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Cold Spray Dan Shot Blocker Arab
Cold Spray Dan Shot Blocker Arab
Sedat Bilge, MD, Attila Aydin, MD, Cem Gun, MD, Hasan Aldinc, MD, Yahya A. Acar, MD, Serpil Yaylaci, MD,
Orhan Cinar, MD, Veysel Balci, MD.
Objectives: To compare the efficacy of ShotBlocker Received 25th June 2019. Accepted 15th September 2019.
and cold spray in reducing intramuscular (IM) Address correspondence and reprint request to: Dr. Yahya A. Acar,
injection-related pain in adults. Department of Emergency Medicine, Gulhane Medical School, Health
Sciences University, Ankara, Turkey. E-mail: [email protected]
ORCIDF ID: https://orcid.org/0000-0002-9572-5738
Methos: A prospective, randomized, controlled
study carried out between January 2018 and
March 2018 at the Department of Emergency
Medicine, Acibadem Mehmet Ali Aydinlar
University, School of Medicine, Istanbul, Turkey. Disclosure. Authors have no conflict of interests, and the
Adult patients receiving IM injection of diclofenac work was not supported or funded by any drug company.
the Kolmogorov–Smirnov test. For categorical variables, level. The upper limit of type-I error level for statistical
Chi-square test was used in multiple comparisons when significance (p-value) was regarded as 5% (p<0.05).
Chi-square condition was met, whereas Fisher’s exact
test when Chi-square condition was not met. Spearman Results. Demographic data (including gender,
correlation analysis was performed to determine the age, and body weight), fear of injection, and skin
relationship among normally distributed numerical characteristics were similar in all 3 groups (Table 1). The
variables. Multiple group comparisons were performed VAS scores were lower in the ShotBlocker (11 mm) and
with analysis of variance (ANOVA) if the data were cold spray (10 mm) groups than in the control group
distributed normally. Kruskal–Wallis test was used (31 mm) (p=0.001). The VAS scores of the cold spray
for analyzing non-normally distributed data. Post hoc
analyses were performed with the Mann-Whitney
U test using the Bonferroni correction. The effects of
independent risk factors on VAS scores were analyzed
using linear regression analysis. The initial candidate
risk factors for regression model were selected according
to the expert authors’ opinion. The VAS scores were
evaluated for normal distribution extensively using
Shapiro-Wilk test, QQ-detrended plot, histogram
graph, skewness-kurtosis, and coefficient of variation
being below 30%. The linearity between VAS scores and
risk factors were evaluated visually using scatterplots
and quantitatively using the Pearson correlation
analyses for numerical variables or student t-tests for
dichotomous dummy variables, where appropriate.
The model fit was analyzed using residual analyses and
goodness-of-fit statistics. The residuals were evaluated
for normal distribution and homoscedasticity. The
results of the linear regression analyses were summarized Figure 3 - Mean pain scores of the ShotBlocker, cold spray, and control
using parameter coefficients and statistical significance groups.
Table 1 - Intergroup analysis of the demographic data and clinical characteristics of study groups.
and ShotBlocker group were found similar to each Table 3 - Correlation between age and weight based on visual
analog scale scores according to the study groups.
other (Figure 3).
No significant differences were observed in VAS Parameter n Correlation coefficient*
scores according to gender and skin characteristics ShotBlocker group
among the study groups (Mann–Whitney U test; Age 40 −0.003
p=0.467 and p=0.408). In the ShotBlocker and cold Weight (kg) 40 0.154
spray groups, the VAS scores were significantly higher Cold spray group
Age 40 0.037
in patients with fear of injection than in those without Weight (kg) 40 −0.138
(Table 2). When the VAS scores of the 3 groups were Control group
examined according to age and body weight, no Age 40 0.009
significant differences were observed (Table 3). Weight (kg) 40 −0.066
Operator difficulties in using ShotBlocker were *Spearman’s rho correlation analysis, n - frequency
reported by the users as follows: “it was not difficult at
all” (n=8/40), “mildly difficult” (n=16/40), “moderately
Table 4 - Results of the linear regression analysis in the study groups.
difficult” (n=11/40), and “very difficult” (n=5/40).
Operator difficulties associated with the use of cold spray Study groups B P-value
were reported by the users as follows: “not difficult” ShotBlocker® group
(n=37/40) and “slightly difficult” (n=3/40). Other Constant -8.847 0.458
degrees of difficulty were not selected by operators in Leg movements during injection 12.662 0.098
Characteristics of the skin 1.185 0.821
the cold spray group.
