Glucose analgesia?

[Aussieaid]

Squint, the sucrose is only for mildly painful procedures such as lab draw or an IV start where you would not be giving an opioid anyway. I agree that infants especially in the NICUs are not adequately pain managed and I advocate giving appropriate pain medication when required. I think infants and children are grossly undermanaged for pain in all environments including prehospital as well as ICUs. On the other hand there is no need to use a bandage when a bandaid will do. I also use tylenol but it doesn't give the immediate effect that sucrose does for mild procedures.

I also don't care exactly how it works but I have seen it work and will continue to use it when appropriate.

Cheers.

[melclin]

tuniqs,

What would be the point of an adult study? No one is suggesting it works for adults. In the books I mentioned, it was for kiddies <6 months with an emphasis on the first thirty days with some qualifying factors regarding premature births that I didn't care to go into because I'm busy with some other stuff.

As Aussieaid said, its seems to be indicated for situations where, normally you wouldn't give any opiate pain relief.

I can't really comment on the methodology in the studies, I haven't had the time to read the articles that closely, but a consensus statement from International Evidence-Based Group for Neonatal Pain, published in the Archives of Pediatric and Adolescent medicine a while back was quite clear in its support for sucrose analgesia. So I'm not sure it is necessarily so simple to say the studies are rubbish.

I found the quotes you published to be a little confusing so maybe I'm missing your point, but I don't think there is any serious suggestion that it be used as the sole sedative in ventilated kiddies, or at all in vent pts. All I've seen is that people have suggested doing research into the topic of its use in ventilated neonates.

From: Altman, AJ (ed). Supportative care for children with cancer: current therapy and guidelines from the children's oncology group. 3rd Ed. Baltimore: The Johns Hopkins university press; 2004

c) use of sucrose analgesia does not obviate the needs for other methods of sedation.

The point you make about hyperglycemia is interesting. I think it would be very easy to assume that sugar is harmless and not worry too much about the side affects. The cochrane review I mentioned previously says briefly that only 6 of the 24 studies used in the review measured adverse affects and only one reported any negative side affects. The extent of the adverse affects measurement appears to have only involved noting anything obvious at the time of the study (a sudden desaturation was noted as was a one participant who choked on the 'placebo' sterile water preparation). From this, sucrose analgesia was deemed 'safe' in the conclusion. Poor science to say the least.

Edited November 29, 2009 by melclin

[tniuqs]

'melclin':

What would be the point of an adult study?

No one is suggesting it works for adults. In the books I mentioned, it was for kiddies <6 months with an emphasis on the first thirty days with some qualifying factors regarding premature births that I didn't care to go into because I'm busy with some other stuff.

As Aussieaid said, its seems to be indicated for situations where, normally you wouldn't give any opiate pain relief.

EMLA® Cream [lidocaine and prilocaine] can be used in advance (45 minutes) as a local anesthetic through intact skin at the intended puncture site.

I can't really comment on the methodology in the studies, I haven't had the time to read the articles that closely, but a consensus statement from International Evidence-Based Group for Neonatal Pain, published in the Archives of Pediatric and Adolescent medicine a while back was quite clear in its support for sucrose analgesia. So I'm not sure it is necessarily so simple to say the studies are rubbish.

I found the quotes you published to be a little confusing so maybe I'm missing your point, but I don't think there is any serious suggestion that it be used as the sole sedative in ventilated kiddies, or at all in vent pts. All I've seen is that people have suggested doing research into the topic of its use in ventilated neonates.

The point you make about hyperglycemia is interesting. I think it would be very easy to assume that sugar is harmless and not worry too much about the side affects. The cochrane review I mentioned previously says briefly that only 6 of the 24 studies used in the review measured adverse affects and only one reported any negative side affects. The extent of the adverse affects measurement appears to have only involved noting anything obvious at the time of the study (a sudden desaturation was noted as was a one participant who choked on the 'placebo' sterile water preparation). From this, sucrose analgesia was deemed 'safe' in the conclusion. Poor science to say the least.

Best read the studies presented, realistically in the EMS world starting lines in the field and or any invasive procedures are emergent not "optional" I just get a feeling that your musings in most cases you are looking for zebras when you hear the hoof beats think horses. Point being learn the accepted conventional treatments FIRST. If I were a student I would focus on the circulation of the neonatal, brown fat metabolism, how to improvise a neutral thermal environment (in the field) medication dosages and anomalies before introduction of controversial therapy's of pain control with the use of lollipops.

