External thermomechanical stimulation versus vapocoolant for adult venipuncture pain: pilot data on a novel device.

OBJECTIVES: Mechanoreceptor and noxious thermal inhibitory stimulation modulate pain conduction but have not been clinically tested in combination. Our objectives were to determine whether a vibrating cold device decreased adult venipuncture pain on a 10 cm visual analog scale more than no intervention, and compared with vapocoolant analgesia versus no intervention. METHODS: The design was a prospective randomized crossover clinical trial. Thirty healthy adult volunteers were randomized to the study device or vapocoolant intervention. One nurse attempted cannulation on both intervention and control hands with a 22 gauge intravenous catheter. Vapocoolant was applied to the cannulation site, or the device was applied 5 to 10 cm proximally throughout the intervention attempt. Visual analog scale assessed needle fear and the primary outcome of self-reported pain. RESULTS: Sixteen device and 14 vapocoolant participants were included in this study. One participant felt discomfort from device prongs before the needle stick and was excluded. Compared with no intervention, the device reduced pain significantly (mean 9.9 mm, 95% confidence interval 0.82-19, P=0.035, SD 16) whereas vapocoolant did not (mean 7.9 mm, 95% confidence interval -1.8-17.7, P=0.1, SD 16.9). Mean pain reduction for device group participants was not significantly different from vapocoolant participants. Each 20 mm of prior anxiety increased the likelihood of intervention pain relief (odds ratio 2, P=0.043). One venipuncture failure occurred in the vapocoolant intervention. DISCUSSION: The combination of cold and vibration gave significant venipuncture pain relief without affecting cannulation success. Interventions were more helpful for those with greater preprocedural fear. Larger sample sizes and a prongless device could better compare equivalence or superiority to existing pain relief modalities.

Etomidate versus pentobarbital for computed tomography sedations: report from the Pediatric Sedation Research Consortium.

OBJECTIVE: To compare efficacy, sedation duration, and adverse events after administration of etomidate or pentobarbital for diagnostic computed tomography (CT) scans. METHODS: A cohort of children sedated for CT scans between July 2004 and October 2005 was identified from a prospectively generated Pediatric Sedation Research Consortium database. The 24 Pediatric Sedation Research Consortium institutions prospectively record consecutive sedation data and adverse events on a Web-based tool. This study included all patients of American Society for Anesthesiologists (ASA) class I or II, between 6 months and 6 years old, sedated with etomidate or with intravenous pentobarbital with or without midazolam. Outcomes included sedation efficacy, duration (time from drug administration until cessation of monitoring), and complication rate. RESULTS: Of 3397 pediatric sedations for CT scans, 2587 met age and ASA criteria. Etomidate was administered by pediatric emergency physicians as the sole sedative for 446 sedation service cases; pentobarbital with or without midazolam was used in 396 sedations by a variety of providers. Sedation was "not ideal" for 11 pentobarbital sedations and 1 etomidate sedation. Median etomidate dose was 0.33 mg/kg (intraquartile rank, 0.30-0.44 mg/kg); median pentobarbital dose was 4 mg/kg (intraquartile rank, 3.2-4.8 mg/kg). Mean etomidate sedation (34 minutes; 95% confidence interval [CI], 32-36 minutes) was shorter than pentobarbital (144 minutes; 95% CI, 139-150 minutes). Etomidate patients were younger (24 vs. 29 months), whereas pentobarbital patients were more often of ASA class II (52% vs. 34%), both P < 0.001. Adverse events were more common with pentobarbital (4.5% vs. 0.9%; relative risk, 3.38%; 95% CI, 1.28%-9.45%). One etomidate and 2 pentobarbital patients experienced apnea. CONCLUSIONS: Etomidate as given by emergency physicians was more effective and efficient than pentobarbital, with rare adverse events.