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Three Part Question

For [intravenous cannulation of children in Emergency Departments] does [ethyl chloride spray or nothing] lead to [less pain]?

Clinical Scenario

A three year-old boy is brought in to the Emergency Department following a stand-by call. He has delayed capillary refill, a purpuric rash and a temperature of 39 degrees Celcius but is alert. You need immediate intravenous access for antibacterial therapy and fluid resuscitation. As there is no time for topical anaesthesia, you wonder if ethyl chloride spray may lead to reduced pain on cannulation.

Search Strategy

OVID Medline 1966 - 2004
exp Ethyl Chloride/ AND (exp Infusions, Intravenous OR exp Catheterisation, Peripheral/ OR exp Phlebotomy/ OR intravenous cannulation.mp. OR exp Infusions, Parenteral/ OR exp Veins/ OR exp Bloodletting/ OR venepuncture.mp. OR exp Blood Specimen Collection/) AND (exp Pain/ OR exp Pain Measurement/) limit to human and english language and all child <0-18 years>

Search Outcome

Of the papers identified by the reported search, only one was relevant to the three-part question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Ramsook C, Kozinetz CA, Moro-Sutherland D 2001 Oct USA	222 patients aged 3-18 years who presented to the Emergency Department requiring intravenous cannulation or venepuncture, randomised to receive either ethyl chloride (n=114) or isopropyl alcohol (placebo, n=108)	PRCT	Success rate (% first attempts)	Ethyl chloride 78%, isopropyl alcohol 85% (not significant)	Method of randomisation not described Procedure difficulty rated from 1-4 but results reported only as the percentage of procedures judged difficult. No standardisation of distraction techniques Only subjective assessment of pain scores by patient used Inadequate sample size to detect significant differences in pain scores among stratified age groups
			Procedure difficulty (% judged difficult)	Ethyl chloride 26%, isopropyl alcohol 9% (p=0.05)
			Impairment of vein visibility (% with no impairment)	Ethyl chloride 60%, isopropyl alcohol 73% (not significant)
			Pain score (Faces Pain Scale for ages 3-10 years, Numeric Pain Scale for ages >10)	No significant difference

Comment(s)

Venous cannulation is an unpleasant procedure for a young child. Topical anaesthesia requires a minimum application time of 45 minutes, which is often an unacceptable delay for an acutely ill child in the Emergency Department. Local infiltration causes discomfort on administration. Ethyl chloride is non-invasive and effective within seconds, which are highly desirable qualities for use in this situation. There is a paucity of evidence in this area. The one paper that addresses the three-part question showed no significant difference between ethyl chloride and placebo (isopropyl alcohol). In addition, there was a tendency towards increased dificulty of cannulation in the ethyl chloride group. Further studies that measure pain scores by objective behavioural assessment may be useful.

Clinical Bottom Line

There is no evidence of benefit in using ethyl chloride for emergency venous cannulation in children. Ethyl chloride may increase the difficulty of cannulation but further evidence is needed.

References

1. Ramsook C, Zokinetz CA, Moro-Sutherland D Efficacy of ethyl chloride as a local anaesthetic for venepuncture and intravenous cannula insertion in a pediatric emergency department Pediatric Emergency Care 2001 Oct, 17(5): 341-3