2017, Mayoral et al., 2010, Olday et al., 2002, Russell et al., 1988, Guevara Sanz and Conde Anguita, 2001, Smith et al., 1990, Tran et al., 2002, Aaron et al., 2003, Micu et al., 2006, Ruetzler et al., 2012), cryotherapy (n = 9) (Ballesteros-Peña et al., 2017, Bastami et al., 2015, Farahmand et al., 2017, Haynes, 2015, Khalil, 2017, L'Her et al., 2001, Mahto et al., 2016, Pagnucci et al., 2020, Rüsch et al., 2017), local anesthetic infiltration (n = 5) (Matheson et al., 2014, Lightowler and Elliott, 1997, Giner et al., 1996, France et al., 2008, Wade et al., 2015), narrower needle gage (n = 5) (Patout et al., 2015, Giner et al., 1997, Ibrahim et al., 2015, Guevara Sanz and Requena Castillo, 2011, Yee et al., 2015), ultrasound-guided procedure (n = 3) (Bobbia et al., 2013, Grandpierre et al., 2019, Carpizo et al., 2014), topical anesthetics combined with local anesthetic infiltration (n = 1) (Tatlı et al., 2018), iontophoresis using anesthetics (n = 1) (Sherwin et al., 2003), engineered blood gas syringe (n = 1), (Baskın et al., 2014) jet injector (n = 1) (Hajiseyedjavady et al., 2012), and local massage (n = 1) (Lasocki et al., 2020). A significant difference between interventions was identified (p<0.01) (Fig. 2).
Arterial puncture-related pain remains unaddressed across several clinical settings. Analgesic techniques are not routinely employed before arterial puncture despite the recommendation that local anesthesia be used, except in emergencies. A comprehensive review of interventions aimed at reducing arterial puncture-related pain and their potential effectiveness is lacking, and the benefit of some interventions is uncertain.
To describe interventions aimed at reducing arterial puncture-related pain and provide an estimate of their effectiveness.
Systematic review and meta-analysis (PROSPERO no. CRD42020212299).
PubMed, CINAHL EBSCO, EMBASE, the Cochrane Database of Systematic Reviews, and Scopus were searched from their inception to 7 October 2020. No temporal or language limits were applied.
Published, quantitative studies on interventions aimed at reducing arterial puncture-related pain among adults were included. Screening, quality appraisal, and data extraction were undertaken independently by two reviewers. Random effects meta-analyses were performed to assess the association between interventions aimed at reducing arterial puncture-related pain and patients’ perceived pain using difference in means (MD) with 95% confidence intervals (CIs). A funnel plot and Egger test were used to assess publication bias.
The titles and abstracts of the 2446 identified articles were screened, and 43 and 31 studies were finally included in the systematic review and meta-analysis, respectively. Interventions to reduce arterial puncture-related pain included: topical anesthetics (n = 16), cryotherapy (n = 9), local anesthetic infiltration (n = 5), narrower needle gage (n = 5), ultrasound-guided procedure (n = 3), topical anesthetics combined with local anesthetic infiltration (n = 1), iontophoresis using anesthetics (n = 1), engineered blood gas syringe (n = 1), jet injector (n = 1), and local massage (n = 1). Topical anesthetics [MD -0.58, 95% CI -1.00, -0.15], cryotherapy [MD -1.13, 95% CI -1.72, -0.53], and local anesthetic infiltration [MD -1.13, 95% CI -1.72, -0.53] reduced arterial puncture-related pain. No benefit was found for narrower needle gage [MD -0.07, 95% CI -0.86, 0.71] or ultrasound-guided procedure [MD -1.74, 95% CI -3.51, 0.03]. No publication bias was detected.
Local anesthetic infiltration provided the greatest pain reduction and should be considered standard practice. Cryotherapy may be a safe, convenient alternative to local anesthetic infiltration. Topical anesthetics had limited benefit, and their lengthy time of onset makes them unsuitable for critical or emergency situations, though they may represent an option when comorbid conditions make cooling impossible. Caution must be used when interpreting these results, given the high risk of bias in the methods of included studies and the heterogeneity across the studies.
Comparison of the Effect of Massage and EMLA Cream on Children's Physiological Indices During Venipuncture: A Factorial Clinical Trial
2020, Journal of Perianesthesia Nursing
The aim of this study was to identify the effect of massage, EMLA cream, and the combination of these two methods on changes in physiological indices because of pain caused by intravenous line insertion in preschool children.
A four-group randomized nonblinded clinical trial with factorial design.
