The Art and Science of Infusion Nursing

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OPEN

Local anesthesia is used to relieve pain associated with intravenous (IV) cannulation and arterial blood gas (ABG) sampling in various countries. However, the use of pain management for these procedures is

given a low priority in many health institutions throughout Saudi Arabia, and there is a significant lack of recommen-dations regarding local anesthesia for these procedures. 1 , 2Therefore, adults and children are subjected to pain and the associated anxiety, which could otherwise be managed with the use of local anesthesia.

DEFINITIONS

Local anesthesia refers to the method of eliminating sen-sations in, or numbing, a specific part of the body for relieving the pain associated with invasive procedures. 3 , 4 It is typically administered through 1 of 2 routes: topical and parenteral. Topical local anesthesia is applied to the skin surface as creams, gels, sprays, and patches. Parenteral local anesthesia is administered as injections through intra-dermal or subcutaneous layers of the skin. 4

IV cannulation is an invasive procedure used for vascular access that requires the insertion of a catheter containing a needle to administer medications, fluids, and other ther-apeutic treatment. 5 ABG sampling is a test performed by inserting a needle into an artery to obtain blood samples; this is more painful than a venipuncture because of the need to insert the needle more deeply into highly inner-vated anatomical locations, such as the wrist, antecubital fossa, or groin. 6

OBJECTIVE

Pain related to needle punctures is associated with physical and psychosocial complications. Fear of procedures that use needles and the associated pain may lead to patients avoiding preventive health care. This may cause delays in the treatment of illnesses, which poses a long-term burden on the health care system and society. 7 The use of local anesthesia helps reduce patient distress at the time of the procedure, serves to facilitate needle insertion, and helps

ABSTRACT The use of local anesthetics to relieve pain associated with intravenous cannulation and arterial blood gas sampling is given low priority in many health institutions. This review sought to identify factors influencing nurses’ use of local anesthetics for these procedures. The Database Syntax Guide for Systematic Reviewers was used; health-relevant studies were critically assessed with appropriate Critical Appraisal Skills Programme tools. Significant factors influenc-ing the use of local anesthetics for parenteral procedures were identified, including the level of effectiveness among types of local anesthetics, the perceived benefits of facilitating needle insertions and patient satisfaction, the under-estimation of pain associated with needle punctures, time concerns, physician authorization, and costs. Key words: arterial blood gases , catheterization , factors , intravenous cannulation , local anesthesia , nurses , pain reduction

Author Affiliation: King Saud Medical City, Riyadh, Saudi Arabia.

Fatimah Yahya Alobayli, MSN, BSN, RN, is currently a PhD student in nursing science at University of Edinburgh, United Kingdom, supported by King Saud Medical City. Her nursing experience is clinically based, largely focused on critical care in Saudi Arabia. She has also gained profound experience from clin-ical placements in different settings during her overseas nursing studies in New Zealand (2011-2012) and Australia (2013-2014). Her current work focuses on evidence-based projects, including exploration of advanced practices to ease patient distress, reduce nurses’ workloads, and improve quality of care.

The author has no conflicts of interest to disclose .

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal .

Corresponding Author: Fatimah Yahya Alobayli, MSN, BSN, RN, Administrative Nurse Manager, King Saud Medical City, Ulaishah, Riyadh 12746, Saudi Arabia ( f.alobayli@ksmc.med.sa ).

Factors Influencing Nurses’ Use of Local Anesthetics for Venous and Arterial Access

Fatimah Yahya Alobayli , MSN, BSN, RN

DOI: 10.1097/NAN.0000000000000316

92 Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. Journal of Infusion Nursing on behalf of the Infusion Nurses Society.

improve patient satisfaction and hospital experience.7-9 This review sought to identify factors influencing nurses’ use of local anesthesia for IV cannulation and ABG sampling.

METHODS

Article Search and Selection ProcessThe search process was performed in accordance with the Database Syntax Guide for Systematic Reviewers,10 which helped identify relevant articles in health-related databas-es. The databases searched included the Cumulative Index to Allied and Health Literature (CINAHL), MEDLINE, and PsycINFO. The main search terms were local anesthesia, pain reduction, intravenous cannulation, arterial blood gases, nurses, factors, and barriers. The search was limited to the English language and abstracts that contain the key-words local anesthesia. Titles and abstracts of articles that resulted from the search strategy were assessed for rele-vance to the research subject. As a result, 38 of the 54 arti-cles identified did not meet the aforementioned inclusion criteria and were excluded. In addition, the reference lists of the included articles were searched manually to identify additional studies. No studies were found that had been performed in Saudi Arabia regarding the use of local anes-thesia for IV cannulation or ABG sampling. Additionally, recent studies related to the use of local anesthesia for invasive procedures rarely involved nursing. Thus, articles published from 2005 onward that contained 2 or more of the search terms and that discussed important aspects relevant to the research topic were included. A total of 16 articles were included in this literature review.

Critical Appraisal of the StudiesArticles that met selection criteria for the literature review were critically assessed with the use of appraisal tools and programs and appropriate checklists. Most studies were trials that examined the effectiveness of local anesthesia for reducing the pain associated with venous and arterial access. All trial studies were critically assessed by using the relevant tool designed by the Critical Appraisal Skills Programme (CASP).11 Survey studies were assessed with the Critical Appraisal of a Survey checklist, produced by the Centre for Evidence-Based Management (CEBMa),12 and the included studies were evaluated by means of the CASP tool designed for systematic reviews.13 Critical appraisal tools were used for the articles, based on the suitability of screening ques-tions and similarity of study approaches. A critical analysis of each study was undertaken to identify and critique their purpose, method, findings, limitations, and significance (Appendix 1).14-27 The rigor of the reviewed studies was assessed through identification of limitations and strengths.

Thematic AnalysisThematic analysis helped organize and describe the data set of the research topic28 and allowed further scope beyond

evaluation of existing structural data. It enabled exploration of various aspects of the research topic in terms of factors that have an impact on the use of local anesthesia for procedural pain. After individual analyses of the studies, articles were grouped together based on recurrent themes that emerged from the findings (Appendix 2). Findings are presented with themes that were extracted from the reviewed articles.

RESULTS

Effectiveness of Local Anesthetics

Intradermal InjectionsThe effectiveness of local anesthesia injection types has been studied in terms of the reduction of the pain associat-ed with venipunctures. Matheson et al21 aimed to identify an effective method for reducing the pain associated with ABG sampling. The study compared 3 methods of analgesic administration at the site of arterial puncture (0.7 mL 1% lidocaine, 0.7 mL buffered 1% lidocaine, or 0.7 mL bacterio-static saline) to determine which method was most effec-tive at minimizing the pain associated with arterial needle puncture. The investigation involved a randomized, par-tially blinded, prospective study convenience sample of 40 hospitalized patients in the United States. The findings sug-gested that although lidocaine and buffered lidocaine were both effective for reducing pain associated with the ABG sampling procedure (P = .000 and P = .041, respectively), compared with bacteriostatic saline (P = .665), lidocaine alone resulted in the most significant reduction of pain.

Another study by McNaughton et al22 compared pain and anxiety associated with IV cannulation after pretreating patients with 1% subcutaneous buffered lidocaine, 4% lido-caine cream, or no local anesthesia. A randomized cross-over study of 70 participants (medical students or nurses) who participated in hospital workshops for IV insertion in the United States was conducted. Three IV cannulations were performed for each participant; each insertion was pretreated randomly with either no treatment, lidocaine cream, or buffered lidocaine. Participants were asked to report the level of pain, anxiety, and preference for the use of local anesthesia, for themselves and patients, on a 10-point numeric rating scale.

The study showed that pain and anxiety associated with IV cannulation were significantly minimized by using either type of local anesthesia. Buffered lidocaine injection reduced venipuncture pain more than lidocaine cream did, without affecting the success of insertion. There were no significant differences in anxiety scores between the use of lidocaine cream or injected buffered lidocaine. Seventy percent of the participants reported that they would always want buffered lidocaine in the future.

Similarly, Burke et al14 compared the efficacy of intrader-mal bacteriostatic normal saline with that of intradermal buffered lidocaine in providing local anesthesia to adult

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patients before IV catheterization. A randomized, dou-ble-blind, parallel-design, quasi-experimental study was conducted on 148 adult patients from the hospital’s same-day surgery unit. The study’s strength was that it tested 2 types of local anesthesia using the same route of adminis-tration, which eliminated other confounding variables. It was determined that intradermal buffered lidocaine was significantly superior to intradermal bacteriostatic normal saline for reducing IV catheterization pain (P = .007).

Hudson et al18 reviewed studies and recommendations related to the use of intradermal lidocaine to reduce pain during arterial punctures. The findings showed that the use of intradermal lidocaine before arterial puncture clearly decreased pain associated with the procedure and did not interfere with the success rate. Overall, intradermal lidocaine injection was more efficacious for reducing procedural pain among the types of local anesthesia tested in those studies.

Intradermal Needleless DeviceA needleless intradermal jet injector (eg, J-Tip; National Medical Products, Irvine, CA) is another type of local anes-thesia used to reduce pain associated with cannulation and ABG sampling. Hajiseyedjavady et al9 conducted a random-ized, controlled clinical trial to compare pain levels from ABG sampling performed with and without application of lidocaine through a jet injector. Forty-two alert and coop-erative volunteers who required ABG sampling as part of their pain management were recruited in the emergency department (ED) of the Imam-Reza Hospital in Tabriz, Iran.

Despite the small sample size, the study showed that the visual analog pain scale score during ABG sampling was con-siderably lower in the treatment group than in the control group. All residents reported ease of use for the lidocaine jet injection procedure (P < .05). Another study by Jimenez et al19 compared the effectiveness of administering 1% buffered lidocaine with a jet injector vs using a topical trans-dermal agent, such as a eutectic mixture of local anesthetics (eg, EMLA; AstraZeneca, Cambridge, United Kingdom) to facilitate IV cannulation and provide adequate analgesia before catheter placement. The study was a randomized, controlled trial of 116 young patients (7-19 years old) at the Children’s Hospital and Regional Medical Centre in Seattle, Washington. The findings showed a statistically significant difference (P = .0001) in the pain ratings during IV cannu-lation between the topical transdermal agent (median = 3) and the jet injector (median = 0), indicating that the jet injector group experienced less pain than the topical trans-dermal agent group.

Interestingly, the jet injector was well tolerated, and the children were not frightened by the “pop” sound produced by the device, in contrast to the researchers’ expectations. It was concluded that applying 1% buffered lidocaine through a jet injector before IV cannulation is not painful and has better anesthetic effectiveness than applying the topical transdermal agent.

In addition, Crowley et al8 conducted a comprehensive literature review to provide evidence-based information for

emergency nurses in terms of reducing pain and distress in pediatric patients undergoing minor invasive procedures in the ED. The study classified the outcomes according to lev-els of recommendation for practice: Level A, High; Level B, Moderate; and Level C, Weak or Not Recommended for Practice. All forms of lidocaine/tetracaine (amethocaine) injections were Level A. The form of lidocaine delivered in the needleless jet injection device was superior to other forms of local anesthesia (Level A).

Topical Local AnesthesiaTopical local anesthesia, such as creams, gels, sprays, and patches, are used to reduce pain associated with needle punctures. Hijazi et al17 examined the effectiveness and safety of a topical alkane vapocoolant spray in reducing pain associated with venous cannulation in adults in an ED. The study used a randomized, double-blind, placebo- controlled approach that involved 201 adult patients in the ED of a metropolitan hospital in Australia. A visual analog scale was used to assess cannulation pain and discomfort induced by the spray; this is a highly discriminant method of assessing pain.

The study showed that application of topical alkane vapocoolant spray less than 15 seconds before cannulation was successful in numbing the area and reducing pain. Median pain scores for IV cannulation in the control and intervention groups were 36 (19-51) mm and 12 (5-40) mm, respectively (P < .001); 59 (60%) and 33 (32%) patients, respectively, reported pain scores ≥ 30 mm (P < .001). The vapocoolant intervention was concluded to be effec-tive, safe, and acceptable for reducing pain associated with peripheral cannulation in adults in the ED.

Similarly, Page and Taylor25 compared the efficacy, acceptability, and safety of a topical vapocoolant alkane spray and 1% subcutaneous lidocaine for reducing pain from IV cannulation. They conducted a nonblinded, ran-domized, controlled trial on a convenience sample of 220 participants (adult and pediatric) from a metropolitan ED. The study findings suggested that although vapocoolant spray was less painful to administer, it was less effective for reducing pain associated with cannulation than lidocaine injection. Vapocoolant spray was associated with greater cannulation success (83.6% vs 67.3%; P = .005), required less time to administer (median 9.0 vs 84.5 seconds; P < .001), and was more convenient for staff (median 5 vs 4; P < .001), although the overall patient satisfaction scores were similar between the groups. They concluded that although lidocaine was superior, vapocoolant spray offered a useful alternative in the ED setting.

