Best Practices for Pain Reduction Associated with Venipuncture in Children University of Alaska...

Best Practices for Pain Reduction Associated with Venipuncture in Children

University of Alaska AnchorageNS 400

Jennifer Crow, Dawn Reishus, Brenda (Cooper) McMillan,

Char Corkery, Rachel Chesser

Evidence Synthesis Table Studies Design Sample Study Length Sponsorship

Bias Finding 1 Finding 2

Cold/Vibration reduces pain & anxiety during venipuncture

Randomized Control Trial (level 2 evidence)

120 children 6-12 years old

February – March 2010

None External cold & vibration can reduce pediatric pain and anxiety during blood specimen collection without IV success.

Vibration devices are inexpensive to operate per use.

Cold/Vibration on pain & anxiety during venipuncture


81 children 4-18 year olds

April – August 2008 None Cold & vibration decreased venipuncture pain without affecting procedural success

Vibration devices are inexpensive to operate per use.

Distracting children during blood draws: Looking through Distraction Cards


123 Children 6-12 years January 14, 2010 to February 20, 2010

None Significant finding? Children in experimental group had significantly lower pain levels than the control group

Anxiety level evaluated by parent and observer report was significantly lower in experimental group

EMLA and amethocaine for reduction of children’s pain associated with needle insertion

Systematic review of randomized control trials (Level 1 evidence)

534 children 3 months – 15 years

Varied None Amethocaine significantly favored over EMLA (the child was 22% less likely to report pain) Self Report: child was 37% less likely to report pain with amethocaine versus EMLA Observational: Difference was not significant

Comparison of adverse reactions to Amethocaine and EMLA favored EMLA suggesting it resulted in redness less often than amethocaine

Comparison study of Jet-delivered lidocaine, jet-delivered placebo and no pretreatment for pain relief during needle insertion

Randomized control trail (level 2 evidence)

197 children 5-18 years April 1, 2007 to August 1, 2008

None No significant difference between the jet delivered lidocaine and the jet delivered placebo for pain reduction in needle insertion

Comparison of jet-delivered lidocaine or placebo to no pretreatment suggested that the intervention group showed superior pain relief to the control group.

Comparison of pain reduction during needle insertion using topical xylocaine spray to no intervention

Randomized control trail (level 2 evidence)

40 neonates under 34 weeks gestation

July – November 2004

None The intervention group maintained more stable heart rates, respiratory rates, and oxygen saturation during needle insertion

Xylocaine spray is fast acting and cost effective method of reducing pain

Evaluating reduction in pain of newborns receiving glucose compared to EMLA cream prior to venipuncture

Randomized controlled trial, double blind

201 newborns undergoing venipuncture for clinical purposes

January 1999 – October 2000

None Glucose is effective in reducing pain symptoms from venipuncture in newborns

Glucose is more effective than local anesthetic EMLA cream

Comparing non nutritive sucking to glucose solution for reduction in pain during venipuncture

Randomized controlled trial, parallel group

105 neonates at least 32 weeks gestational

June-October 2006 None NNS can effectively decrease pain during venipunctures GW can effectively decrease pain during venipunctures

Evaluation of studies looking at pain reduction of needle related procedures with sweet tasting solutions

Systematic review of randomized controlled trials

4 studies, 330 children 12 months to 16 years

Varied None Infants 0-12months have decreased pain with sweet tasting solutions

Children 1-16years do not experience a reduction in pain with sweet tasting solutions

Conclusion

• Reduction of pain in children during venipuncture will help prevent increased pain and anxiety in future procedures.

• Pain control methods can be achieved through various inexpensive, non-invasive means.

• Further education and training is advised for nursing staff regarding pain reduction techniques for children.

Databases Searched• CINAHL• Cochrane• Google Scholar• PsychINFO

Summary of Evidence

• Sweet-tasting solutions significantly reduce pain of venipuncture in infants under 1 year of age (Gradin et al., 2002; Harrison et al., 2011).

• Amethocaine cream provided significant pain relief of venipuncture compared to EMLA cream in children 3 months - 15 years old (Lander & Weltman, 2006).

• Xylocaine topical spray significant reduced pain of venipuncture in neonates under 34 weeks gestation in addition to standard care (Chen et al., 2006).

• Jet delivery of lidocaine or a placebo provided superior pain relief to no pretreatment for children 5-18 years old (Auerbach et al., 2009).

• Children 6-12 years old self-reported less pain when distraction by flip-cards was used (Inal & Kelleci, 2011).

• External cold and vibration significantly reduced pain and anxiety in children ages 4-18 years old versus standard care (Baxter et al., 2011; Inal & Kelleci, 2012).

Background• Venipuncture is found to be a common cause of

pain in children. (Inal & Kelleci, 2012)• Venipuncture pain in children may lead to long

term avoidance of seeking health care, immunizations, and donations. (Baxter et al., 2011)

Searchable Question: What are best nursing practices to reduce the pain of venipuncture in children?

Suggestions for Future Research• Additional qualitative studies regarding various

methods of pain reduction for venipuncture in children.

• Additional RCT studies to support use of sweet-tasting solutions for children over 1 year of age.