In total, 140 eligible 3- to 6-year-old children entered the study in Tabriz Children's Hospital in 2017 and were randomly allocated to four groups (EMLA cream, massage, combination of the two, and control). Physiological responses were measured before and immediately after interventions in all groups. Data were collected and analyzed using SPSS version 19.
Comparison of the physiological indices changes caused by pain between groups showed that changes in children's heart rate (HR) and respiratory rate (RR) in the EMLA group and in the combined-method group were statistically significant (P < .05). No significant differences were found in systolic blood pressure and oxygen saturation (SPo₂) between the four groups.
Results indicated that EMLA cream was more effective than massage and a combination of EMLA and massage in reducing an increase in the HR and RR caused by pain in children. Massage alone was not effective in significantly lowering the children's increased physiological indices such as the HR and RR, and it seems the effectiveness of massage is more noticeable in conjunction with EMLA cream.
Reducing Pain During Emergency Arterial Sampling Using Three Anesthetic Methods: A Randomized Controlled Clinical Trial
2020, Journal of Emergency Medicine
Taking a sample of arterial blood is widely reported as a cause of significant pain.
To compare three anesthetic methods with standard practice (no anesthesia) to establish which was the most effective in reducing pain caused by radial artery puncture in patients requiring an arterial blood gas test in the emergency department (ED).
A randomized controlled trial was conducted to compare the effectiveness between anesthetic cream, cryoanalgesia, and subcutaneous mepivacaine in reducing pain caused by radial artery puncture in ED patients.
After comparing perceived pain during arterial puncture, the lowest median score was obtained in the mepivacaine group (1 interquartile range 0.6–1.3) and the highest median score in the control group (5 interquartile range 4.0–7.0). When comparing the control group with the three intervention groups, the Kruskal-Wallis test showed that mepivacaine (p = 0.023) and cryoanalgesia (p = 0.012) were associated with significantly lower pain scores. The anesthetic cream (p = 0.861) intervention group did not produce a statistically significant median difference compared with the control group.
The results of this study encourage the use of anesthetic methods like cryoanalgesia or mepivacaine for their proven effectiveness in reducing or eliminating pain during arterial puncture.
Modelling nurses’ use of local anaesthesia for intravenous cannulation and arterial blood gas sampling: A cross-sectional study
2020, Heliyon
Citation Excerpt :
A pilot study was conducted on a small group of nurses having experience with needle related procedures to improve the reliability of the instrument, which helped refining the survey questions for clarity and proper phrasing to avoid misunderstandings or misinterpretations of the questions. As we used Likert scales (i.e., ordinal measures) to evaluate nurses' attitudes and ability to use LA, statistics for interval/ratio data were deemed inappropriate (Grimby et al., 2012). For similar reasons, we opted for Rasch analysis to measure reliability, instead of Cronbach's alpha, as the latter cannot confirm if the survey items are unidimensional (Sijtsma, 2009).
Needle insertions are painful, yet they are frequently performed for adults and children without using local anaesthetic (LA) to minimise pain and anxiety.
A hypothetical model was formulated to explore the factors related to Saudi nurses’ self-reported readiness to use LA prior to undertaking parenteral procedures in their workplaces.
This was an exploratory, cross-sectional study.
Four hundred seventy-five nurses were recruited from one hospital in Saudi Arabia. We considered eighteen latent variables related to nurses’ attitudes and ability to pursue six roles associated with LA before needle procedures. A model was created to identify the staff attitudes and self-efficacy pathways influencing readiness to use LA.
The nurses' readiness to use LA before needle procedures was directly predicted by organisational factors (e.g., hospital policy, doctors' orders), procedural time constraints, underestimation of needle pain, patient characteristics and medical conditions, nurses’ knowledge and skills related to LA, and parenteral procedure practices.
Nurses' readiness to use LA was influenced by their beliefs about certain aspects of their practice and the nature of patients’ presenting problems.
Identifying factors that affect LA use helps us understand this issue and may assist policymakers in developing nursing practice.
Needle-Free Jet Lidocaine Administration for Preinjection Anesthesia in Trigger Finger Injection: A Randomized Controlled Trial