Mirzaei et al23 conducted a quasi-experimental study to compare the effect of transdermal cream, lidocaine spray, and ice packs on the intensity of pain experienced with arteriovenous cannulation in hemodialysis patients. The study involved 40 patients > 18 years old in Shahid Rahnemoon Hospital in Iran. Transdermal cream was found to be highly effective for reducing pain intensity compared with lidocaine spray and ice packs (P < .001). Similarly,

94 Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. Journal of Infusion Nursing on behalf of the Infusion Nurses Society.

findings from Crowley and colleagues’ literature review8 included classifications of topical anesthesia that were recommended for management of pain and distress associ-ated with venipuncture, in which vapocoolant spray in the form of ethylvinylchloride was Level C, and pentafluoropro-pane and tetrafluoroethane were Level B.

Papa and Zempsky24 surveyed 2187 nurses from 3 nursing societies in the United States to examine nurses’ attitudes and experiences regarding techniques used to manage venous access pain in pediatric patients. Although the study did not specify which types of topical anesthesia were used in those settings, the findings suggested that topical local anesthesia was considered more effective than nonpharmacological techniques, but was used less often because of concerns about its slow-acting nature. Most nurses (92%) agreed that an effective, fast-acting topical local anesthetic would benefit pediatric patients, their fam-ilies, and the nurses who treat them.

This review has presented common types of local anes-thesia that have been studied for their effectiveness in reducing pain associated with venous and arterial punc-tures. Evidence and recommendations presented in the reviewed studies show the efficacy of local anesthesia for minimizing procedural pain at different levels. Table 1 shows the levels of recommendations for those methods of local anesthesia, as well as some of their characteristics, according to the reviewed literature. Notably, the levels of effectiveness of those methods of local anesthesia in pain reduction, as well as their positive and negative character-istics, are important factors that can influence the use of local anesthesia by nurses.

Additional Strategies for Procedural Pain Management

Application of IceApplication of ice is another technique that can be used by nurses as an alternative method for reducing pain associ-ated with needle-related procedures. Haynes16 conducted a study that investigated whether precooling a puncture site with ice could reduce the pain associated with arterial puncture. A convenience sample of 80 adult outpatients

with a physician’s order for ABG sampling was obtained. The study used a prospective, stratified, randomized, con-trolled trial approach and showed significant reductions in pain in the treatment group (ice application) compared with the control group. This suggested that the application of ice is an effective alternative option for reducing pain associated with arterial puncture because it is noninvasive, nonpharmacologic, inexpensive, and readily available.

Similarly, a previous quasi-experimental study by Rostami et al26 was conducted with 80 children (6-12 years old) in an ED of a pediatric center in Ahwaz, Iran. The study aimed to determine the effect of local application of ice for 3 minutes before venipuncture on pain-related responses in school-aged children. They tested this hypothesis in relation to physiological and psychological variables and found no significant differences in physiological responses before and after procedures between the 2 groups (P = .07). However, behavioral and subjective responses before and after the procedure were lower in the test group (P = .0011 and P = .0097, respectively). The study conclud-ed that the application of ice to the skin before venipunc-ture can be an effective and safe intervention for reducing puncture-related pain.

In addition, Mirzaei et al23 showed that the ice method was effective in reducing pain intensity associated with arteriovenous cannulation in hemodialysis patients; how-ever, it was inferior to transdermal agents. Those previous findings are consistent with the classifications of pain management by Crowley et al8 regarding needle-related procedures recommended for practice, in which the local application of ice for reducing the pain and distress associ-ated with venipuncture was classified as Level B.

Behavioral InterventionBehavioral intervention is an area in nursing care that can be used effectively for pain management in needle-related procedures. Crowley et al8 reported classifications of pain management for needle-related procedures that were recommended for practice. The level of recommenda-tion for a behavioral intervention to reduce the pain and distress associated with venipuncture was classified as Level A because of sufficient evidence-based information

TABLE 1

Effectiveness of Local Anesthesia for Reducing Pain Associated With Venipuncture According to Reviewed LiteratureLocal Anesthetics Level of Recommendation Onset of Effect Disadvantages

Lidocaine jet injector (needleless) High Fast Makes “pop” sound

Intradermal lidocaine High Fast Additional needlestick needed

Intradermal buffered lidocaine High Fast Additional needlestick needed

Vapocoolant alkane spray Moderate Fast Inferior to lidocaine for pain reduction

Transdermal agent (topical mixture of lidocaine and prilocaine)

Moderate Slow acting Long wait time required to produce effect

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supporting the efficacy of cognitive behavioral therapy, breathing exercises, appropriate distractions, and hypnosis. However, Papa and Zempsky24 found that nonpharmacolog-ical techniques, although frequently used by nurses, were perceived by nurses as insufficient in alleviating procedural pain when used alone.

Other Benefits of Local Anesthesia

Facilitation of Successful Needle InsertionsThe use of local anesthesia facilitates successful IV can-nulation and ABG sampling because of the reduction of associated pain and anxiety, which helps patients remain still during the procedure. According to Hudson et al,18 the administration of local anesthesia for ABG sampling was helpful in increasing the success rates of gaining arterial access because it minimizes patient movement during the procedure. Similarly, Crowley et al8 evaluated the success rate of injection and topical anesthetics; all reviewed studies indicated that the success rates were enhanced by the administration of local anesthesia. Furthermore, the administration of topical anesthetics was associated with increased success rates of catheter insertions. Likewise, Hajiseyedjavady et al9 found that the use of jet injectors resulted in a marked reduction of the pain of arterial puncture and contributed to a greater success rate of ABG sampling. They stated that the ABG procedure frequently fails because of the deeper anatomical location of the artery, which causes more pain. This makes it difficult for the patient to hold still during the procedure, which com-plicates the performance of the practitioner. Therefore, Hajiseyedjavady et al9 believed that greater pain relief would lead to more successful sampling.

Improved SatisfactionThe use of local anesthesia for invasive procedures by nurses provides patients with optimal pain management, thus improving patients’ satisfaction and hospital experi-ence. This can have a positive impact on patients’ future well-being. Papa and Zempsky24 examined the impact of managing venous access pain in pediatric patients, accord-ing to the nurses’ perceptions. Ninety-six percent of nurses acknowledged that performing IV cannulation in a fearful and anxious child was challenging. Thus, most nurses (91%) agreed that better-quality pain control improved their sat-isfaction with their job performance, increased their overall job satisfaction (81%), increased positive relationships with patients and families (91%), and had a positive impact on the hospital experience of children and their families (97%).

Furthermore, McNaughton et al22 conducted a study on health care providers (ie, medical students and nurses). The researchers investigated whether participants would want local anesthesia for IV insertion for themselves and their patients. The study showed interesting outcomes, in that many participants were more influenced by personal experience to use local anesthesia for themselves and their patients in the future. In addition, an exploratory study

by Levitt and Ziemba-Davis20 explored the knowledge of patient preferences for pain control during IV cannulation. One aim was to measure patients’ rates of satisfaction with the treatments they chose. Only 4 patients chose the tradi-tional strategy of no pain management. In contrast, 86.6% of participants preferred pain control. All participants in all groups reported that patient involvement in decision making regarding pain management was very important. Patient satisfaction and staff convenience, including the convenience of nurses, regarding the use of local anes-thesia for invasive procedures were measured in some reviewed studies, and the outcomes were satisfactory.9,17,25

Factors Leading to the Low Use Rate of Local Anesthesia

Staff Members’ Underestimation of Procedural PainPain associated with a needle puncture can be perceived as insignificant by health care practitioners, which can hinder the use of local anesthetics by nurses and other health pro-fessionals. Sado and Deakin27 measured the prevalence of local anesthetic use for IV cannulation and ABG sampling by physicians. The authors stated that although many studies recommended the use of local anesthesia for these pro-cedures, previous surveys indicated that ward physicians were more likely than anesthetists to ignore such advice.

The authors sought to determine whether these differ-ences persist. A questionnaire was given to 178 anesthe-tists, physicians, and surgeons in 8 hospitals in the United Kingdom. Although the study was conducted 10 years ago, interestingly, the findings were consistent with the hypoth-esis of that study, in which 60% of anesthetists used local anesthesia for these procedures compared with 2% of ward physicians. Similarly, Hudson et al18 reviewed the literature and recommendations related to the use of intrader-mal lidocaine to decrease pain during arterial punctures. Although some articles reviewed in their study were old, they showed that, except among anesthesia providers, the use of a local anesthetic before arterial puncture was not universal. This is contrary to the standard of practice, which supports the use of local anesthetic to minimize arterial puncture pain. A number of false perceptions may hinder wider use of such anesthetics. Despite differences between physicians and nurses, certain beliefs and attitudes can con-tribute to a similar practice of disregarding the use of local anesthesia for invasive procedures. IV cannulation and ABG sampling, in particular, are performed by nurses in Saudi Arabia, and there is a lack of recommendations for using local anesthesia for these procedures in local practice.1,2

Staff Concerns About Time Taken in Administering Local AnesthesiaTime is a critical factor that can have an impact on nurses’ use of local anesthesia for invasive procedures. Nurses surveyed in a study by Papa and Zempsky24 reported that they used topical local anesthesia in only 29% of cases.

96 Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. Journal of Infusion Nursing on behalf of the Infusion Nurses Society.

One of the reasons most frequently identified was the slow onset of topical anesthetics, which is associated with treatment delays. Likewise, the findings of Czarnecki et al15 showed that the majority of nurses identified insufficient time to premedicate patients before procedures as one of the most common barriers to pediatric pain management. Furthermore, Hijazi et al17 and Page and Taylor25 stated that the application time of topical anesthesia, such as a transdermal agent (45 minutes), is often unacceptable in an acute care environment, where immediate cannulation is required. They studied the practicality of using vapocoolant spray as a fast-acting topical anesthetic in the ED and found that this spray could produce the desired effect within less than 15 seconds after application.17,25 In their literature review, Hudson et al18 suggested that the effectiveness of lidocaine ointment, amethocaine gels, and transdermal creams, as alternatives to intradermal lidocaine, is limited in critical settings because of the lengthy application time required (30-60 minutes) to produce a sufficient effect. The findings concluded that ABG analysis was required in less time than allowed by use of topical anesthetics. As a con-cern related to this issue, Hajiseyedjavady et al9 tested the efficacy of jet injectors for ABG sampling. The findings sug-gested that the jet injector was effective and beneficial in providing rapid anesthesia in less than 6 minutes. Similarly, Jimenez et al19 measured the time from application to can-nulation for both transdermal agents and the jet injector and found that transdermal agents required 69 minutes compared with 1.8 minutes for the jet injector group. Using the jet injector was recommended, especially in emergency or busy situations, when there is insufficient time for the transdermal agents to take effect.

Lack of Physician AuthorizationPhysicians’ orders regarding local anesthesia are an import-ant factor that can hinder use by nurses. A cross-sectional study conducted by Czarnecki et al15 identified barriers that were perceived to interfere with nurses’ abilities to provide optimal pain management in pediatric patients. A survey study was conducted on 272 nurses from the Children’s Hospital of Wisconsin. The most significant barriers iden-tified for optimal pediatric pain management included insufficient physicians’ orders for local anesthesia before procedures (mean 4.98, standard deviation [SD] 2.67; and mean 4.92, SD 2.81, respectively). Furthermore, Papa and Zempsky24 explored nurses’ perceptions of the impact of pain management in pediatric patients. ED nurses were most challenged in terms of pain control and most often resorted to nonpharmacological management. Papa and Zempsky24 stated that because of the rapid responses required in the ED, nurses working in the ED might be less likely to order pain control measures, which requires a phy-sician’s authorization, because of concerns regarding the consequent delay in treatment. Hudson et al18 agreed that the need for a physician’s order to administer local anesthe-sia before arterial access is a barrier that limits the use of

local anesthesia by nurses. Therefore, it was recommended that nurse managers establish standing orders to incorpo-rate the use of local anesthesia (subcutaneous lidocaine) as a standard protocol for obtaining blood samples for ABG analysis.18

The Cost of Local AnesthesiaCost is another factor that contributes to the availability of local anesthesia for nurses. In their review, Hudson et al18 compared the cost of local anesthesia methods and suggested that intradermal lidocaine is inexpensive com-pared with transdermal agents. Transdermal agent patches cost $7 per application, and lidocaine and syringes cost approximately 17 cents, so the additional lidocaine needed for basic ABG sampling requirements would cost less than 20 cents per procedure.18

In addition, Page and Taylor25 calculated the cost of vapocoolant spray and lidocaine subcutaneous injection per patient (in Australian dollars) from the vapocoolant spray retailer and hospital pharmacy department. The cost of 1 can of vapocoolant spray (250 g) was approximately $16.12 AU and provided 70 administrations. Notably, the authors did not state the price of lidocaine. However, although vapocoolant spray was less expensive than lido-caine, it was concluded that both agents were considered inexpensive.