• Determine whether external cold and vibration devices could offer pain relief for more invasive procedures.

Results

Critical appraisal of the literature suggests that some form of pain control during venipuncture will be beneficial for children.

Research Question

What are the best nursing

practices to reduce the pain of

venipuncture in children?

Background & Significance

Venipuncture procedures are found

to be a common cause of pain in

children.

(Inal & Kelleci, 2012)

Venipuncture pain in children may lead to

long-term negative effects later in life such

as future avoidance of medical care,

immunizations, and blood donations.

(Baxter et al., 2011)

Topical Xylocaine Spray for Reducing the Pain of Venipuncture in Neonates

(Chen, et al. 2006)

Design: RCT, Level 2

Population: Newborn infants in the neonatal intensive care units with gestational age of more than 34 weeks (n=40)

Sample: Purposive Sample/ Random Group Assignment

Intervention: Administration of a 10% xylocaine solution pump spray applied topically before venipuncture.

Findings: Infants in the study group had lower heart rate and less changes in oxygen saturations than infants in the

control group.

Strengths of the Study

• Financially feasible intervention

• RCT

Weaknesses of the Study

• Small population

• Assumes that heart rate, respiratory rate and oxygen

saturation are associated with pain.

A Randomized, Double-blind Controlled Study of Jet Lidocaine Compared to Jet Placebo for Pain Relief in Children Undergoing

Needle Insertion in the Emergency Department(Auerbach et al. 2009)

Design: RCT, Double Blind Study, Level 2

Population: Children ages of 5-18 at a pediatric hospital requiring acute needle insertion (venipuncture or peripheral venous

cannulation) (n=197)

Sample: Convenience Sample/ Random Group Assignment

Intervention: Pretreatment with jet delivered lidocaine (n=75) or a with jet-delivered placebo 60 seconds before undergoing

needle insertion. (n=75)

Findings: The mean needle insertion pain score for both the jet lidocaine and the jet placebo groups were lower than the needle

insertion pain scores for the no device group.


• Pain scores are subjective • Parental presence or lack of was not documented for each

patient• Nonintervention group was smaller than the intervention

groups• Variations in provider’s skills could impact the study.


• RCT, Double-blind study• Financially feasible intervention• Large sample size• Patients reported pain levels using a CAS tool

Pain reduction at venipuncture in newborns: oral glucose compared with local anesthetic cream

(Gradin et. al, 2002)

Design: Experimental-controlled randomized double blind

Population: 201 Newborns

Interventions: Newborns receiving glucose prior to venipuncture

Findings: Significantly fewer scored as having pain (19.3%) compared to EMLA group (41.7%)


• Decreased wait time

• Easy to use

• RCT

• Large sample size

• Financially possible.

.


• Habituation to glucose

• Difficult to measure pain

• Effectiveness applies to newborns only

• Unknown reason why glucose works best

Using non-nutritive sucking and oral glucose solution with neonates to relieve pain: A randomized controlled

trial(Liu et. al, 2010)

Design: Randomized, parallel group controlled trial

Population: 105 neonates at least 32 weeks gestational

Interventions: Newborns receiving glucose prior to venipuncture

Findings: Glucose group and non nutritive sucking group had significantly lower pain scores than

control group


• Limited generalizability

• No use of double blind


• Use of NIPS

• RCT

• Relevance to Clinical Practice

Sweet tasting solutions for reduction of needle-related procedural pain in children aged one to 16 years.

(Harrison et al., 2011)

f

Design: Systematic Review of RCTs, Level I Evidence

Population: 4 studies and 330 children 12 months to 16 years of age

Intervention: The use of sweet tasting solutions in children over one year of age during venipuncture.

Findings: Sweet tasting solutions did not show a reduction in pain with needle related proceedures in

children 12 months to 16 years of age.


• High Level Cochrane Review


• Conflicting Studies

• Requires more well-conducted RCTs with

larger sample sizes

Distracting children during blood draw: Looking through distraction cards


Design: RCT, Level II

Population: Children 6 – 12 years (n=123)

Sample: Convenience Sample, Random Group Assignment

Intervention: Flippits® Distraction Cards during blood draw procedures

Findings: Children receiving intervention self-reported and were observed to have less pain and

anxiety


• RCT, large sample

• Financially feasible


• Not suitable for children with neurologic, visual, or

auditory deficits

• Effectiveness after multiple uses with one child are

unclear

EMLA and Amethocaine for reduction of children’s pain associated with needle insertion (Review)

(Lander, Weltman, & So, 2010)

Design: Systematic Review of RCT, Level I

Population: 6 trials of 534 children 3 months to 15 years of age

Intervention: Compared EMLA to Amethocaine in reduction of pain associated with venipuncture

Findings: Amethocaine significantly reduced risk of pain when compared with EMLA


• High-level Cochrane review

• Exhaustive database search and hand-

search of reference lists and journals


• Some of the trials used scales that had

not been properly analyzed

An Integration of Vibration and Cold Relieves Venipuncture Pain in a Pediatric Emergency Department

(Baxter et al., 2011)


Population: Children 4-18 years (n=81)

