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BET 1: Local anaesthetics in intraosseous access

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Report by: Michael Stewart, St5 Emergency Medicine

Search checked by: Shelley Regan, St5 Emergency Medicine

Institution: Blackpool Victoria Hospital, Blackpool, UK

Abstract

A short-cut review was carried out to establish whether flushing an intraosseous needle with local anaesthetic or saline is more effective at reducing the pain injecting drugs or fluid via this route. Two studies were relevant to the question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are shown in table 1. The clinical bottom line is that injecting lidocaine both before and after flushing an intraosseous needle is an effective method of reducing the pain of fluid infusion via this route.

Three-part question

In (conscious adults receiving drugs or fluids via the intraosseous route) is (an initial flush with local anaesthetic or with saline) more effective at (reducing pain)?

Clinical scenario

Having been unable to obtain intravenous access you have just placed an intraosseous needle in a 30-year-old intravenous drug user who has attended the emergency department with a Glasgow coma scale score of 6, pinpoint pupils and respiratory rate of 3 following an opiate overdose. You are about to inject lidocaine to reduce the pain of the infusion when a passing colleague suggests that it is a waste of time as it will not be effective (as the pain is caused by pressure effects distant to the injection site). You wonder if there is any evidence to support your practice?

Search strategy

Medline 1950–Week 46 2012 via NHS Evidence EMBASE 1980–Week 46 2012 via NHS Evidence [exp INFUSIONS, INTRAOSSEOUS/OR intraosseous.ti,ab OR IO.ti,ab] AND [exp PAIN/ or pain.ti,ab] Limit to: English language A further search was performed using:

[exp Lidocaine/ or exp Tetracaine/ or exp Anesthetics, Local/ or exp

Bupivacaine/ or exp Anesthesia, Local/ or local anaesthetic.mp or

lignocaine.mp or exp Prilocaine/] AND [exp Infusions, Intraosseous/]

This did not reveal any more evidence.

Search outcome

A total of 379 papers was identified by the stated search in Medline and 566 in EMBASE. Of these, two papers provided the best evidence to answer the question.

Table 1

Relevant paper(s)

Comments

Injecting lidocaine to reduce the pain of fluid infusion via the intraosseous route is widely advocated but little studied. The two papers quoted are simple open-label trials with healthy volunteers comparing different doses of lidocaine rather than lidocaine against placebo. The fact that higher doses appear to be more effective in reducing pain (in the 2009 study) does suggest that local anaesthetic has some effect. The 2010 study suggests that proximal humerus intraosseous access is less painful than tibial. As there is some evidence of efficacy, further placebo-controlled trials in patients may be unethical. Further research to determine the optimum doses and rate of injection would still be beneficial.

Clinical bottom line

Injecting lidocaine both before and after flushing an intraosseous needle is an effective method of reducing the pain of fluid infusion via this route.

▸ Philbeck TE, Miller L, Montez D. Pain management during intraosseous infusion through the proximal humerus. Ann Emerg Med 2009;54:S128.

▸ Philbeck TE, Miller LJ, Montez D, et al. Hurts so good. Easing IO pain and pressure. J Emerg Med Serv 2010;35:58–62.

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