Jimenez et al19 also compared the cost of the jet injector vs transdermal agent per IV insertion in their institution. The cost of the jet injector was $2.10 compared with $2.80 for a transdermal agent. That study recommended the implementation of jet injector local anesthetic as a cost-effective alternative. In addition, Burke et al14 reported that use of a transdermal agent as a topical local anesthesia was inappropriate because of the cost.

DISCUSSION

As illustrated by this review, different forms of local anes-thesia exhibit different levels of effectiveness for reducing the pain associated with IV cannulation and ABG sampling. The level of efficacy of the medication is an important factor to consider when using local anesthesia to provide effective pain management for needle punctures. Other factors can influence nurses’ decisions regarding local anes-thesia use, such as the age of the patient, its practicality in specific clinical settings (critical or noncritical), and type of procedure performed (eg, gaining venous or arterial access). For example, topical anesthetics are commonly used for pediatric patients because children are more anx-ious and less tolerant of needle insertions compared with adult patients.7

According to studies included in this review, jet injection is highly recommended compared with other forms of local anesthesia because it is needleless and penetrates intrader-mally to produce fast-acting pain relief. It is also deemed

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safe and effective. This device works effectively in ABG sampling because the arterial access required is more inva-sive than gaining venous access, and the associated pain is greater. Furthermore, its cost is reasonable. Although McSwain and Yeager29 argued that the concept of this device has gained popularity, it is not yet broadly available.

Transdermal cream is effective for reducing procedural pain. However, it may not be practical in nursing practice because of its slow-acting effect, especially in situations where time is critical. Because of this, the use of fast-acting local anesthetic alternatives can influence nurses’ use of local anesthesia. This would help to eliminate barriers relat-ed to time concerns associated with treatment delay.

In addition, ice can be used by nurses as an alternative method to reduce procedural pain effectively (because it is noninvasive, nonpharmacological, inexpensive, and readily available) and when local anesthesia is not available or is not offered to patients in some settings. Behavioral inter-ventions, which can be partially effective, are often used by nurses to lessen pain associated with needle-related procedures. However, reliance on behavioral interventions alone to relieve pain associated with invasive procedures is insufficient. The use of local anesthesia should be incor-porated into these interventions to provide patients with optimal pain management.

Individuals who have experienced better pain manage-ment with local anesthesia for invasive procedures prefer to have local anesthesia in the future. This observation is important because it can affect future emotional and phys-ical well-being. Despite physicians’ orders that may limit the use of local anesthesia, nurses should take the initiative to help eliminate such barriers by negotiating with medical and nursing directors to establish standing orders or to develop appropriate protocols. Cost was also identified as an important factor that may encourage or hinder the use of local anesthesia.

A concern that may be perceived as a barrier to using local anesthesia injection by nurses is that its adminis-tration can affect successful insertion because it causes subcutaneous wheal formation, obscuring visibility of the blood vessel and subsequently increasing the difficulty of venipuncture. However, evidence from the reviewed studies disproved this. The rates of successful insertions with injectable local anesthesia were satisfactory in those studies. Another potential concern for nurses regarding the use of local anesthesia injections could be the exposure of patients to additional pain as a result of 2 needlesticks. The local anesthetic needlestick is less painful because of the small size of the needle used compared with the procedural needle insertion.27 Alternative modes of local anesthesia, which can be used according to their appropriateness for the situation, such as transdermal agents, vapocoolant sprays, and jet injectors, have been suggested.

Anecdotal evidence suggests that the lack of hospital policies or guidelines can be barriers to the use of local anesthesia for IV cannulation and ABG sampling. This is

the case in the largest tertiary care center in Riyadh, Saudi Arabia. In addition, lack of education or training in nursing education in Saudi Arabia hinders the use of local anesthe-sia for needlesticks. As a consequence, nursing practice is shaped by these factors. Pain relief for needle-related pro-cedures is underestimated in health care in Saudi Arabia, which affects the quality of care available to patients.

Implications for Nursing PracticeNo studies have been conducted in Saudi Arabia that sup-port the use of local anesthesia for venous and arterial needle punctures to date. The research findings presented in this article add to knowledge regarding factors that have an impact on the use of local anesthesia for vascular access. Identifying these factors from an international perspective provides a valuable understanding of the issue at a local level, which may help policy makers develop strategies to improve the quality of nursing practice. This review was undertaken to benefit society to improve the quality of health care and enhance patients’ satisfaction and hospital experience, as well as prevent physical, psychological, and economic concerns.

CONCLUSION

Factors that can have an impact on the use and availability of local anesthesia by nurses were identified in this review. These include (1) the level of effectiveness among types of local anesthesia; (2) underestimating pain associated with catheter insertion, time for administration, and onset of action, especially in critical settings; (3) lack of provider authorization; and (4) cost. The absence of hospital policies and a lack of education or training also influence the use of local anesthesia because nursing practice is shaped by these organizational guidelines. A core responsibility of nursing is to alleviate pain and advocate for patients’ best interests. This review informs stakeholders about the gap in nursing practice in Saudi Arabia as substantiated by the recommendations and evidence in the literature.

ACKNOWLEDGMENTS

The author would like to acknowledge the support provided by Flinders University in South Australia and the Research Centre at King Saud Medical City in Riyadh, Saudi Arabia. Special thanks to P.J. Parameaswari, PhD, for her constructive feedback.

REFERENCES

1. Ministry of Health, General Directorate of Nursing. Manual of Nursing Policies and Procedures. Critical Care Nursing. 2nd ed. https://www.moh.gov.sa/depts/NursingDepts/Policiesandprocedures/Inhospitals/Documents/CCN.pdf. Accessed March 27, 2018.

2. Ministry of Health, General Directorate of Nursing. Manual of Nursing Policies and Procedures. Emergency Care. 2nd ed. https://www.moh.gov.sa/depts/NursingDepts/Policiesandprocedures/Inhospitals/Documents/ERDN.pdf. Accessed March 27, 2018.

98 Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. Journal of Infusion Nursing on behalf of the Infusion Nurses Society.

3. Logothesis DD. Local anesthesia in dental hygiene practice: an intro-duction. In: Nathe CN, ed. Local Anesthesia for the Dental Hygienist. St. Louis, MO: Elsevier/Mosby; 2016.

4. Malamed SF. Handbook of Local Anesthesia. Maryland Heights, MO: Mosby/Elsevier Health Sciences; 2014.

5. Phillips S, Collins M, Dougherty L, eds. Venepuncture and Cannulation. Chichester, UK: Wiley; 2011.

6. Yee K, Shetty AL, Lai K. ABG needle study: a randomised control study comparing 23G versus 25G needle success and pain scores. Emerg Med J. 2015;32(5):343-347.

7. McMurtry CM, Pillai Riddell R, Taddio A, et al. Far from “just a poke”: common painful needle procedures and the development of needle fear. Clin J Pain. 2015;31(10 suppl):S3-S11.

8. Crowley MA, Storer A, Heaton K, et al. Emergency nursing resource: needle-related procedural pain in pediatric patients in the emergency department. J Emerg Nurs. 2011;37(3):246-251.

9. Hajiseyedjavady H, Saeedi M, Eslami V, Shahsavarinia K, Farahmand S. Less painful arterial blood gas sampling using jet injection of 2% lidocaine: a randomized controlled clinical trial. Am J Emerg Med. 2012;30(7):1100-1104.

10. Damrell R. Database Syntax Guide for Systematic Reviews. Bedford Park, Australia: Flinders University Library; 2016.

11. Critical Appraisal Skills Programme. 11 questions to help you make sense of a trial. http://media.wix.com/ugd/dded87_40b9ff0bf53840478331 915a8ed8b2fb.pdf. Updated May 31, 2013. Accessed March 20, 2018.

12. Center for Evidence-Based Management. Critical appraisal of a cross-sectional study (survey). https://www.cebma.org/wp-content/uploads/Critical-Appraisal-Questions-for-a-Cross-Sectional-Study-july-2014.pdf. Accessed March 20, 2018.

13. Critical Appraisal Skills Programme. 11 questions to help you make sense of a review. http://media.wix.com/ugd/dded87_a02ff2e3445f4952992d5a96ca562576.pdf. Updated May 31, 2013. Accessed March 20, 2018.

14. Burke SD, Vercler SJ, Bye RO, Desmond PC, Rees YW. Local anesthesia before IV catheterization. Am J Nurs. 2011;111(2):40-47.

15. Czarnecki ML, Simon K, Thompson JJ, et al. Barriers to pediatric pain management: a nursing perspective. Pain Manag Nurs. 2011;12(3): 154-162.

16. Haynes JM. Randomized controlled trial of cryoanalgesia (ice bag) to reduce pain associated with arterial puncture. Resp Care. 2015;60 (1):1-5.

17. Hijazi R, Taylor D, Richardson J. Effect of topical alkane vapocoolant spray on pain with intravenous cannulation in patients in emergency departments: randomised double blind placebo controlled trial. BMJ. 2009;338:b215. doi:https://doi.org/10.1136/bmj.b215.

18. Hudson TL, Dukes SF, Reilly K. Use of local anesthesia for arterial punc-tures. Am J Crit Care. 2006;15(6):595-599.

19. Jimenez N, Bradford H, Seidel KD, Sousa M, Lynn AM. A comparison of a needle-free injection system for local anesthesia versus EMLA® for intra-venous catheter insertion in the pediatric patient. Anesth Analg. 2006; 102(2):411-414.

20. Levitt FC, Ziemba-Davis M. An exploratory study of patient prefer-ences for pain management during intravenous insertion: maybe we should sweat the small stuff. J Perianesth Nurs. 2013;28(4):223-232.

21. Matheson L, Stephenson M, Huber B. Reducing pain associated with arterial punctures for blood gas analysis. Pain Manag Nursing. 2014;15(3):619-624.

22. McNaughton C, Zhou C, Robert L, Storrow A, Kennedy R. A random-ized, crossover comparison of injected buffered lidocaine, lidocaine cream, and no analgesia for peripheral intravenous cannula insertion. Ann Emerg Med. 2009;54(2):214-220.

23. Mirzaei S, Javadi M, Eftekhari A, Hatami M, Hemayati R. Investigation of the effect of EMLA cream, lidocaine spray, and ice pack on the arte-riovenous fistula cannulation pain intensity in hemodialysis patients. Health Sci. 2018;7(2):51-57.

24. Papa A, Zempsky W. Nurse perceptions of the impact of pediatric peripheral venous access pain on nurse and patient satisfaction. Adv Emerg Nurs J. 2010;32(3):226-233.

25. Page DE, Taylor DM. Vapocoolant spray vs subcutaneous lidocaine injection for reducing the pain of intravenous cannulation: a random-ized, controlled, clinical trial. Br J Anaesth. 2010;105(4):519-525.

26. Rostami S, Salsali M, Keikhaee B, Moradi A. Effect of local refrigeration prior to venipuncture on pain related responses in school age chil-dren. Aust J Adv Nurs. 2006;24(2):51-55.

27. Sado DM, Deakin CD. Local anaesthesia for venous cannulation and arte-rial blood gas sampling: are physicians using it?J R Soc Med. 2005;98(4): 158-160.

28. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77-101.

29. McSwain SD, Yeager BE. Is there an easy, effective, efficient, and inex-pensive technique to reduce pain of arterial punctures?Resp Care. 2015; 60(1):141-143.

VOLUME 42 | NUMBER 2 | MARCH/APRIL 2019 journalofinfusionnursing.com 99

AP

PE

ND

IX 1

Lite

ratu

re R

evie

w

Aut

hor

and

Dat

eA

im/O

bjec

tive

Sam

ple

and

Sett

ing

Met

hods

and

M

etho

dolo

gyM

ajor

Fin

ding

sLi

mit

atio

ns a

nd R

igor

/Va

lidit

ySi

gnifi

canc

e to

the

Is

sue

Burk

e et

al,

2011

14Th

e pu

rpos

e of

the

stu

dy

was

to c

ompa

re t

he

effic

acy

of in

trad

erm

al

bact

erio

stat

ic n

orm

al

salin

e w

ith t

hat

of

intr

ader

mal

buf

fere

d lid

ocai

ne in

pro

vidi

ng

loca

l ane

sthe

sia

to

adul

t pa

tient

s be

fore

IV

cath

eter

izat

ion.