Fear of injection 11.305 0.002
The linear regression analysis performed to define the Cold Spray Group
risk factors affecting the VAS scores revealed that fear Constant -8.000 0.260
of injection was a significant risk factor increasing the Leg movements during injection 5.743 0.315
severity of VAS scores both in the ShotBlocker (p=0.002) Characteristics of the skin 4.201 0.092
and cold spray groups (p<0.001). On the other hand, Fear of injection 12.113 <0.001
Control Group
fear of injection was not found as a significant risk Constant 20.463 0.199
factor increasing the VAS scores in the control group Leg movements during injection 5.192 0.601
(p=0.061). The results of the linear regression analyses Characteristics of the skin -0.299 0.965
of the study groups are presented in Table 4. Fear of injection 10.127 0.061
B - unstandardized regression coefficient
Discussion. Different methods that reduce IM
injection-related pain in both adult and pediatric patients compression, vibration, acupuncture, or transcutaneous
have been reported. Prior experiences of patients, pH, electrical nerve stimulation, closes the gates to painful
osmolality, viscosity, speed of injection, and chemical
input in the central nervous system, thereby preventing
properties of the drug have been associated with this
type of pain.7,11 The gate control theory was described painful stimuli. This method can alternatively induce
by Melzack and Wall.12 This theory proposes that a stimuli that inhibit pain sensations. In ShotBlocker and
painless physical input, such as warm-cold application, cold spray applications, the gate control theory may
underscore the mechanisms of action by which IM in accordance with the results of studies conducted on
injection-related pain is attenuated. different populations comprising different age and race
ShotBlocker can be used as a non-pharmacological groups.5,9,16 These studies have collectively demonstrated
method in the ED during injections for reducing pain. that cold sprays can reduce the intensity of injection-
ShotBlocker is a plastic material that is compressed related pain without causing any complications, and
to the site of injection during the procedure, and the that they are effective in different age groups and
injection is performed through the space at the center. body regions when used in different interventional
The ShotBlocker has several short and blunt contact procedures. Nevertheless, patients’ allergies should be
points on its surface which contact the patient’s skin. taken into consideration when adopting this approach.
When the device is pressed against the skin, these contact In a randomized controlled study comparing the
points stimulate the small-diameter, fast-conducting ShotBlocker and control groups, Caglar et al17 evaluated
nerve fibers. However, the requirement for pressing the perception of pain in neonates during IM injections
ShotBlocker with one hand has been considered a of hepatitis B vaccine. Pain scores in the ShotBlocker
complicating factor. group (1.64±0.80) during IM injections were lower
In the study by Celik et al,7 the effects of ShotBlocker (p<0.001) than control group (2.96±0.73), indicating
in reducing pain associated with IM injection of that the use of ShotBlocker reduced the intensity of
diclofenac sodium, VAS scores were lower in the acute pain.17 In our study, the use of ShotBlocker in the
ShotBlocker arm (7 mm) than placebo (20 mm) and adult group reduced IM injection-related pain; thus,
control (26 mm) arms. Our study was conducted on a ShotBlocker appears to be effective across different age
population with identical characteristics. Our data were groups.
compatible with the results of Çelik et al.7 Both studies Chung et al18 reported that compression applied
indicated that ShotBlocker was an effective method with the fingers at the site of injection over the deltoid
to reduce pain caused by IM injection of diclofenac muscle before injections was associated with lower pain
sodium. Furthermore, our study demonstrated that the intensity scores compared to those for conventional IM
use of either the cold spray or ShotBlocker reduced IM injections. Compression with the fingers may adopt the
injection-related pain. No side effects were observed in same mechanism in gate control theory as that of the
any group. ShotBlocker was found to be more difficult ShotBlocker mechanism.
to apply than the cold spray. The relationship between pain and anxiety has
Mawhorter et al13 have applied cold sprays or +4°C been described in the literature, which has revealed
saline-impregnated cool cotton balls as placebo at the that a reduction in the severity of anxiety using non-
site of injection to compare the effects of these distinct pharmacological methods may lead to a reduction in
applications on IM injection-related pain during pain intensity.19,20 A notable finding of our study is
vaccine administrations. The study concluded that the that the use of ShotBlocker and cold spray in patients
administration of topical cold spray prevented pain. with fear of injection led to a significant increase in
According to the results of our study, the administration VAS scores. Patients with fear of injection may benefit
of cold spray contributed to reduction of IM injection- more from an anxiolytic drug than from cold spray or
related pain intensity. No complications were observed ShotBlocker prior to injection. Further, inclusion in a
during the application of cold spray in our study. clinical study may be an anxiogenic factor.
However, Mawhorter et al13 reported flammability and Study limitations. This study was conducted
fluorocarbon content as limiting factors of cold spray at a single center, which limits its generalizability;
administration. Since both ShotBlocker and cold spray this is considered a major limitation. The anxiety
effectively reduce pain, ShotBlocker is the preferable scores of the participants were not evaluated, which
option as it is not constrained by any limiting factors. is another limitation of the study. In addition, the
Irkoren et al14 reported that a significant reduction non-pharmacological methods used in the study were
in the intensity of pain induced by botulinum toxin not compared with pharmacological methods, and a
injections on the forehead was achieved with the use of placebo group was not included.
a topical anesthetic cream and ethyl chloride-containing
cold sprays. Similarly, cold spray application reduces the In conclusion, the use of ShotBlocker and cold spray
intensity of pain in arteriovenous fistula procedures as can be effective in reducing pain during injections.
effectively as a topical anesthetic cream.15 Moreover, Neither of these methods caused complications;
cold sprays decrease the intensity of IM injection-related however, the use of ShotBlocker was associated with
pain in pediatric patients.16 The results of this study are application difficulties.
Further studies may be beneficial to facilitate the use 11. Ozdemir L, Piotanarciota E, Akay BN, Akyol A. Effect of
of ShotBlocker in routine practice. methylprednisolone injection speed on the perception of
intramuscular injection pain. Pain Manag Nurs 2013; 14: 3-10.
Acknowledgment. The authors gratefully acknowledge Editage 12. Melzack R, Wall PD. Pain mechanisms: a new theory. Science
(www.edditage.com) for English language editing. 1965; 150: 971-979.
13. Mawhorter S, Daugherty L, Ford A, Hughes R, Metzger D,
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