Abstract
To the Editor:
We are very pleased with the interest 1 shown in our article, entitled “Comparison of Intravenous Paracetamol, Dexketoprofen Trometamol, or Topical Lidocaine Use for Pain Relief in Scorpion Stings: A Placebo-Controlled, Randomized Study.” 2
First of all, as we mentioned in the article, we included patients who did not have systemic symptoms and only had local pain. Analgesics are not the main drugs for scorpion stings, but they should be used because of intense or distressing pain. 3 In the literature, there are insufficient studies investigating the effectiveness of analgesics for scorpion stings, and our study sought to address this deficiency. 4
Placebo is often used in randomized controlled trials to determine if drugs or methods actually work. For example, the efficacy of different analgesics for severe pain caused by renal colic and migraine headache has been studied by several groups of investigators to determine the most effective approach to pain management caused by these conditions. 5 -7 It has been reported that scorpion sting pain may be accompanied by partial reduction and recurrence. 3 The latter information about pain evolution after scorpion stings stimulated our investigation. We received our local ethics committee approval by stating that there would be a placebo in the study. However, as noted by Mohanty et al, the ethicality of using a placebo is a matter of debate in the scientific community. 8 It is important to recognize that informed consent was obtained from all patients, and at no time did any patient in the placebo group experience any hemodynamic abnormalities. As stated in the Methods section, the patients were randomized and the study carefully double-blinded. The low mean baseline visual analog scale (VAS) scores in the placebo group were purely coincidental. In addition, it was determined that the VAS0 values between the groups were not statistically different (P=0.212).
In the study, we applied rescue medication to patients whose pain continued after 1 h. Regarding this, we saw in the literature that rescue medication was generally administered based on the patient’s complaints, not the control VAS value or another scale. 9 Mohanty et al understandably express concern about the potential side effects of tramadol. However, we chose tramadol as the rescue analgesic because it has been investigated in relevant studies and is readily available in our region. 10 In addition, the good analgesic effect of tramadol and the use of less rescue medication in cases of tramadol use enabled us to choose it despite its possible side effects. 11 As mentioned in the article, we did not detect any side effects related to tramadol in any of our patients. It is important to reiterate that the rate of use of rescue medication was higher in the placebo group, but there was no statistically significant difference between the groups (P=0.2566). 2
Nonliposomal anestol ointment 5% (Sandoz) was used in the study. Aksel et al 4 also used this ointment in their study. We agree with Mohanty et al that the absorption of a topical ointment will be delayed, as will the analgesic effect. So, we canceled the VAS measurement that we planned to perform at 15 min. As we mentioned in the Limitations section, we did not measure VAS after 60 min. Therefore, we cannot comment on the effectiveness of topical lidocaine after 1 h.
Animal bites and stings are mostly inflicted in the extremities. For this reason, regional anesthesia to the area where the scorpion sting occurs can be a suitable option for analgesia. However, the effectiveness of regional anesthesia is dependent on operator skill/familiarity with this intervention and preferably includes ultrasound guidance of the technique. These requirements are not available in many regions affected by scorpion envenoming.