148

adul

ts (M

= 2

6,

F =

48

each

gro

up)

from

the

res

earc

h-er

’s ho

spita

l sam

e-da

y su

rger

y un

it

Qua

ntita

tive

Rand

omiz

ed,

doub

le-b

lind,

pa

ralle

l-des

ign,

qua

si-

expe

rimen

tal s

tudy

Intr

ader

mal

buf

fere

d lid

ocai

ne

was

dem

onst

rate

d to

be

sign

ifi-

cant

ly s

uper

ior

to in

trad

erm

al

bact

erio

stat

ic n

orm

al s

alin

e in

re

duci

ng t

he p

ain

of IV

cat

he-

teriz

atio

n (P

= .0

07).

Larg

e sa

mpl

e.Pr

actic

e se

ttin

g w

as n

ot

iden

tifie

d.A

skill

ed in

fusi

on n

urse

pe

rfor

med

the

pro-

cedu

re, w

hich

cou

ld

lead

to a

mis

sing

co

nfou

ndin

g va

riabl

e of

diff

eren

t ski

lls a

nd

expe

rienc

e of

a g

roup

of

pro

fess

iona

ls.

Two

type

s of

loca

l ane

s-th

esia

wer

e te

sted

us

ing

the

sam

e ro

ute

of a

dmin

istr

atio

n,

whi

ch e

limin

ated

oth

er

varia

bles

tha

t co

uld

affe

ct t

he o

utco

mes

.

Two

type

s of

loca

l ane

s-th

esia

wer

e te

sted

, w

hich

pro

vide

d a

use-

ful c

ompa

rison

am

ong

othe

r ty

pes

used

for

the

sam

e pu

rpos

e of

re

duci

ng p

roce

dura

l pa

in. T

his

can

help

de

term

ine

thei

r pr

acti-

calit

y an

d co

nven

ienc

e in

nur

sing

pra

ctic

e.

Crow

ley

et a

l, 20

118

The

purp

ose

of t

he s

tudy

w

as to

add

to t

he

deve

lopm

ent

of e

mer

-ge

ncy

nurs

ing

reso

urce

s ev

iden

ce-b

ased

info

r-m

atio

n re

gard

ing

pain

an

d di

stre

ss r

educ

tion

in p

edia

tric

pat

ient

s du

ring

min

or in

vasi

ve

proc

edur

es in

the

ED

.

Com

preh

ensi

ve li

tera

-tu

re r

evie

wTh

e au

thor

s us

ed s

tan-

dard

ized

wor

kshe

ets,

in

clud

ing

the

Evid

ence

-Ap

prai

sal T

able

Te

mpl

ate,

Crit

ique

W

orks

heet

, and

the

Ag

ree

Wor

kshe

et to

pr

epar

e ta

bles

of e

vi-

denc

e ra

nkin

g ea

ch

artic

le in

term

s of

the

le

vel o

f evi

denc

e, t

he

qual

ity o

f evi

denc

e,

and

its r

elev

ance

an

d ap

plic

abili

ty to

pr

actic

e.

Cate

gorie

s of

effe

ctiv

enes

s fo

r pa

in re

lief a

re ra

nked

as

follo

ws:

1. B

iobe

havi

oral

inte

rven

tions

. (L

evel

A: H

igh)

.2.

Der

mal

ane

sthe

tic: V

apoc

oola

nt

spra

y.i.

Ethy

l vin

yl c

hlor

ide

(Lev

el C

: W

eak)

. ii.

Pen

taflu

orop

ropa

ne a

nd

tetr

aflu

oroe

than

e (L

evel

B:

Mod

erat

e).

iii. A

ll tr

ansd

erm

al fo

rms

of

lidoc

aine

/tet

raca

ine

(am

etho

-ca

ine)

(Lev

el B

: Mod

erat

e).

3. S

ubde

rmal

loca

l ane

sthe

tic

with

nee

dlel

ess

deliv

ery

(eg,

jet

inje

ctio

n de

vice

) as

a de

liver

y m

etho

d fo

r lid

ocai

ne is

sup

erio

r to

oth

er fo

rms

of p

repa

ratio

n (L

evel

A: H

igh)

.4.

Loc

al a

pplic

atio

n of

ice

(Lev

el B

: M

oder

ate)

.5.

Pac

ifier

s an

d su

cros

e fo

r in

fant

s 0-

3 m

onth

s:i.

Paci

fiers

(Lev

el B

: Mod

erat

e).

ii. S

ucro

se (L

evel

C: W

eak)

.

Seco

ndar

y so

urce

.Pr

actic

e se

ttin

g w

as n

ot

iden

tifie

d.

Prov

ided

leve

ls o

f rec

-om

men

datio

ns fo

r di

ffere

nt t

ypes

of

pain

man

agem

ent

for

need

le-r

elat

ed

proc

edur

es in

chi

ldre

n ba

sed

on e

vide

nce

rank

ing,

whi

ch c

an

help

sup

port

the

st

udy

of t

heir

effe

c-tiv

enes

s. F

acto

rs t

hat

cont

ribut

ed to

suc

h co

nclu

sion

s in

thi

s st

udy

are

impo

rtan

t to

re

sear

ch b

ecau

se t

hey

can

influ

ence

the

use

of

loca

l ane

sthe

tics

by

nurs

es.

(con

tinue

s)

100 Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. Journal of Infusion Nursing on behalf of the Infusion Nurses Society.

AP

PE

ND

IX 1

Lite

ratu

re R

evie

w (

Cont

inue

d)

Aut

hor

and

Dat

eA

im/O

bjec

tive

Sam

ple

and

Sett

ing

Met

hods

and

M

etho

dolo

gyM

ajor

Fin

ding

sLi

mit

atio

ns a

nd R

igor

/Va

lidit

ySi

gnifi

canc

e to

the

Is

sue

Czar

neck

i et

al,

2011

15Th

e st

udy

aim

ed to

iden

-tif

y ba

rrie

rs p

erce

ived

as

inte

rfer

ing

with

RN

s’

abili

ty to

pro

vide

opt

i-m

al p

edia

tric

pai

n m

an-

agem

ent.

272

of 9

70 s

urve

ys

wer

e re

turn

ed fr

om

RNs

(F =

226

, M

= 6

)Ch

ildre

n’s

Hos

pita

l of

Wis

cons

in is

a p

edi-

atric

teac

hing

hos

pi-

tal i

n so

uthe

aste

rn

Wis

cons

in.

Qua

ntita

tive,

cr

oss-

sect

iona

l des

ign

The

5 m

ost

sign

ifica

nt b

arrie

rs

iden

tifie

d w

ere

insu

ffic

ient

or

ders

, ins

uffic

ient

phy

sici

an

orde

rs b

efor

e pr

oced

ures

, in

suff

icie

nt t

ime

to p

rem

edic

ate

patie

nts

befo

re p

roce

dure

s, t

he

perc

eptio

n th

at p

ain

man

age-

men

t by

med

ical

sta

ff is

a lo

w

prio

rity,

and

par

ents

’ rel

ucta

nce

to h

ave

patie

nts

rece

ive

pain

m

edic

atio

n.Ad

ditio

nal b

arrie

rs w

ere

iden

tifie

d th

roug

h na

rrat

ive

com

men

ts.

Larg

e sa

mpl

e si

ze.

Nur

ses

wer

e fr

om a

sin

gle

sett

ing.

The

stud

y pr

ovid

ed

deta

iled

desc

riptio

n of

da

ta.

The

maj

ority

of p

artic

-ip

ants

wer

e fe

mal

e,

whi

ch c

ould

sho

w b

ias

resp

onse

s; h

owev

er,

this

may

ref

lect

the

re

ality

of t

he n

ursi

ng

popu

latio

n, in

whi

ch

the

maj

ority

oft

en a

re

fem

ale.

Alth

ough

thi

s st

udy

is

limite

d to

ped

iatr

ics

and

is n

ot s

peci

fical

ly

abou

t lo

cal a

nes-

thet

ics,

it id

entif

ied

impo

rtan

t fa

ctor

s fr

om

nurs

es’ p

ersp

ectiv

es

that

are

bar

riers

to

optim

al p

ain

man

-ag

emen

t, w

hich

are

us

eful

to t

he r

esea

rch.

In

add

ition

, the

use

of

topi

cal a

nalg

esic

s fo

r pr

oced

ural

pai

n w

as

invo

lved

as

part

of t

his

stud

y, w

hich

is r

ele-

vant

to t

he r

esea

rch.

Hay

nes,

201

516Th

e st

udy

inve

stig

ated

w

heth

er a

pplic

atio

n of

ic

e to

the

pun

ctur

e si

te

coul

d re

duce

the

pai

n as

soci

ated

with

art

eria

l pu

nctu

re.

Conv

enie

nce

sam

ple

of 8

0 ad

ult

outp

a-tie

nts

with

a p

hy-

sici

an o

rder

for

an

ABG

test

Qua

ntita

tive,

pro

spec

tive,

st

ratif

ied,

rand

omiz

ed,

cont

rolle

d tr

ial

Sign

ifica

nt r

educ

tion

of p

ain

in t

he

trea

tmen

t gro

up c

ompa

red

with

th

e co

ntro

l gro

up. (

Mea

n vi

sual

an

alog

sca

le 1

3.8 ±

16.

9 vs

25

± 2

3 m

m, P

= .0

1; m

edia

n vi

sual

ana

log

scal

e 7

mm

, IQ

R 1.

5–19

vs

20 m

m; I

QR

4.5–

38.5

m

m, P

= .0

1).

Onl

y 3

subj

ects

wer

e un

able

to

tole

rate

3-m

in ic

e ap

plic

atio

n.

Rece

nt s

tudy

.Pr

actic

e se

ttin

g w

as n

ot

iden

tifie

d.A

sing

le p

hleb

otom

ist

drew

all

ABG

s, s

o th

ere

mig

ht b

e a

mis

sing

co

nfou

ndin

g va

riabl

e be

caus

e a

grou

p of

pr

ofes

sion

als

with

var

-io

us s

kills

and

exp

eri-

ence

was

not

invo

lved

.

Appl

icat

ion

of ic

e is

an

othe

r te

chni

que

that

can

be

used

by

RNs

as a

n al

tern

ativ

e fo

r pr

oced

ural

pai

n re

duct

ion

beca

use

it is

non

inva

sive

, non

-ph

arm

acol

ogic

, ine

x-pe

nsiv

e, a

nd r

eadi

ly

avai

labl

e, e

spec

ially

w

hen

loca

l ane

sthe

sia

is n

ot a

vaila

ble

or is

no

t of

fere

d to

pat

ient

s in

som

e se

ttin

gs.

(con

tinue

s)

VOLUME 42 | NUMBER 2 | MARCH/APRIL 2019 journalofinfusionnursing.com 101

AP

PE

ND

IX 1

Lite

ratu

re R

evie

w (

Cont

inue

d)

Aut

hor

and

Dat

eA

im/O

bjec

tive

Sam

ple

and

Sett

ing

Met

hods

and

M

etho

dolo

gyM

ajor

Fin

ding

sLi

mit

atio

ns a

nd R

igor

/Va

lidit

ySi

gnifi

canc

e to

the

Is

sue

Czar

neck

i et

al,

2011

15Th

e st

udy

aim

ed to

iden

-tif

y ba

rrie

rs p

erce

ived

as

inte

rfer

ing

with

RN

s’

abili

ty to

pro

vide

opt

i-m

al p

edia

tric

pai

n m

an-

agem

ent.

272

of 9

70 s

urve

ys

wer

e re

turn

ed fr

om

RNs

(F =

226

, M

= 6

)Ch

ildre

n’s

Hos

pita

l of

Wis

cons

in is

a p

edi-

atric

teac

hing

hos

pi-

tal i

n so

uthe

aste

rn

Wis

cons

in.

Qua

ntita

tive,

cr

oss-

sect

iona

l des

ign

The

5 m

ost

sign

ifica

nt b

arrie

rs

iden

tifie

d w

ere

insu

ffic

ient

or

ders

, ins

uffic

ient

phy

sici

an

orde

rs b

efor

e pr

oced

ures

, in

suff

icie

nt t

ime

to p

rem

edic

ate

patie

nts

befo

re p

roce

dure

s, t

he

perc

eptio

n th

at p

ain

man

age-

men

t by

med

ical

sta

ff is

a lo

w

prio

rity,

and

par

ents

’ rel

ucta

nce

to h

ave

patie

nts

rece

ive

pain

m

edic

atio

n.Ad

ditio

nal b

arrie

rs w

ere

iden

tifie

d th

roug

h na

rrat

ive

com

men

ts.