2017, Journal of Hand Surgery
Citation Excerpt :
Needle-free jet injection has been demonstrated to reduce pain and length of cry compared with placebo during lumbar puncture in a randomized, double-blinded study in pediatric patients.17 Although there is no currently available literature regarding the use of J-tip in the hand, lidocaine jet injectors have additionally been used to deliver anesthetic for small wound sutures,18 arterial blood gas sampling,19 and no-scalpel vasectomy,20 with no negative consequences or complications. A limitation of this study was the difference in the total fluid injected through the needle.
To evaluate the efficacy of needle-free jet lidocaine (J-tip) administration for pain reduction in trigger finger corticosteroid injection compared with simultaneous lidocaine injection with corticosteroid.
A prospective randomized clinical trial was performed in which patients received either 0.25 mL of 2% lidocaine administered by J-tip just prior to 0.5 mL of corticosteroid injection by needle or 0.5 mL of 1% lidocaine and 0.5 mL of corticosteroid administered simultaneously through a needle for the treatment of trigger finger. Both the expected pain preinjection and the actual pain experienced postinjection were measured with a visual analog scale (VAS). Pain catastrophizing scale (PCS) scores were recorded before injection.
The use of the J-tip demonstrated a lower mean actual pain, 3.3 VAS, compared with the control group, 4.6 VAS. Both study groups anticipated more pain than they actually experienced. The PCS did not correlate to pre- or post-injection scores.
Needle-free jet administration of lidocaine reduces the pain associated with trigger finger injection. Patients anticipate more pain than they experience with trigger finger injection.
Therapeutic I.
Comparison of local anesthetic effect of lidocaine by jet injection vs needle infiltration in lumbar puncture
2016, American Journal of Emergency Medicine
Usual routes of drug administration are often painful and invasive. Nowadays, using jet injection has been introduced successfully, as a noninvasive and painless method of anesthetic delivery in performing different procedures.
The objective of the study is to compare the local anesthetic effect of lidocaine by jet injection vs needle infiltration in performing lumbar puncture in the emergency department (ED).
A randomized single-blind controlled study was performed in 65 patients needing lumbar puncture recruited from the ED from July to November 2014. We enrolled 44 patients and excluded 21 patients by the exclusion criteria. Local lidocaine was delivered in 1 group by jet injector (group B), whereas in the other group conventional method, needle infiltration was used (group A). In both groups, intravenous midazolam 1 mg was administered as an anxiolytic drug before the procedure. Patients' pain score (visual analog scale [VAS]) from 0 to 10 was recorded both during drug delivery and performing the procedure itself. The observer who collected patients' data and fulfill the questionnaire was blinded to the study.
During lidocaine injection, the mean ± SD VAS score was 5.27 ± 1.77 in group A and 2.95 ± 1.81 in group B (mean difference, 2.31; 95% confidence interval, 1.22-3.41) (P= .000). During performing the procedure, the mean ± SD VAS score in groups A and B was 3.77 ± 1.77 vs 2.18 ± 1.50 (mean difference, 1.59; 95% confidence interval, 0.59-2.58) (P= .003).
Injecting lidocaine by jet injector is less painful than infiltrating it by needle and syringe.

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Original ContributionLess painful arterial blood gas sampling using jet injection of 2% lidocaine: a randomized controlled clinical trial

Abstract

Objective

Background

Materials and Methods

Results

Conclusion

Introduction

Section snippets

Study design

Results

Discussion

Conclusion

Injury

J Emerg Nurs

J Oral Maxillofac Surg

Am J Emerg Med

Am J Emerg Med

J Clin Anesth

Chest

J Urol

Respir Med

Chest

Acute pain at the emergency department: better treatment required

Ned Tijdschr Geneeskd

Pain prevalence and patient preferences concerning pain management in the emergency department

Pflege

Pain management in the emergency department and its relationship to patient satisfaction

J Emerg Trauma Shock

Evaluation of a needle-free injection system for local anaesthesia prior to venous cannulation

Anaesthesia

A needle-free jet-injection system with lidocaine for peripheral intravenous cannula insertion: a randomized controlled trial with cost-effectiveness analysis

Anesth Analg

Original Contribution
Less painful arterial blood gas sampling using jet injection of 2% lidocaine: a randomized controlled clinical trial