Further: IMHO giving any pediatric something to suck on during any procedure is not rubbish its noise abatement only.

cheers

Edited November 29, 2009 by tniuqs

[melclin]

Perhaps you would like to volunteer in the adult control group sans analgesia, step up to the plate ? Do you understand it would be rather unethical to do invasive procedures to test this theorem.

For venupuncture and heel pricks? Yeah I would, considering they don't use analgesia anyway.

You'd have no trouble getting ethics approval to for an adult RCT randomising consenting participants who were having blood taken anyway into an experimental group who receive a little sucrose before hand and the other, a little water before hand. The only problem you'd have would be explaining the evidence base for wanting to do the study in the first place. There's no reason to suggest that sucrose has analgesic properties in adults, that I've seen anyway.

But YOU are the OP and too busy with other "stuff" is there anything else you would like the members of EMT City to do for you ? You are the one that asked for opinion.

Now here seems to be where I've annoyed you. I've read the links posted. I've enjoyed the discussion. I just haven't had time (nor do I feel like making the effort) to extensively follow up every single side issue that I discover in my own reading. One paper, and a chapter of a one book mentioned some other papers about the effects at different extremes of premature birth, and I just didn't feel like fully exploring that component. Not the end of the world.

And when I said this:

I can't really comment on the methodology in the studies, I haven't had the time to read the articles that closely

I wasn't referring to the links provided, I was referring to other literature on the matter.

The quote I presented IS from the study, of the ventilated Neonatal population, I was not too busy to actually read docharris and Aussiead links so kindly provided

I read the paper. The issues of analgesia in the ventilated population were separate to those of minor procedural pain management with sucrose. Never did it suggest that sucrose should be used for sedation/analgesia for ventilation. It wasn't even clear to me that it was being used on vent pts at all for minor procedural pain. I don't know what you're getting so annoyed about. We're talking about tylenol for a bump on the knee and you're talking CABG surgery, then having a go at tylenol for not being good enough.

Best read the studies presented, realistically in the EMS world starting lines in the field and or any invasive procedures are emergent not "optional" I just get a feeling that your musings in most cases you are looking for zebras when you hear the hoof beats think horses. Point being learn the accepted conventional treatments FIRST. If I were a student I would focus on the circulation of the neonatal, brown fat metabolism, how to improvise a neutral thermal environment (in the field) medication dosages and anomalies before introduction of controversial therapy's of pain control with the use of lollipops.

Whats with these assumptions? Can't help but think I've hit a nerve or done something to p**s you off. I did read the articles presented. I didn't study them precisely (so if I might have missed something, by all means point it out as you did, although next time minus the condescending attitude), but enough to engage in an interesting discussion on a web forum - I'm not writing a textbook or doing a systematic review, just chatting.

My musings? What musings? What zebras? I just thought it was an interesting idea, and wondered if anyone else here knew of it (at the time I was assuming that the medic in question was right when she said there was no literature on it). "anything else you would like the members of EMT City to do for you". Do what for me? You seem to have attached yourself to the notion that I'm ignoring my studies to go off on wild goose chases, but asking EMT-city members to do important research for me that I'm too lazy to do myself, but that I will then dangerously and ignorantly integrate into my practice.

1) Obviously, they don't have to do anything. If people want to comment, do research or post links, good for them - it very interesting to see the results - but I'm not asking them to go out of their way. I'm hardly putting them out by asking if they knew of a practice being common in their area.

2) As it happens I'm on holidays from uni at the moment, so reading about other practices that are not strictly part of the my future practicum is my prerogative, as are the extracurricular research projects I'm involved in.

3) The 'accepted practices' are part of my degree, and what with paramedic education not being a complete joke here in Australia, I don't really need to log onto an internet forum to hear that I need to learn them.

4) The point of my question was simply to establish whether or not anyone else had heard of it being accepted practice, and any discussion that grew from there was a bonus. I simply thought it was an interesting idea, and wanted to know more about it, regardless of its applications in paramedic practice. Some helpful and interesting posts inspired me to read a bit more on the topic, and I've got what a wanted out of the thread.

[Aussieaid]

I advocate using EMLA and sucrose if possible. Sometimes you don't have the time required for the EMLA to work. Sometimes topical anesthetics are not appropriate for some procedures. There are situations where sucrose is appropriate and some where EMLA is appropriate or both. If it works I will use it and I have found that sucrose works. Sometimes EMLA makes the IV start harder and you end up taking longer to establish an IV therefore causing more pain to the infant.

One more study to look at comparing sucrose and EMLA and it appears sucrose is actually more effective. I still recommend giving both if feasible.

In the prehospital environment you don't have time to wait for the EMLA to work so sucrose is a valid alternative and if it works for the infant why would you not use it? Anything that helps the infants pain is preferable to nothing in my opinion.