Larg

e sa

mpl

e si

ze.

Nur

ses

wer

e fr

om a

sin

gle

sett

ing.

The

stud

y pr

ovid

ed

deta

iled

desc

riptio

n of

da

ta.

The

maj

ority

of p

artic

-ip

ants

wer

e fe

mal

e,

whi

ch c

ould

sho

w b

ias

resp

onse

s; h

owev

er,

this

may

ref

lect

the

re

ality

of t

he n

ursi

ng

popu

latio

n, in

whi

ch

the

maj

ority

oft

en a

re

fem

ale.

Alth

ough

thi

s st

udy

is

limite

d to

ped

iatr

ics

and

is n

ot s

peci

fical

ly

abou

t lo

cal a

nes-

thet

ics,

it id

entif

ied

impo

rtan

t fa

ctor

s fr

om

nurs

es’ p

ersp

ectiv

es

that

are

bar

riers

to

optim

al p

ain

man

-ag

emen

t, w

hich

are

us

eful

to t

he r

esea

rch.

In

add

ition

, the

use

of

topi

cal a

nalg

esic

s fo

r pr

oced

ural

pai

n w

as

invo

lved

as

part

of t

his

stud

y, w

hich

is r

ele-

vant

to t

he r

esea

rch.

Hay

nes,

201

516Th

e st

udy

inve

stig

ated

w

heth

er a

pplic

atio

n of

ic

e to

the

pun

ctur

e si

te

coul

d re

duce

the

pai

n as

soci

ated

with

art

eria

l pu

nctu

re.

Conv

enie

nce

sam

ple

of 8

0 ad

ult

outp

a-tie

nts

with

a p

hy-

sici

an o

rder

for

an

ABG

test

Qua

ntita

tive,

pro

spec

tive,

st

ratif

ied,

rand

omiz

ed,

cont

rolle

d tr

ial

Sign

ifica

nt r

educ

tion

of p

ain

in t

he

trea

tmen

t gro

up c

ompa

red

with

th

e co

ntro

l gro

up. (

Mea

n vi

sual

an

alog

sca

le 1

3.8 ±

16.

9 vs

25

± 2

3 m

m, P

= .0

1; m

edia

n vi

sual

ana

log

scal

e 7

mm

, IQ

R 1.

5–19

vs

20 m

m; I

QR

4.5–

38.5

m

m, P

= .0

1).

Onl

y 3

subj

ects

wer

e un

able

to

tole

rate

3-m

in ic

e ap

plic

atio

n.

Rece

nt s

tudy

.Pr

actic

e se

ttin

g w

as n

ot

iden

tifie

d.A

sing

le p

hleb

otom

ist

drew

all

ABG

s, s

o th

ere

mig

ht b

e a

mis

sing

co

nfou

ndin

g va

riabl

e be

caus

e a

grou

p of

pr

ofes

sion

als

with

var

-io

us s

kills

and

exp

eri-

ence

was

not

invo

lved

.

Appl

icat

ion

of ic

e is

an

othe

r te

chni

que

that

can

be

used

by

RNs

as a

n al

tern

ativ

e fo

r pr

oced

ural

pai

n re

duct

ion

beca

use

it is

non

inva

sive

, non

-ph

arm

acol

ogic

, ine

x-pe

nsiv

e, a

nd r

eadi

ly

avai

labl

e, e

spec

ially

w

hen

loca

l ane

sthe

sia

is n

ot a

vaila

ble

or is

no

t of

fere

d to

pat

ient

s in

som

e se

ttin

gs.

(con

tinue

s)

AP

PE

ND

IX 1

Lite

ratu

re R

evie

w (

Cont

inue

d)

Aut

hor

and

Dat

eA

im/O

bjec

tive

Sam

ple

and

Sett

ing

Met

hods

and

M

etho

dolo

gyM

ajor

Fin

ding

sLi

mit

atio

ns a

nd R

igor

/Va

lidit

ySi

gnifi

canc

e to

the

Is

sue

Haj

isey

edja

vady

et

al,

2012

9Th

e ai

m o

f the

stu

dy w

as

to c

ompa

re p

ain

leve

ls

from

ABG

sam

plin

g pe

r-fo

rmed

with

or

with

out

appl

icat

ion

of li

doca

ine

thro

ugh

an in

trad

erm

al

jet

inje

ctor

.

42 a

lert

and

coo

p-er

ativ

e vo

lunt

eers

re

quiri

ng A

BG s

am-

ple

as p

art

of t

heir

man

agem

ent

in

the

EDG

roup

A v

s G

roup

B

(M =

15

and

F =

6

vs M

= 1

0 an

d F =

11)

Imam

-Rez

a H

ospi

tal i

n Ta

briz

, Ira

n

Qua

ntita

tive,

rand

omiz

ed,

cont

rolle

d cl

inic

al t

rial

The

pain

vis

ual a

nalo

g sc

ale

scor

e du

ring

ABG

sam

plin

g w

as

cons

ider

ably

low

er in

gro

up A

co

mpa

red

with

gro

up B

(1.2

9 ±

0.

90 v

s 4.

19 ±

1.4

3; P

< .0

01).

The

num

ber

of a

ttem

pts

requ

ired

for

ABG

was

sig

nific

antly

low

er

in g

roup

A c

ompa

red

with

gr

oup

B (1

.29 ±

0.4

6 vs

2.1

±

0.12

; P =

.009

).Al

l res

iden

ts r

epor

ted

ease

of u

se

with

the

lido

cain

e je

t in

ject

ion

proc

edur

e (P

< .0

5).

Smal

l sam

ple.

The

cont

rol g

roup

re

ceiv

ed a

con

vent

iona

l m

etho

d of

mild

loca

l an

esth

esia

; how

ever

, it

was

not

exp

lain

ed w

hy

this

was

don

e.Co

ntra

dict

ory

info

rma-

tion

prov

ided

in t

he

abst

ract

abo

ut t

he

met

hod

(app

licat

ion

of

loca

l ane

sthe

sia

5 m

in

befo

re t

he p

roce

dure

).

Alth

ough

the

re w

as n

o nu

rsin

g in

volv

emen

t in

th

is s

tudy

in w

hich

ED

re

side

nts

perf

orm

ed

the

proc

edur

e, t

he

stud

y co

mpa

red

the

use

of a

jet

inje

ctor

de

vice

with

oth

er

type

s of

loca

l ane

s-th

esia

. Thi

s st

udy

has

rele

vant

asp

ects

th

at m

ay in

fluen

ce

the

use

of t

his

devi

ce

by n

urse

s, s

uch

as

adm

inis

trat

ion

time,

su

cces

sful

inse

rtio

n,

and

conv

enie

nce.

Hija

zi e

t al

, 20

0917

The

auth

ors

exam

ined

the

ef

fect

iven

ess

and

safe

ty

of u

sing

a to

pica

l alk

ane

vapo

cool

ant

spra

y in

re

duci

ng p

ain

asso

ciat

-ed

with

ven

ous

cann

ula-

tion

in a

dults

in E

Ds.

201

adul

t pa

tient

s in

th

e ED

of a

met

-ro

polit

an te

achi

ng

hosp

ital i

n Au

stra

lia

Qua

ntita

tive

appr

oach

Rand

omiz

ed d

oubl

e-

blin

d, p

lace

bo-

cont

rolle

d tr

ial

Med

ian

pain

sco

res

for

cann

ula-

tion

in t

he c

ontr

ol a

nd in

ter-

vent

ion

grou

ps w

ere

36 (1

9-51

) an

d 12

(5-4

0) m

m, r

espe

ctiv

ely

(P <

.001

), an

d 59

(60%

) and

33

(32%

) rep

orte

d pa

in s

core

s ≥

30

mm

(P <

.001

). Su

cces

s ra

tes

for

first

can

nula

tion

atte

mpt

did

not

diff

er b

etw

een

grou

ps (P

= .3

9).

39%

and

62%

pat

ient

s sa

id t

hey

wou

ld c

hoos

e th

e sp

ray

they

re

ceiv

ed fo

r an

alge

sia

in t

he

futu

re (P

= .0

02).

Topi

cal a

lkan

e va

poco

olan

t sp

ray

is e

ffect

ive,

saf

e, a

nd a

ccep

tabl

e in

red

ucin

g ca

nnul

atio

n pa

in

(less

tha

n 15

s o

f app

licat

ion)

in

adul

ts in

ED

.

Larg

e sa

mpl

e si

ze.

Pote

ntia

l con

foun

d-er

s w

ere

mea

sure

d to

ens

ure

accu

rate

ou

tcom

es.

Visu

al a

nalo

g sc

ale

was

us

ed, w

hich

is a

hig

hly

disc

rimin

ant

met

hod

of

asse

ssin

g pa

in.

Clea

r an

d de

taile

d in

for-

mat

ion

was

pro

vide

d th

at e

xpre

sses

rel

iabi

li-ty

of t

he s

tudy

.

Alth

ough

it w

as e

xclu

sive

to

onl

y 1

type

of l

ocal

an

esth

esia

, thi

s st

udy

help

s su

ppor

t th

e ev

i-de

nce

of v

apoc

oola

nt

spra

y ef

fect

iven

ess

in

redu

cing

pai

n as

so-

ciat

ed w

ith v

enou

s ca

nnul

atio

n.It

is a

lso

bene

ficia

l to

com

pare

with

oth

er

type

s of

loca

l ane

sthe

-si

a th

at a

re u

sed

for

the

sam

e pu

rpos

e to

ex

amin

e as

pect

s th

at

can

influ

ence

nur

ses’

us

e, s

uch

as le

vel o

f ef

fect

iven

ess

and

onse

t of

act

ion.

(con

tinue

s)

102 Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. Journal of Infusion Nursing on behalf of the Infusion Nurses Society.

AP

PE

ND

IX 1

Lite

ratu

re R

evie

w (

Cont

inue

d)

Aut

hor

and

Dat

eA

im/O

bjec

tive

Sam

ple

and

Sett

ing

Met

hods

and

M

etho

dolo

gyM

ajor

Fin

ding

sLi

mit

atio

ns a

nd R

igor

/Va

lidit

ySi

gnifi

canc

e to

the

Is

sue

Hud

son

et a

l, 20

0618

The

purp

ose

of t

he s

tudy

w

as to

rev

iew

rec

om-

men

datio

ns a

nd s

tudi

es

rela

ted

to t

he u

se o

f in

trad

erm

al li

doca

ine

to d

ecre

ase

pain

dur

ing

arte

rial p

unct

ures

.

Lite

ratu

re r

evie

wA

syst

emat

ic c

om-

pute

rized

sea

rch

of M

EDLI

NE

(198

0-Ja

nuar

y 20

06)

Exce

pt a

mon

g an

esth

esia

pro

-vi

ders

, the

use

of a

loca

l ane

s-th

esia

bef

ore

arte

rial p

unct

ure

is n

ot u

nive

rsal

, con

trar

y to

th

e st

anda

rd o

f pra

ctic

e. A

nu

mbe

r of

fals

e pe

rcep

tions

m

ay p

reve

nt w

ider

use

of s

uch

anes

thet

ics.

Seco

ndar

y so

urce

.Pr

actic

e se

ttin

g w

as n

ot

iden

tifie

d.

Alth

ough

the

rev

iew

sp

ecifi

ed 1

typ

e of

lo

cal a

nest

hesi

a an

d so

me

revi

ewed

art

icle

s ar

e co

nsid

ered

old

, it

expl

ored

man

y fa

ctor

s th

at c

an in

fluen

ce t

he

use

of lo

cal a

nest

hesi

a by

nur

ses,

suc

h as

st

anda

rd o

f pra

ctic

e,

effe

ctiv

enes

s of

intr

a-de

rmal

lido

cain

e, to

pi-

cal a

nest

hesi

a, b

arrie

rs

of u

se, e

ffect

on

succ

essf

ul in

sert

ion,

an

d co

st.

Jimen

ez e

t al

, 20

0619

The

stud

y ai

med

to c

om-

pare

the

effe

ctiv

enes

s of

1%

buf

fere

d lid

ocai

ne

with

an

intr

ader

mal

je

t in

ject

or v

s a

topi

cal

tran

sder

mal

age

nt, (

eg,

EMLA

) to

faci

litat

e IV

ca

nnul

atio

n an

d pr

ovid

e ad

equa

te a

nalg

esia

be

fore

IV p

lace

men

t.