Sample: Convenience Sample/Random Group Assignment

Intervention: The use of both cold & vibration during venipuncture

Findings: Children in the device group had significantly lower pain by parent report and the

observational scale than children in the standard care group


• RCT

• Quick-acting option vs. topical analgesics

• Low cost ($0.09 per attempt)


• Small Sample

• Subjects & coders not blinded to intervention groups

• No control for placebo effects

Relief of Pain During Blood Specimen Collection in Pediatric Patients



Population: Children 6-12 years (n=120)

Sample: Convenience Sample/Random Group Assignment

Intervention: using the “Buzzy” or cold & vibration applied to the site of insertion during venipuncture

Findings: Children in the device group had significantly lower pain (p<0.001) and anxiety (p<0.001)


• RCT

• Quick-acting option vs. topical analgesics

• Large sample size

• Pain & anxiety levels not assess by researcher to limit bias


• Not double-blind

• No control for placebo effects

• Nurses not randomly selected

Stake Holders

Nurses Certified Nursing Assistants Phlebotomists Intravenous Access Team Facility Administration/Accounting

Future Research

Additional qualitative studies regarding various methods of pain reduction for

venipuncture in children.

Additional RCT studies to support use of sweet-tasting solutions for children over 1

year of age.

Determine whether external cold and vibration devices could offer pain relief for

more invasive procedures.

Summary of EvidenceXylocaine topical spray significantly reduced the pain of venipuncture in

neonates under 34 weeks gestation in addition to standard care.

(Chen et al., 2006)

Sweet-tasting solutions significantly reduce the pain of

venipuncture in infants under one year of age.

(Gradin et al., 2002; Harrison et al., 2011).

Summary of EvidenceChildren 6-12 years old self-reported

less pain when distraction by flip-cards was used

(Inal & Kelleci, 2011).

External cold and vibration significantly reduced pain and anxiety in children ages 4-18

years old versus standard care (Baxter et al., 2011; Inal & Kelleci, 2012).

Summary of Evidence

Jet delivery of lidocaine or a placebo provided superior pain relief to no

pretreatment for children 5-18 years old.

(Auerbach et al., 2009)

Amethocaine cream provided significant pain relief of venipuncture compared to EMLA cream in children 3 months - 15

years old.(Lander & Weltman, 2006)

Results

Critical appraisal of the literature suggests that some form of pain

control during venipuncture will be beneficial for children.

Implementation

Create EBP quality intervention teams

Provide training for staff regarding pain relief methods

Implement protocol for venipuncture pain relief

Evaluation

Assess pain using hospital approved pain scales

Document pain response to used intervention

Periodic review of documentation regarding response to intervention

Conclusion

Pain control methods can be achieved through various inexpensive, non-

invasive means.

Further education and training is advised for nursing staff regarding pain reduction techniques for children.

Reduction of pain in children during venipuncture will help prevent increased pain and anxiety in future

procedures.

References

Auerbach, M., Tunik, M., & Mojica, M. (2009). A randomized, double-blind controlled study of jet lidocaine compared

to jet placebo for pain relief in children undergoing needle insertion in the emergency department. Academic

Emergency Medicine, 16(5), 388-393. doi:10.1111/j.1553-2712.2009.00401.x

Baxter, A., Cohen, L., McElvery, H., Lawson, M., & von Baeyer, C. (2011). An integration of vibration and cold

relieves venipuncture pain in a pediatric emergency department. Pediatric Emergency Care, 27(12), 1151-1156.

Chen, H., Tzeng, C., Liu, W., Huang, Y., & Chen, Y. (2006). Topical xylocaine spray for reducing the pain of

venipuncture in neonates. Clinical Neonatology, 13(2), 38-41.

Gradin, M., Eriksson, M., Holmqvist, G., Holstein, Å., & Schollin, J. (2002). Pain reduction at venipuncture in

newborns: oral glucose compared with local anesthetic cream. Pediatrics, 110(6 part 1), 1053-1057.

Harrison D., Yamada J., Adam-Webber T., Ohlsson A., Beyene J., & Stevens B. Sweet tasting solutions for reduction of

needle-related procedual pain in children aged one to 16 years. cochrane review 2011, Issue 10

References

Inal, S., & Kelleci, M. (2012). Distracting children during blood draw: Looking through distraction cards is effective in

pain relief of children during blood draw. International Journal Of Nursing Practice, 18(2), 210-219.

doi:10.1111/j.1440-172X.2012.02016.x

İnal, S., & Kelleci, M. (2012). Relief of Pain During Blood Specimen Collection in Pediatric Patients. MCN: The

American Journal Of Maternal Child Nursing, 37(5), 339-345. doi:10.1097/NMC.0b013e31825a8aa

Lander JA, Weltman BJ, So SS. EMLA and Amethocaine for reduction of children's pain associated with needle

insertion. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD004236. DOI:

10.1002/14651858.CD004236.pub2.

Liu, M., Lin, K., Chou, Y., & Lee, T. (2010). Using non-nutritive sucking and oral glucose solution with neonates to

relieve pain: A randomized controlled trial. Journal Of Clinical Nursing, 19(11-12), 1604-1611.

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