Good discussion,

Thanks and Happy Holidays to all.

[fireflymedic]

I used EMLA cream several times frequently while working in the ER providing the situation and time allowed. If it didn't then we did other comfort pain measures such as providing a pacifier, IPOD to watch, etc. I know our children's hospital broke out the use of vision goggles that were a distraction allowing them to do even some of the more painful procedures like central and PICC lines or lumbar punctures with nothing more than your standard lido that's given. They have also found that IPOD's reduce pre-operative anxiety and also hospitals that utilize music therapy for both cancer patients and post operative need for narcotic pain meds. The power of reducing anxiety is amazing. I believe the more anxiety there is about a procedure (ie perceived pain) the more you will focus on it and be aware of it. If a distraction of some sort is provided then it is invaluable, especially in pediatric patients. I know any of you that have worked for a solely peds transport team in a dedicated "baby buggy" can attest to the power of barney, blues clues, dora and the wiggles (even if you are ready to kill yourself after seeing it for the 100th time !).

EMLA cream and glucose

http://www.nichd.nih.gov/cochrane/Taddio/Taddio1.htm

http://pediatrics.aappublications.org/cgi/content/full/110/6/1053

http://www.entrepreneur.com/tradejournals/article/150366883_3.html

Diversion

http://jpepsy.oxfordjournals.org/cgi/content/full/jsn023v1

http://www.musictherapy.org/factsheets/MT%20Pain%202006.pdf

http://www.cancer.org/docroot/ETO/content/ETO_5_3X_Music_Therapy.asp

http://etd.gsu.edu/theses/available/etd-04052006-092010/unrestricted/lim_crystal_s_200605_ma.pdf

http://www.mskcc.org/mskcc/html/11790.cfm?Disclaimer_Redirect=%2Fmskcc%2Fhtml%2F69308.cfm

http://www.ncbi.nlm.nih.gov/pubmed/17338592

http://www.anesthesia-analgesia.org/cgi/content/full/98/5/1260

(no I'm not using you tube as a reference, it is a demo of operative use of Ipod)

Check these out - some really good things to think about, some of these studies involve the adult as well as pediatric population, though I tried to focus solely on peds for the purpose of this thread.

[tniuqs]

For venupuncture and heel pricks? Yeah I would, considering they don't use analgesia anyway.

You'd have no trouble getting ethics approval to for an adult RCT randomising consenting participants who were having blood taken anyway into an experimental group who receive a little sucrose before hand and the other, a little water before hand. The only problem you'd have would be explaining the evidence base for wanting to do the study in the first place. There's no reason to suggest that sucrose has analgesic properties in adults, that I've seen anyway.

Now here seems to be where I've annoyed you. I've read the links posted. I've enjoyed the discussion. I just haven't had time (nor do I feel like making the effort) to extensively follow up every single side issue that I discover in my own reading. One paper, and a chapter of a one book mentioned some other papers about the effects at different extremes of premature birth, and I just didn't feel like fully exploring that component. Not the end of the world.

And when I said this: I wasn't referring to the links provided, I was referring to other literature on the matter.

I read the paper. The issues of analgesia in the ventilated population were separate to those of minor procedural pain management with sucrose. Never did it suggest that sucrose should be used for sedation/analgesia for ventilation. It wasn't even clear to me that it was being used on vent pts at all for minor procedural pain. I don't know what you're getting so annoyed about. We're talking about tylenol for a bump on the knee and you're talking CABG surgery, then having a go at tylenol for not being good enough.

Whats with these assumptions? Can't help but think I've hit a nerve or done something to p**s you off. I did read the articles presented. I didn't study them precisely (so if I might have missed something, by all means point it out as you did, although next time minus the condescending attitude), but enough to engage in an interesting discussion on a web forum - I'm not writing a textbook or doing a systematic review, just chatting.

Pissed off quite laughable ... unlikely I have a great tolerance for Students, you provided the ammunition to shoot yourself you walked into your own snare.

My musings? What musings? What zebras? I just thought it was an interesting idea, and wondered if anyone else here knew of it (at the time I was assuming that the medic in question was right when she said there was no literature on it). "anything else you would like the members of EMT City to do for you". Do what for me? You seem to have attached yourself to the notion that I'm ignoring my studies to go off on wild goose chases, but asking EMT-city members to do important research for me that I'm too lazy to do myself, but that I will then dangerously and ignorantly integrate into my practice.

1) Obviously, they don't have to do anything. If people want to comment, do research or post links, good for them - it very interesting to see the results - but I'm not asking them to go out of their way. I'm hardly putting them out by asking if they knew of a practice being common in their area.