116

youn

g pa

tient

s (7

-19

y ol

d)To

pica

l tra

nsde

rmal

ag

ent

grou

p =

59

Intr

ader

mal

jet

inje

c-to

r gr

oup =

57

Child

ren’

s H

ospi

tal a

nd

Regi

onal

Med

ical

Ce

nter

in S

eatt

le,

Was

hing

ton

Qua

ntita

tive

Rand

omiz

ed, c

ontr

olle

d tr

ial

Ther

e w

as a

sig

nific

ant

diffe

renc

e in

pai

n ra

tings

(P =

.000

1)

durin

g IV

can

nula

tion

betw

een

the

topi

cal t

rans

derm

al a

gent

(m

edia

n =

3) a

nd t

he in

trad

er-

mal

jet

inje

ctor

(med

ian =

0).

84%

of p

atie

nts

repo

rted

no

pain

at

the

tim

e of

the

intr

ader

mal

je

t in

ject

or li

doca

ine

appl

ica-

tion

com

pare

d w

ith 6

1% in

the

to

pica

l tra

nsde

rmal

age

nt g

roup

at

the

tim

e of

dre

ssin

g re

mov

al

(P =

.004

).N

o di

ffere

nces

wer

e fo

und

in

the

num

ber

of a

ttem

pts

for

IV

cann

ulat

ion.

Intr

ader

mal

jet

inje

ctor

app

lica-

tion

of 1

% b

uffe

red

lidoc

aine

be

fore

IV c

annu

latio

n is

not

pa

infu

l and

has

bet

ter

anes

thet

-ic

effe

ctiv

enes

s co

mpa

red

with

a

topi

cal t

rans

derm

al a

gent

.

Larg

e sa

mpl

e.La

ck o

f con

trol

gro

up w

as

not

expl

aine

d in

the

st

udy.

Blin

ding

of s

tudy

per

son-

nel w

as n

ot p

rovi

ded.

This

stu

dy is

use

ful t

o th

e re

sear

ch to

pic

beca

use

it te

sted

an

intr

ader

-m

al je

t in

ject

or lo

cal

anes

thet

ic a

gain

st a

to

pica

l tra

nsde

rmal

ag

ent

to m

easu

re t

he

effe

ctiv

enes

s be

twee

n bo

th, a

nd it

mea

sure

d re

leva

nt a

spec

ts, s

uch

as s

ucce

ssfu

l ins

er-

tion

rate

, tim

e, a

nd

conv

enie

nce.

It a

lso

test

ed t

he h

ypot

hesi

s th

at c

hild

ren

wou

ld

be fr

ight

ened

by

the

pop

soun

d, y

et t

he

oppo

site

was

pro

ven.

Al

l of t

hese

res

ults

ar

e fa

ctor

s th

at c

ould

in

fluen

ce t

he u

se o

f lo

cal a

nest

hetic

s by

nu

rses

.

(con

tinue

s)

VOLUME 42 | NUMBER 2 | MARCH/APRIL 2019 journalofinfusionnursing.com 103

AP

PE

ND

IX 1

Lite

ratu

re R

evie

w (

Cont

inue

d)

Aut

hor

and

Dat

eA

im/O

bjec

tive

Sam

ple

and

Sett

ing

Met

hods

and

M

etho

dolo

gyM

ajor

Fin

ding

sLi

mit

atio

ns a

nd R

igor

/Va

lidit

ySi

gnifi

canc

e to

the

Is

sue

Levi

tt a

nd

Ziem

ba-D

avis

, 20

1320

The

purp

ose

of t

his

stud

y w

as to

exp

lore

kno

wl-

edge

abo

ut p

atie

nt

pref

eren

ces

for

pain

co

ntro

l dur

ing

perip

her-

al v

enou

s ca

nnul

atio

n.Sp

ecifi

c ai

ms

wer

e to

(1

) elu

cida

te p

atie

nts’

de

sire

to b

e in

volv

ed

in d

ecis

ions

abo

ut p

ain

man

agem

ent;

(2) d

eter

-m

ine

whe

ther

pat

ient

s ha

ve a

pre

fere

nce

for

diffe

rent

pai

n m

anag

e-m

ent

stra

tegi

es; (

3)

dete

rmin

e pa

tient

sat

-is

fact

ion

with

the

pai

n m

anag

emen

t ch

oice

; an

d (4

) rec

ord

pain

ra

tings

and

sat

isfa

ctio

n w

ith IV

inse

rtio

n.

30 p

atie

nts

recr

uite

d fr

om a

ref

erra

l hos

-pi

tal i

n th

e U

nite

d St

ates

Qua

ntita

tive

appr

oach

.Ex

plor

ator

y st

udy.

Patie

nts

wer

e as

ked

to

answ

er s

ome

ques

-tio

ns b

efor

e an

d af

ter

the

proc

edur

e.Th

ree

grou

ps: i

ntra

der-

mal

lido

cain

e, g

uide

d im

ager

y, a

nd n

o in

terv

entio

n.

Four

pat

ient

s ch

ose

the

trad

ition

al

stra

tegy

of n

o pa

in c

ontr

ol. I

n co

ntra

st, 8

6.6%

of p

artic

ipan

ts

pref

erre

d to

hav

e pa

in c

ontr

ol.

The

stud

y fo

und

that

pai

n in

the

in

trad

erm

al li

doca

ine

grou

p w

as

sign

ifica

ntly

low

er.

All p

artic

ipan

ts in

the

3 g

roup

s re

port

ed t

hat

the

patie

nt’s

invo

lvem

ent

in d

ecis

ion

mak

ing

rega

rdin

g pa

in m

anag

emen

t is

ve

ry im

port

ant.

Rece

nt s

tudy

.Sm

all s

ampl

e si

ze.

Stud

y m

etho

dolo

gy w

as

uncl

ear.

Lack

of b

lindi

ng a

nd e

qual

tr

eatm

ent

limit

its r

eli-

abili

ty.

Rand

omiz

atio

n to

gro

ups

was

not

pos

sibl

e be

caus

e pa

rtic

ipan

t ch

oice

s ab

out

pain

m

anag

emen

t st

rate

-gi

es w

ere

a ke

y st

udy

outc

ome.

Des

pite

lim

itatio

ns,

this

stu

dy is

use

ful

beca

use

it ex

plor

ed

the

impo

rtan

ce o

f pai

n m

anag

emen

t st

rate

-gi

es fo

r IV

inse

rtio

n fr

om p

atie

nts’

per

-sp

ectiv

es. I

n ad

ditio

n,

its im

plic

atio

ns fo

r nu

rsin

g pr

actic

e ar

e pa

rtic

ular

ly r

elev

ant

to

the

conc

erns

out

lined

in

thi

s ar

ticle

.

Mat

heso

n et

al,

2014

21Th

e st

udy

aim

ed to

com

-pa

re s

tand

ard

prac

tice

and

3 m

etho

ds o

f ana

l-ge

sic

infil

trat

ion

(0.7

mL

1% li

doca

ine,

0.7

mL

buffe

red

1% li

doca

ine,

or

0.7

mL

bact

erio

stat

ic

salin

e to

det

erm

ine

if 1

met

hod

was

mor

e su

c-ce

ssfu

l tha

n th

e ot

hers

at

red

ucin

g pa

in a

ssoc

i-at

ed w

ith A

BG s

ampl

ing.

Conv

enie

nce

sam

ple

of 4

0 ho

spita

lized

pa

tient

s at

OSF

Sa

int

Anth

ony

Med

ical

Cen

ter,

in

Rock

ford

, Illi

nois

Qua

ntita

tive,

rand

omiz

ed,

part

ially

blin

ded,

pro

-sp

ectiv

e de

sign

Com

parin

g th

e no

nint

erve

ntio

n gr

oup

with

the

3 in

terv

entio

ns

show

ed t

hat

the

buffe

red

(P =

.0

41) a

nd p

lain

lido

cain

e (P

=

.000

) ind

uced

sig

nific

antly

less

ar

teria

l pun

ctur

e pa

in t

han

the

noni

nter

vent

iona

l gro

up, b

ut

ther

e w

as n

o st

atis

tical

sig

nifi-

canc

e w

ith t

he u

se o

f bac

terio

-st

atic

sal

ine

(P =

.665

).O

vera

ll, p

lain

lido

cain

e w

as t

he

inte

rven

tion

that

res

ulte

d in

sig

-ni

fican

t re

duct

ion

of p

ain.

Rece

nt s

tudy

.Sm

all s

ampl

e si

ze a

nd

part

ial r

ando

miz

atio

n.Pa

tient

s w

ere

trea

ted

equa

lly.

All A

BGs

wer

e dr

awn

by 1

re

sear

cher

; out

com

es

coul

d be

affe

cted

if d

if-fe

rent

leve

ls o

f ski

ll an

d ex

perie

nce

of a

gro

up

of h

ealth

pro

fess

iona

ls

wer

e in

volv

ed.

Base

d on

pat

ient

s fr

om a

si

ngle

set

ting.

The

stud

y is

use

ful t

o su

ppor

t ef

fect

iven

ess

of lo

cal a

nest

hesi

a fo

r pr

oced

ural

pai

n. It

is

also

rel

evan

t to

the

st

udy

topi

c, a

s th

e re

sear

cher

is a

nur

se

who

has

als

o ex

eri-

men

ted

with

way

s to

re

duce

pai

n as

soci

ated

w

ith a

rter

ial p

unct

ure

for

ABG

sam

plin

g.

(con

tinue

s)

104 Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. Journal of Infusion Nursing on behalf of the Infusion Nurses Society.

AP

PE

ND

IX 1

Lite

ratu

re R

evie

w (

Cont

inue

d)

Aut

hor

and

Dat

eA

im/O

bjec

tive

Sam

ple

and

Sett

ing

Met

hods

and

M

etho

dolo

gyM

ajor

Fin

ding

sLi

mit

atio

ns a

nd R

igor

/Va

lidit

ySi

gnifi

canc

e to

the

Is

sue

McN

augh

ton

et a

l, 20

0922

The

stud

y ai

med

to c

om-

pare

pai

n an

d an

xiet

y as

soci

ated

with

IV c

an-

nula

tion

afte

r pr

etre

at-

ing

patie

nts

with

1%

su

bcut

aneo

us b

uffe

red

lidoc

aine

, 4%

lido

cain

e cr

eam

, or

no a

pplic

atio

n of

loca

l ane

sthe

sia.

70 m

edic

al s

tude

nt

and

nurs

e vo

lun-

teer

s w

ho p

artic

-ip

ated

in h

ospi

tal

wor

ksho

ps fo

r IV

in

sert

ion

in t

he

Uni

ted

Stat

es

Qua

ntita

tive,

rand

omiz

ed,

cros

sove

rPa

in a

nd a

nxie

ty a

ssoc

iate

d w

ith

IV c

annu

latio

n w

as s

igni

fican

tly

min

imiz

ed b

y th

e us

e of

lido

-ca

ine

crea

m o

r in

ject

ed b

uff-

ered

lido

cain

e.Th

ere

was

no

sign

ifica

nt d

if-fe

renc

e in

anx

iety

sco

res

in

patie

nts

rece

ivin

g lid

ocai

ne

crea

m a

nd t

hose

inje

cted

with

bu

ffere

d lid

ocai

ne.

70%

of s

ubje

cts

repo

rted

tha

t th

ey w

ould

alw

ays

requ

est

buff-

ered

lido

cain

e in

the

futu

re.

Man

y pa

rtic

ipan

ts w

ere

influ

ence

d by

the

ir po

sitiv

e pe

rson

al e

xpe-

rienc

es in

rec

eivi

ng lo

cal a

nes-

thes

ia a

s a

reas

on to

adm

inis

ter

it to

the

ir pa

tient

s.

The

sam

ple

was

bia

sed

to

heal

th p

rofe

ssio

nals

, w

hich

mig

ht a

ffect

the

va

lidity

of t

he fi

nd-

ings

in te

rms

of t

heir

know

ledg

e ab

out

loca

l an

esth

esia

.Th

ey w

ere

not

blin

ded,

an

d a

plac

ebo

was

no

t us

ed b

ecau

se o

f th

e cl

aim

of e

thic

al

cons

ider

atio

n.

The

stud

y is

rel

evan

t to

th

e re

sear

ch to

pic,

in

whi

ch it

sup

port

s th

e ef

fect

iven

ess

of lo

cal

anes

thes

ia fo

r re

duc-

ing

pain

and

anx

iety

as

soci

ated

with

IV c

an-

nula

tion.

