Needle-free jet injection of lidocaine for local anesthesia during lumbar puncture: a randomized controlled trial.

BACKGROUND: Lumbar puncture (LP) is an essential procedure in the emergency department (ED) for the evaluation of meningitis. Subcutaneous injection of lidocaine before LP for local anesthesia is not a pain-free procedure. The J-Tip device allows an intradermal needle-free jet injection of 1% buffered lidocaine. This study compares needle-free jet injection of lidocaine to saline in reducing pain before LP in infants. METHODS: This is a randomized, double-blinded, placebo-controlled trial involving infants, younger than 3 months, presenting to the ED meeting clinical criteria for LP. All patients were administered the J-Tip and randomized to either treatment with 1% buffered lidocaine or an equivalent amount of sterile normal saline before LP. Vital signs were recorded during the procedure. Facial expressions as well as crying times were video recorded from start to finish. Independent reviewers assigned pain scores based on the validated Neonatal Facial Coding System with possible scores ranging from 0 to 5. RESULTS: A total of 55 patients were enrolled. Mean (SD) pain scores at the time of needle insertion were 4.1 (1.3) for the lidocaine group and 4.8 (0.5) for the saline group (P = 0.01). Length of cry was also shorter for those in the lidocaine group, 38.5 versus 48.8 seconds (P = 0.04). Overall, κ was 0.76 between 2 independent reviewers. CONCLUSIONS: Needle-free injection of 1% buffered lidocaine administered before needle insertion for LP in infants reduces pain and length of cry, compared with normal saline.

Changing incidence of methicillin-resistant staphylococcus aureus skin abscesses in a pediatric emergency department.

OBJECTIVES: The primary objective of this study was to determine the etiology of skin abscesses in a pediatric emergency department (ED) during a 4-year period and to determine whether the incidence of methicillin-resistant Staphylococcus aureus (MRSA) skin abscesses has increased. The secondary objective was to characterize MRSA infections by antibiotic susceptibility during the same period. METHODS: A retrospective chart review examining all cases of skin abscess requiring an incision and drainage seen in a free-standing children's hospital ED from January 1, 2003, to December 30, 2006, was performed. Demographic and clinical data were abstracted from the medical records. Culture results, including sensitivities to antibiotics, were obtained to identify how many of these patients had MRSA. RESULTS: The charts of 442 children were analyzed, and 274 (62%) had MRSA isolated during the entire study period. In 2003, 36.2% of all drained abscesses were caused by MRSA, and by 2006, this increased to 66.5% (P < 0.001). Methicillin-resistant S. aureus isolates were sensitive to trimethoprim-sulfamethoxazole in 99% of the cases, but the sensitivity of MRSA to clindamycin decreased from 96% in 2003 to 87% by 2006. All isolates remain sensitive to rifampin, vancomycin, and gentamicin. CONCLUSIONS: The incidence of MRSA skin abscesses has increased in the pediatric ED population and now accounts for greater than 50% of all abscesses. If antimicrobial therapy is indicated for the treatment of these abscesses, cultures should be obtained, and antibiotics should be chosen to provide MRSA coverage.