2) As it happens I'm on holidays from uni at the moment, so reading about other practices that are not strictly part of the my future practicum is my prerogative, as are the extracurricular research projects I'm involved in.

3) The 'accepted practices' are part of my degree, and what with paramedic education not being a complete joke here in Australia, I don't really need to log onto an internet forum to hear that I need to learn them.

4) The point of my question was simply to establish whether or not anyone else had heard of it being accepted practice, and any discussion that grew from there was a bonus. I simply thought it was an interesting idea, and wanted to know more about it, regardless of its applications in paramedic practice. Some helpful and interesting posts inspired me to read a bit more on the topic, and I've got what a wanted out of the thread.

I am so pleased, So will you be putting a bottle of Glucose in your Kit?

I advocate using EMLA and sucrose if possible. Sometimes you don't have the time required for the EMLA to work. Sometimes topical anesthetics are not appropriate for some procedures. There are situations where sucrose is appropriate and some where EMLA is appropriate or both. If it works I will use it and I have found that sucrose works. Sometimes EMLA makes the IV start harder and you end up taking longer to establish an IV therefore causing more pain to the infant.

One more study to look at comparing sucrose and EMLA and it appears sucrose is actually more effective. I still recommend giving both if feasible.

In the prehospital environment you don't have time to wait for the EMLA to work so sucrose is a valid alternative and if it works for the infant why would you not use it? Anything that helps the infants pain is preferable to nothing in my opinion.

Good discussion,

Thanks and Happy Holidays to all.

One must ask is this a reward system with obesity now a Pandemic ?

Food for thought ?

[Aussieaid]

I think you are being deliberately obtuse to play the Devil's advocate here!

Sweet ease is only used for babies up to 6 months in a controlled environment. It is administered under a Doctor's orders and not given as an arbitrary "treat" to "bribe" babies. I think this population is fairly immune to the whole idea of the reward system. All they understand is that they are hurting and if you give them something to help that pain it is not going to turn them into a obese child later in life.

Infants burn through glucose much faster than adults and they do not store it like we do so giving them very small amounts of sweet ease for the occasional painful procedure is really not going to have the major impact on them that you are inferring.

The concentration and amount that you use is so minimal it usually does not have any effect on their glucose levels that I have observed.

If you are really not interested in the looking into new methods for providing pain relief to this chronically under pain managed population that's your prerogative but the OP heard of a new method of pain control and was interested enough to look into it further. Just because you have never heard of it doesn't mean that it is not a valid treatment option. I have changed my views on traditional treatments and techniques when I have researched new ideas and concepts and feel that it benefits my practice and my patients to have an open mind to new ideas. I may not agree with all of them but I try not to make up my mind until I have done a fair amount of research into it. Even then sometimes there are controversial ideas and often two opposing views on just about everything related to medicine, so I read and decide what I feel is the best evidence based practice and adjust my own practice accordingly or not.

Cheers

[tniuqs]

I think you are being deliberately obtuse to play the Devil's advocate here!

Sweet ease is only used for babies up to 6 months in a controlled environment. It is administered under a Doctor's orders and not given as an arbitrary "treat" to "bribe" babies. I think this population is fairly immune to the whole idea of the reward system. All they understand is that they are hurting and if you give them something to help that pain it is not going to turn them into a obese child later in life.

I think you misunderstood, I just can not see every Ambulance in the free world stocking a bottle of sucrose or

The concentration and amount that you use is so minimal it usually does not have any effect on their glucose levels that I have observed.

If you are really not interested in the looking into new methods for providing pain relief to this chronically under pain managed population that's your prerogative but the OP heard of a new method of pain control and was interested enough to look into it further. Just because you have never heard of it doesn't mean that it is not a valid treatment option. I have changed my views on traditional treatments and techniques when I have researched new ideas and concepts and feel that it benefits my practice and my patients to have an open mind to new ideas. I may not agree with all of them but I try not to make up my mind until I have done a fair amount of research into it. Even then sometimes there are controversial ideas and often two opposing views on just about everything related to medicine, so I read and decide what I feel is the best evidence based practice and adjust my own practice accordingly or not.

Cheers

[melclin]

I was going to give replying a good go, but I simply could not agree on a meaning for most of what you wrote. I have come to expect a certain amount of illiteracy from Americans (beyond what is normally acceptable on internet forums), but this goes beyond that.

I'll try again tomorrow when I'm rested and can be bothered trying to make sense of you and your mood ring. Or maybe I'll just choose not to bother; we shall see.