Efficacy of Intradermal Lidocaine and Bacteriostatic Saline - Research Paper Example

?Problem The study was conducted to compare the efficacy of intradermal bacteriostatic normal saline with intradermal buffered lidocaine as local anesthetics in adults for use prior to IV catheterization. The background for the study is the need for using local anesthesia prior to IV catheterization in order to reduce pain and anxiety. The gold standard for local anesthetic has been the use of intradermal lidocaine. However the use of unbuffered lidocaine as an anesthetic causes a stinging sensation when injected due to its acidic nature. This problem is alleviated by buffering lidocaine with sodium bicarbonate. But the use of buffered lidocaine faces some issues as it is a compounded medication and needs to be procured from the pharmacy and with its short half-life the FDA requires this solution to be replaced weekly which has been adopted even for this present study. In the case of bacteriostatic normal saline, the presence of benzyl alcohol as a preservative and an anesthetic has been proposed as a suitable alternative for intradermal lidocaine. Other local anesthetics such as the topical lidocaine-prilocaine suffer from certain disadvantages as it is inappropriate for use on the day of the surgery, is not economical and needs to be applied 30 minutes prior to starting the IV for best results. The practice of using intradermal bacteriostatic saline instead of intradermal buffered lidocaine as the former was cost effective was adopted by a Midwestern community hospital as a pain management strategy during surgeries. However, the concern of the nurses in the hospital has been the lesser number of comparative studies that have determined efficacy of the two anesthetics. Additionally they have provided inconclusive evidence about the use of either intradermal lidocaine or bacteriostatic saline as an effective anesthetic prior to IV injection. Hence the present study aimed to determine the efficacy of the two anesthetics in order to bring about a practice change. Purpose The specific purpose of the study was to determine the efficacy of intradermal lidocaine and bacteriostatic saline which are used as local anesthetics prior to IV catheterization. Prior studies have already established the importance for using local anesthetic before IV catheterization to reduce pain. However, previous studies have been inconclusive in comparing the effectiveness of the two anesthetics: intradermal lidocaine and bacteriostatic saline. Hence the present study was designed to compare the efficacy and determine the degree of pain using the two anesthetics and a randomized double-blind; quasi-experiment, and two-treatment, parallel designed study was conducted. The study was started after approval by the institutional review board. Both male and female same-day surgery patients in the age group of 18 to 80 were invited to take part in the study. The inclusion criteria were the presence of a physician’s order for a peripheral IV line and an ability to express the level of pain experienced. The sample size of the study included 150 adults who were admitted for same-day surgery between the months February and May. Two subjects required more than one venipuncture and in view of inaccurate reporting of the pain they were excluded from the study and others who were excluded include subjects allergic to lidocaine and others who had to take pain medication in the previous four hours. The degree of pain experienced by the subjects was measured using a modified verbal numeric rating scale (VNRS) in which the pain was recorded on a scale of 0 to 10. Buffered lidocaine for the study was prepared by a pharmacist using lidocaine and sodium bicarbonate and commercially available bacteriostatic saline was used. All the study subjects were blinded to the study solution and the basic demographics such as age, sex, race, IV location and catheter size were collected. The study protocol was explained to both the study participants and nurses who were responsible for the catheterization and informed consent was obtained from the participants. This was followed by administering the study solution, puncturing of the vein and the pain experienced was recorded. Findings The study sample was mixed in race with white, black, Hispanic and Latino participants and the women subjects were about 65%. The age of the subjects ranged between 19 to 80 and there were no significant demographic differences between the two treatment groups. Of the 148 participants, 73 were given intradermal buffered lidocaine and 72 with bacteriostatic saline and pain ratings were collected from 145 subjects. The pain perception ranged from 0 to 9 in the lidocaine group while it was 0 to 10 in the bacteriostatic group. And the mean pain rating was higher for the bacteriostatic group with 2.58 while the lidocaine group had a mean rating of 1.56. Nearly 30 patients who received buffered lidocaine reported no pain while only 15 reported the same in the bacteriostatic group. And only 9 subjects reported higher levels of pain in the lidocaine group while 18 participants reported highest pain levels in the bacteriostatic group. Thus the perception of pain experienced by the lidocaine group was considerably lesser compared to the bacteriostatic group. The catheters used for the study varied in sizes with 16, 18, 20 and 22 sized catheters used. The IV insertion site was done mostly in the right forearm and the other sites included the right hand, left forearm, left hand, right wrist, left wrist and the right antecubital site. The catheter size did not have an effect on the pain perceived by the participants. The age, sex, race and site of the IV injection also did not affect the pain rating. Limitations One of the study limitations has been the inclusion of a large number of white populations. This factor limits the generalization of the study results to a larger population of people in different races, cultures and ethnicity. Another possible limitation is the preoperative explanation of the study protocol to the same-day surgery study patients which might have reduced their anxiety levels compared to those patients admitted to other types of nursing departments. Another limitation is that the study included only those patients who were admitted to same-day surgery which prevented a comparison with the results from patients admitted to other nursing departments. Inclusion of patients requiring IV catheterization in different departments will provide a broader outlook about the pain assessment and hence the efficacy of the two anesthetics. In addition, with increasing age the response of pain receptors will also deteriorate progressively which will affect the way in which the participants perceive and express their pain. Also the study did not screen the subjects for any underlying medical conditions such as peripheral neuropathy, numbness, tingling sensation and other problems associated with the extremities. And since the study involved adults alone it cannot be generalized to children. Applicability The discomfort associated with IV cauterization and its subsequent effect on patient well-bring has been well documented. The use of local anesthesia to reduce the pain associated with the procedure has been shown to improve the patient satisfaction. While previous studies have not provided conclusive evidence on the efficacy of the anesthetics that are used for reducing the pain, this study has proved that intradermal buffered lidocaine is a more effective anesthetic as the mean pain experienced was lower compared to the bacteriostatic saline injection. In addition, this study used the VRNS instrument to assess the pain and also the sample size of the present study was larger than the previous studies. The clinical usefulness of the study results for the nursing practice should be based on the available statistical evidence. While the statistical results of this study have implied that buffered lidocaine is a more effective anesthetic in case of use during same-day surgery cases in which multiple IV lines are introduced, the cost factor for preparing the buffered lidocaine should also be borne in mind. The use of the costlier lidocaine may be a preferred choice for a same-day surgery environment, however in case of a clinical unit where lesser IV lines are initiated; use of other anesthetics may also be decided. Such practice changes can only be initiated after suitable training and education for the nursing staff of the institute. In addition, support from the research team that proposed the change and continued follow-up after initiation will help in the right changes to be introduced within a medical institution. Reference Burke, Sandra D et al. “Local Anesthesia Before IV Catheterization.” Ajnonline.com, 2011, 111(2): 40-45. Read More