Inte

rest

ingl

y,

the

stud

y sh

ows

that

pe

rson

al e

xper

ienc

es

of p

artic

ipan

ts h

ave

influ

ence

d th

eir

per-

cept

ion

tow

ard

usin

g lo

cal a

nest

hesi

a in

the

fu

ture

for

them

selv

es

and

thei

r pa

tient

s.

Ther

efor

e, p

erso

nal

expe

rienc

e co

uld

be a

fa

ctor

tha

t in

fluen

ces

nurs

es’ u

se o

f loc

al

anes

thes

ia.

Mirz

aei e

t al

, 20

1823

The

aim

of t

he s

tudy

was

to

inve

stig

ate

the

effe

ct

of to

pica

l tra

nsde

rmal

cr

eam

, lid

ocai

ne s

pray

, an

d ic

e on

art

erio

ve-

nous

can

nula

tion

pain

in

tens

ity in

hem

odia

lysi

s pa

tient

s.

40 h

emod

ialy

sis

patie

nts >

18

y ol

d w

ith a

rter

iove

nous

fis

tula

Shah

id R

ahne

moo

n H

ospi

tal i

n Ya

zd,

Iran

Qua

ntita

tive,

qua

si-

expe

rimen

tal

The

redu

ctio

n in

mea

n pa

in in

ten-

sity

was

sig

nific

antly

gre

ater

w

ith to

pica

l tra

nsde

rmal

cre

am

com

pare

d w

ith li

doca

ine

spra

y an

d ic

e (P

< .0

01).

The

pain

sco

re w

as a

lso

sign

ifi-

cant

ly d

iffer

ent

befo

re in

terv

en-

tion

and

afte

r ap

plic

atio

n of

the

3

inte

rven

tions

(P <

.001

).Th

e st

udy

conc

lude

d th

at a

ll 3

met

hods

of i

nter

vent

ion

wer

e ef

fect

ive

in r

educ

ing

pain

in

tens

ity, w

ith to

pica

l tra

ns-

derm

al c

ream

exe

rtin

g th

e gr

eate

st e

ffect

in d

ecre

asin

g th

e pu

nctu

re-r

elat

ed m

ean

pain

in

tens

ity o

f art

erio

veno

us fi

stu-

la c

annu

latio

n.

Curr

ent

stud

ySm

all s

ampl

e si

zeLa

ck o

f ran

dom

izat

ion

This

is a

rece

nt s

tudy

co

mpa

ring

3 ty

pes

of

loca

l ane

sthe

sia—

a to

pica

l tra

nsde

rmal

ag

ent,

lidoc

aine

spr

ay,

and

ice—

test

ed o

n ar

terio

veno

us c

annu

la-

tion

for

hem

odia

lysi

s.Th

e st

udy

prov

ided

a

usef

ul c

ompa

rison

of

diffe

rent

type

s of

loca

l an

esth

esia

use

d fo

r th

e sa

me

purp

ose

of

redu

cing

pro

cedu

ral

pain

. Thi

s ca

n he

lp

dete

rmin

e th

eir p

ract

i-ca

lity

and

conv

enie

nce

with

in n

ursi

ng p

ract

ice.

(con

tinue

s)

VOLUME 42 | NUMBER 2 | MARCH/APRIL 2019 journalofinfusionnursing.com 105

AP

PE

ND

IX 1

Lite

ratu

re R

evie

w (

Cont

inue

d)

Aut

hor

and

Dat

eA

im/O

bjec

tive

Sam

ple

and

Sett

ing

Met

hods

and

M

etho

dolo

gyM

ajor

Fin

ding

sLi

mit

atio

ns a

nd R

igor

/Va

lidit

ySi

gnifi

canc

e to

the

Is

sue

McN

augh

ton

et a

l, 20

0922

The

stud

y ai

med

to c

om-

pare

pai

n an

d an

xiet

y as

soci

ated

with

IV c

an-

nula

tion

afte

r pr

etre

at-

ing

patie

nts

with

1%

su

bcut

aneo

us b

uffe

red

lidoc

aine

, 4%

lido

cain

e cr

eam

, or

no a

pplic

atio

n of

loca

l ane

sthe

sia.

70 m

edic

al s

tude

nt

and

nurs

e vo

lun-

teer

s w

ho p

artic

-ip

ated

in h

ospi

tal

wor

ksho

ps fo

r IV

in

sert

ion

in t

he

Uni

ted

Stat

es

Qua

ntita

tive,

rand

omiz

ed,

cros

sove

rPa

in a

nd a

nxie

ty a

ssoc

iate

d w

ith

IV c

annu

latio

n w

as s

igni

fican

tly

min

imiz

ed b

y th

e us

e of

lido

-ca

ine

crea

m o

r in

ject

ed b

uff-

ered

lido

cain

e.Th

ere

was

no

sign

ifica

nt d

if-fe

renc

e in

anx

iety

sco

res

in

patie

nts

rece

ivin

g lid

ocai

ne

crea

m a

nd t

hose

inje

cted

with

bu

ffere

d lid

ocai

ne.

70%

of s

ubje

cts

repo

rted

tha

t th

ey w

ould

alw

ays

requ

est

buff-

ered

lido

cain

e in

the

futu

re.

Man

y pa

rtic

ipan

ts w

ere

influ

ence

d by

the

ir po

sitiv

e pe

rson

al e

xpe-

rienc

es in

rec

eivi

ng lo

cal a

nes-

thes

ia a

s a

reas

on to

adm

inis

ter

it to

the

ir pa

tient

s.

The

sam

ple

was

bia

sed

to

heal

th p

rofe

ssio

nals

, w

hich

mig

ht a

ffect

the

va

lidity

of t

he fi

nd-

ings

in te

rms

of t

heir

know

ledg

e ab

out

loca

l an

esth

esia

.Th

ey w

ere

not

blin

ded,

an

d a

plac

ebo

was

no

t us

ed b

ecau

se o

f th

e cl

aim

of e

thic

al

cons

ider

atio

n.

The

stud

y is

rel

evan

t to

th

e re

sear

ch to

pic,

in

whi

ch it

sup

port

s th

e ef

fect

iven

ess

of lo

cal

anes

thes

ia fo

r re

duc-

ing

pain

and

anx

iety

as

soci

ated

with

IV c

an-

nula

tion.

Inte

rest

ingl

y,

the

stud

y sh

ows

that

pe

rson

al e

xper

ienc

es

of p

artic

ipan

ts h

ave

influ

ence

d th

eir

per-

cept

ion

tow

ard

usin

g lo

cal a

nest

hesi

a in

the

fu

ture

for

them

selv

es

and

thei

r pa

tient

s.

Ther

efor

e, p

erso

nal

expe

rienc

e co

uld

be a

fa

ctor

tha

t in

fluen

ces

nurs

es’ u

se o

f loc

al

anes

thes

ia.

Mirz

aei e

t al

, 20

1823

The

aim

of t

he s

tudy

was

to

inve

stig

ate

the

effe

ct

of to

pica

l tra

nsde

rmal

cr

eam

, lid

ocai

ne s

pray

, an

d ic

e on

art

erio

ve-

nous

can

nula

tion

pain

in

tens

ity in

hem

odia

lysi

s pa

tient

s.

40 h

emod

ialy

sis

patie

nts >

18

y ol

d w

ith a

rter

iove

nous

fis

tula

Shah

id R

ahne

moo

n H

ospi

tal i

n Ya

zd,

Iran

Qua

ntita

tive,

qua

si-

expe

rimen

tal

The

redu

ctio

n in

mea

n pa

in in

ten-

sity

was

sig

nific

antly

gre

ater

w

ith to

pica

l tra

nsde

rmal

cre

am

com

pare

d w

ith li

doca

ine

spra

y an

d ic

e (P

< .0

01).

The

pain

sco

re w

as a

lso

sign

ifi-

cant

ly d

iffer

ent

befo

re in

terv

en-

tion

and

afte

r ap

plic

atio

n of

the

3

inte

rven

tions

(P <

.001

).Th

e st

udy

conc

lude

d th

at a

ll 3

met

hods

of i

nter

vent

ion

wer

e ef

fect

ive

in r

educ

ing

pain

in

tens

ity, w

ith to

pica

l tra

ns-

derm

al c

ream

exe

rtin

g th

e gr

eate

st e

ffect

in d

ecre

asin

g th

e pu

nctu

re-r

elat

ed m

ean

pain

in

tens

ity o

f art

erio

veno

us fi

stu-

la c

annu

latio

n.

Curr

ent

stud

ySm

all s

ampl

e si

zeLa

ck o

f ran

dom

izat

ion

This

is a

rece

nt s

tudy

co

mpa

ring

3 ty

pes

of

loca

l ane

sthe

sia—

a to

pica

l tra

nsde

rmal

ag

ent,

lidoc

aine

spr

ay,

and

ice—

test

ed o

n ar

terio

veno

us c

annu

la-

tion

for

hem

odia

lysi

s.Th

e st

udy

prov

ided

a

usef

ul c

ompa

rison

of

diffe

rent

type

s of

loca

l an

esth

esia

use

d fo

r th

e sa

me

purp

ose

of

redu

cing

pro

cedu

ral

pain

. Thi

s ca

n he

lp

dete

rmin

e th

eir p

ract

i-ca

lity

and

conv

enie

nce

with

in n

ursi

ng p

ract

ice.

(con

tinue

s)

AP

PE

ND

IX 1

Lite

ratu

re R

evie

w (

Cont

inue

d)

Aut

hor

and

Dat

eA

im/O

bjec

tive

Sam

ple

and

Sett

ing

Met

hods

and

M

etho

dolo

gyM

ajor

Fin

ding

sLi

mit

atio

ns a

nd R

igor

/Va

lidit

ySi

gnifi

canc

e to

the

Is

sue

Papa

and

Ze

mps

ky,

2010

24

The

purp

ose

of t

he s

tudy

w

as to

exa

min

e nu

rses

’ at

titud

es to

war

d an

d ex

perie

nce

with

ven

ous

acce

ss p

ain

in p

edia

tric

pa

tient

s, a

nd t

heir

per-

cept

ions

of t

he v

alue

of

curr

ent

tech

niqu

es u

sed

for

man

agin

g su

ch p

ain.

2187

nur

ses

who

wer

e m

embe

rs o

f 3 n

urs-

ing

soci

etie

s ba

sed

in t

he U

nite

d St

ates

: th

e Em

erge

ncy

Nur

ses

Asso

ciat

ion,

th

e In

fusi

on N

urse

s So

ciet

y, a

nd t

he

Soci

ety

of P

edia

tric

N

urse

s

Qua

ntita

tive

Web

-bas

ed s

urve

yRe

spon

dent

s in

dica

ted

that

inse

rtin

g an

IV c

athe

ter i

n a

fear

ful,

anxi

ous

child

was

cha

lleng

ing

(96%

).N

onph

arm

acol

ogic

tech

niqu

es

wer

e fr

eque

ntly

use

d bu

t wer

e pe

rcei

ved

as in

suffi

cien

t for

alle

-vi

atin

g pa

in w

hen

used

alo

ne.

Topi

cal l

ocal

ane

sthe

tics

wer

e de

emed

mor

e ef

fect

ive,

but

are

us

ed le

ss o

ften

.M

ost

resp

onde

nts

agre

ed t

hat

impr

oved

pai

n m

anag

emen

t en

hanc

es t

heir

satis

fact

ion

with

th

eir

job

perf

orm

ance

(91%

), in

crea

ses

job

satis

fact

ion

(81%

), in

crea

ses

posi

tive

rela

tions

hip

with

pat

ient

s an

d fa

mili

es

(91%

), an

d po

sitiv

ely

impa

cts

the

hosp

ital e

xper

ienc

e fo

r ch

il-dr

en a

nd t

heir

fam

ilies

(97%

).M

ost n

urse

s (9

2%) a

gree

d th

at

an e

ffect

ive,

fast

-act

ing,

topi

cal

loca

l ane

sthe

tic w

ould

ben

efit

pedi

atric

pat

ient

s, th

eir

fam

ilies

, an

d th

e nu

rses

who

trea

t the

m.

Larg

e, r

epre

sent

ativ

e sa

mpl

e.W

ritte

n la

ngua

ge is

ver

y cl

ear.

Det

aile

d pr

ovis

ion

of

data

.It

did

not

spec

ify w

hich

ty

pes

of to

pica

l ane

s-th

esia

are

use

d in

th

ose

sett

ings

.

