Tetracaine Compared to Placebo for Reducing Pain With Palivizumab - A Pilot Study
Condition: Pain
Study type: Interventional
Phase: Phase 4

Summary: 
      This is a small study known as a pilot study. This pilot study is being done to see if a
      difference in pain from intramuscular palivizumab injection can be detected if tetracaine a
      topical numbing gel is used compared to no medication (placebo). If a difference is found in
      this pilot study, then a larger study may be done to confirm that there is a difference in
      pain experience.
    

Detailed description: 
      Objective:

      1) To determine if tetracaine 4% gel (Ametop ®) reduces the pain of intramuscular palivizumab
      compared to placebo for pediatric patients between 1 month and 2 years of age.

      Rationale:

      Premedication with a systemic analgesic has not been shown to be effective in reducing the
      pain from an acute localized insult. EMLA and tetracaine have been shown to decrease pain
      associated with immunizations. EMLA requires a 60 minute application, which decreases the
      usefulness in a busy clinic. Tetracaine has a quicker onset of action and therefore may be
      more suitable for use in a busy clinic. Efficacy of tetracaine prior to palivizumab has not
      been reported and therefore it is not known if it can reduce the pain associated with
      intramuscular palivizumab injection.

      Setting:

      Respiratory synctial virus (RSV) clinic in the pediatric outpatient ward at Surrey Memorial
      Hospital.

      Procedure:

      A notice will be posted in the RSV clinic inviting parents to contact research staff if
      interested in participating in this study. When a parent contacts staff about the study, a
      nurse or pharmacist involved in the study will meet with the parent to review eligibility and
      obtain informed consent.

      Once informed consent obtained subject will be randomized by study pharmacist to receive
      either tetracaine 4% gel (Ametop®) or placebo before administration of the next palivizumab
      injection (study injection 1); a 4 block randomization design will be used. At the next
      injection (study injection 2) the subject will receive either tetracaine or placebo,
      whichever agent they did not receive at study injection 1. The subjects will serve as their
      own control.

      The placebo (Aquatain; Whitehall-Robins, Mississauga, Ontario, Canada) is visually and
      cosmetically similar to tetracaine 4% gel. One gram of drug or placebo will be dispensed in
      unit dose 5mL oral syringes, heat sealed to prevent evaporation and stored in a refrigerator
      for up to one week, after which it will be discarded if unused and redispensed. Tetracaine is
      commercially available in 1.5g tubes that produce approximately 1g tetracaine.

      On the day of immunization and on arrival to the clinic, a clinic nurse who is unaware of the
      treatment assignment will apply 1g of tetracaine or placebo to the subject's thigh and cover
      it with a dressing (opcit; Smith and Nephew). They will record the time of the application of
      the study gel. The clinic nurse will remove the dressing and study gel after 30-45 minutes
      and record the time of removal. The gel will be wiped from the skin with a paper tissue. A
      4-point scale (none, mild, moderate, and severe) will be used to assess local skin reactions
      after removing study gel. Immediately before the injection the site will be cleaned with an
      alcohol swab, then the dose (15mg/kg using current weight) of palivizumab will be
      administered using a ½ - 5/8 inch 23-25 gauge needle. A RSV clinic nurse will inject
      palivizumab within several minutes of gel removal; clinic nurses will not be aware of the
      treatment assignment for the subjects.

      Study injection 1 and 2 will be video recorded. A mirror will be mounted so the video
      recorder can capture the subject's reaction both face on and from the mirror image. The
      videotape will continue until the subject calms down following the injection. The subject can
      be held by a parent during the injection and provide whatever usual comfort measures they
      would provide. Following the injection the parent will be asked questions to determine their
      interpretation of the subject's pain response to the injections and if there any factors that
      may affect the pain response.

      Once both study injections are completed the video will be reviewed and pain assessed for
      both injections by the same scorer using FLACC pain scale. The scorer will be one pediatric
      registered nurse who is competent in completing pain analysis for infants. The scorer will be
      blind as to which dose is tetracaine and which is placebo.

      Data Collection:

      The data collected will include the FLACC pain scale, parent assessment of patient's pain,
      factors affecting pain response, as well as identify adverse effects from tetracaine and
      placebo.

      Sample size and statistical Analysis:

      The number of subjects with informed consent will determine sample size. Statistical analysis
      will involve descriptive statistics only.

      Ethics:

      Confidentiality will always be maintained. No information as to the identify of the child
      will be placed on the data collection forms. Every child will be assigned a number to
      facilitate identification by the researchers. Informed consent will be obtained.

      Personnel:

      A team consisting of nurses, a physician, and a clinical pharmacist from SMH will conduct the
      study. All personnel are currently involved in the day-to-day management of these children
      and have the required expertise in carrying out this project.

      Timeline:

      The study will be submitted for ethical approval by the research ethics board, Fraser Health
      in April 2007. After approval anticipate patient enrolment to start in November 2007 and
      complete enrolment by March 2008. A further 4 months will be needed to analyze the data and
      prepare a manuscript. Expected completion date for the project is July 2008.

      Budget:

      No additional costs are expected for this study.
    

Intervention name(s): tetracaine 4% gel; Placebo
Intervention type(s): Drug; Drug
Intervention description(s): tetracaine applied prior to 1 injection; placebo applied prior to 1 injection
Other intervention name(s): Ametop; Aquatain used as placebo to look like tetracaine
Intervention MeSH terms: Tetracaine
Allocation: Randomized
Intervention model: Crossover Assignment
Masking: Triple (Participant, Care Provider, Outcomes Assessor)
Primary purpose: Supportive Care