Alth

ough

it o

nly

focu

sed

on p

edia

tric

set

tings

, th

e st

udy

iden

tifie

d so

me

impo

rtan

t fa

c-to

rs t

hat

can

hind

er

the

use

of to

pica

l loc

al

anes

thet

ics

for

IV c

an-

nula

tion

from

the

per

-sp

ectiv

es o

f the

nur

ses

who

per

form

ed t

hese

pr

oced

ures

, whi

ch

supp

orts

the

res

earc

h to

pic.

Page

and

Tay

lor,

2010

25Th

e st

udy’

s ai

m w

as to

co

mpa

re t

he e

ffic

acy,

ac

cept

abili

ty, a

nd s

afet

y of

a to

pica

l vap

ocoo

lant

al

kane

spr

ay a

nd 1

%

plai

n su

bcut

aneo

us li

do-

cain

e in

red

ucin

g pa

in

from

IV c

annu

latio

n.

Conv

enie

nce

sam

ple

of 2

20 a

dult

and

pedi

atric

pa

rtic

ipan

ts in

a

met

ropo

litan

ED

Qua

ntita

tive,

non

blin

ded,

ra

ndom

ized

con

trol

led

tria

l

Ove

rall,

vap

ocoo

lant

spr

ay w

as

less

pai

nful

to a

dmin

iste

r bu

t le

ss e

ffect

ive

in d

ecre

asin

g ca

n-nu

latio

n pa

in t

han

lidoc

aine

. Va

poco

olan

t sp

ray

was

ass

ocia

t-ed

with

gre

ater

can

nula

tion

succ

ess

(83.

6% v

s 67

.3%

; P =

.005

), le

ss t

ime

to a

dmin

-is

ter

(med

ian

9.0

vs 8

4.5

s;

P <

.001

), an

d m

ore

staf

f co

nven

ienc

e (m

edia

n 5

vs 4

; P <

.001

) tha

n lid

ocai

ne.

Ove

rall

patie

nt s

atis

fact

ion

scor

es

wer

e si

mila

r.Va

poco

olan

t sp

ray

offe

rs a

use

ful

alte

rnat

ive

in t

he E

D s

ettin

g.

Larg

e, m

ixed

sam

ple

of

adul

ts a

nd c

hild

ren.

Equa

l allo

catio

n of

110

pa

rtic

ipan

ts fo

r ea

ch

grou

p fo

r a

tota

l of 2

20

part

icip

ants

.Pr

ovid

ed c

lear

and

ric

h de

tails

of i

nfor

mat

ion.

Prac

tice

loca

tion

was

not

id

entif

ied.

Lack

of c

ontr

ol g

roup

was

no

t ex

plai

ned.

Stud

y w

as n

ot b

linde

d.

Two

type

s of

loca

l ane

s-th

esia

wer

e st

udie

d,

whi

ch p

rovi

ded

a us

e-fu

l com

paris

on a

mon

g ot

her

type

s of

loca

l an

esth

esia

use

d fo

r th

e sa

me

purp

oses

as

this

stu

dy.

Mos

t im

port

ant,

it p

oint

-ed

at

cont

ribut

ing

fac-

tors

tha

t ca

n in

fluen

ce

the

use

of lo

cal a

nes-

thes

ia b

y nu

rses

, suc

h as

suc

cess

ful I

V in

ser-

tion,

adm

inis

trat

ion

time,

and

sat

isfa

ctio

n,

whi

ch h

elps

sup

port

th

is r

esea

rch

stud

y.

(con

tinue

s)

106 Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. Journal of Infusion Nursing on behalf of the Infusion Nurses Society.

AP

PE

ND

IX 1

Lite

ratu

re R

evie

w (

Cont

inue

d)

Aut

hor

and

Dat

eA

im/O

bjec

tive

Sam

ple

and

Sett

ing

Met

hods

and

M

etho

dolo

gyM

ajor

Fin

ding

sLi

mit

atio

ns a

nd R

igor

/Va

lidit

ySi

gnifi

canc

e to

the

Is

sue

Rost

ami e

t al

, 20

0626

The

aim

of t

he s

tudy

was

to

det

erm

ine

the

effe

ct

of lo

cal a

pplic

atio

n of

ice

for

3 m

in p

rior

to v

enip

unct

ure

on

pain

-rel

ated

res

pons

es

in s

choo

l-age

d ch

ildre

n.

80 c

hild

ren

(6-1

2 y

old)

in a

ped

iatr

ic

emer

genc

y de

part

-m

ent

of a

ped

iatr

ic

cent

er, i

n Ah

waz

, Ira

n

Qua

ntita

tive

Qua

si-e

xper

imen

tal

No

sign

ifica

nt d

iffer

ence

in p

hys-

iolo

gica

l res

pons

es b

efor

e an

d af

ter

the

proc

edur

e be

twee

n th

e 2

grou

ps (P

= .0

7).

How

ever

, beh

avio

ral a

nd s

ub-

ject

ive

resp

onse

s be

fore

and

af

ter

the

proc

edur

e w

ere

low

er

in t

he te

st g

roup

(P =

.001

1 an

d P =

.009

7, r

espe

ctiv

ely)

.Th

e st

udy

conc

lude

d th

at t

he

appl

icat

ion

of ic

e to

ski

n pr

ior

to v

enou

s pu

nctu

re c

an b

e an

ef

fect

ive

and

safe

inte

rven

tion

for

redu

cing

rel

ated

pai

n.

Clea

r an

d ac

cura

te m

ea-

sure

men

ts p

rovi

ded

Lack

of r

ando

miz

atio

n an

d bl

indi

ng

Appl

icat

ion

of ic

e is

an

othe

r te

chni

que

that

can

be

used

by

nurs

es a

s an

alte

r-na

tive

for

proc

edur

-al

pai

n re

duct

ion

beca

use

it is

non

in-

vasi

ve, n

onph

arm

a-co

logi

c, in

expe

nsiv

e,

and

read

ily a

vaila

ble,

es

peci

ally

whe

n lo

cal

anes

thes

ia is

not

ava

il-ab

le o

r no

t of

fere

d to

pa

tient

s in

som

e se

t-tin

gs. T

his

stud

y is

als

o be

nefic

ial t

o co

mpa

re

with

sim

ilar

stud

ies

cond

ucte

d on

adu

lts

for

the

sam

e pu

rpos

e.

Sado

and

Dea

kin,

20

0527

This

stu

dy m

easu

red

the

prev

alen

ce o

f the

use

of

loca

l ane

sthe

sia

for

veno

us c

annu

latio

n an

d AB

G s

ampl

ing

by

phys

icia

ns.

178

anes

thet

ists

, and

m

edic

al a

nd s

urgi

cal

phys

icia

ns in

8 h

os-

pita

ls in

the

Uni

ted

King

dom

Qua

ntita

tive

Dat

a co

llect

ed t

hrou

gh a

pr

inte

d qu

estio

nnai

re

60%

of a

nest

hetis

ts w

ere

usin

g lo

cal a

nest

hesi

a fo

r th

ese

pro-

cedu

res

com

pare

d w

ith 2

% o

f w

ard

phys

icia

ns.

Larg

e sa

mpl

e.Th

e st

udy

was

con

duct

ed

10 y

ago

.Th

e st

udy

has

been

cite

d m

ultip

le t

imes

.Br

ief d

escr

iptio

n pr

ovid

ed

in t

he s

tudy

.Fa

ctor

s re

leva

nt to

the

is

sue

wer

e di

scus

sed

base

d on

obs

ervi

ng

and

talk

ing

to d

octo

rs,

but

they

wer

e no

t su

p-po

rted

with

evi

denc

e.

This

stu

dy is

use

ful

beca

use

the

mai

n co

ncep

t is

rel

evan

t to

the

res

earc

h to

pic

of t

his

artic

le. W

hile

nu

rses

in S

audi

Ara

bia

are

perf

orm

ing

thes

e pr

oced

ures

, thi

s ar

ti-cl

e in

par

ticul

ar m

ay

assi

st in

iden

tifyi

ng

som

e fa

ctor

s th

at le

ad

to s

imila

r pr

actic

e of

di

sreg

ardi

ng t

he u

se

of lo

cal a

nest

hesi

a by

ph

ysic

ians

for

thes

e pr

oced

ures

.

Abbr

evia

tions

: ABG

, art

eria

l blo

od g

as; E

D, e

mer

genc

y de

part

men

t; F

, fem

ale;

IQR,

inte

rqua

rtile

rang

e; IV

, int

rave

nous

; M, m

ale;

RN

, reg

iste

red

nurs

e.

VOLUME 42 | NUMBER 2 | MARCH/APRIL 2019 journalofinfusionnursing.com 107

AP

PE

ND

IX 1

Lite

ratu

re R

evie

w (

Cont

inue

d)

Aut

hor

and

Dat

eA

im/O

bjec

tive

Sam

ple

and

Sett

ing

Met

hods

and

M

etho

dolo

gyM

ajor

Fin

ding

sLi

mit

atio

ns a

nd R

igor

/Va

lidit

ySi

gnifi

canc

e to

the

Is

sue

Rost

ami e

t al

, 20

0626

The

aim

of t

he s

tudy

was

to

det

erm

ine

the

effe

ct

of lo

cal a

pplic

atio

n of

ice

for

3 m

in p

rior

to v

enip

unct

ure

on

pain

-rel

ated

res

pons

es

in s

choo

l-age

d ch

ildre

n.

80 c

hild

ren

(6-1

2 y

old)

in a

ped

iatr

ic

emer

genc

y de

part

-m

ent

of a

ped

iatr

ic

cent

er, i

n Ah

waz

, Ira

n

Qua

ntita

tive

Qua

si-e

xper

imen

tal

No

sign

ifica

nt d

iffer

ence

in p

hys-

iolo

gica

l res

pons

es b

efor

e an

d af

ter

the

proc

edur

e be

twee

n th

e 2

grou

ps (P

= .0

7).

How

ever

, beh

avio

ral a

nd s

ub-

ject

ive

resp

onse

s be

fore

and

af

ter

the

proc

edur

e w

ere

low

er

in t

he te

st g

roup

(P =

.001

1 an

d P =

.009

7, r

espe

ctiv

ely)

.Th

e st

udy

conc

lude

d th

at t

he

appl

icat

ion

of ic

e to

ski

n pr

ior

to v

enou

s pu

nctu

re c

an b

e an

ef

fect

ive

and

safe

inte

rven

tion

for

redu

cing

rel

ated

pai

n.

Clea

r an

d ac

cura

te m

ea-

sure

men

ts p

rovi

ded

Lack

of r

ando

miz

atio

n an

d bl

indi

ng

Appl

icat

ion

of ic

e is

an

othe

r te

chni

que

that

can

be

used

by

nurs

es a

s an

alte

r-na

tive

for

proc

edur

-al

pai

n re

duct

ion

beca

use

it is

non

in-

vasi

ve, n

onph

arm

a-co

logi

c, in

expe

nsiv

e,

and

read

ily a

vaila

ble,

es

peci

ally

whe

n lo

cal

anes

thes

ia is

not

ava

il-ab

le o

r no

t of

fere

d to

pa

tient

s in

som

e se

t-tin

gs. T

his

stud

y is

als

o be

nefic

ial t

o co

mpa

re

with

sim

ilar

stud

ies

cond

ucte

d on

adu

lts

for

the

sam

e pu

rpos

e.

Sado

and

Dea

kin,

20

0527

This

stu

dy m

easu

red

the

prev

alen

ce o

f the

use

of

loca

l ane

sthe

sia

for

veno

us c

annu

latio

n an

d AB

G s

ampl

ing

by

phys

icia

ns.

178

anes

thet

ists

, and

m

edic

al a

nd s

urgi

cal

phys

icia

ns in

8 h

os-

pita

ls in

the

Uni

ted

King

dom

Qua

ntita

tive

Dat

a co

llect

ed t

hrou

gh a

pr

inte

d qu

estio

nnai

re

60%

of a

nest

hetis

ts w

ere

usin

g lo

cal a

nest

hesi

a fo

r th

ese

pro-

cedu

res

com

pare

d w

ith 2

% o

f w

ard

phys

icia

ns.

Larg

e sa

mpl

e.Th

e st

udy

was

con

duct

ed

10 y

ago

.Th

e st

udy

has

been

cite

d m

ultip

le t

imes

.Br

ief d

escr

iptio

n pr

ovid

ed

in t

he s

tudy

.Fa

ctor

s re

leva

nt to

the

is

sue

wer

e di

scus

sed

base

d on

obs

ervi

ng

and

talk

ing

to d

octo

rs,

but

they

wer

e no

t su

p-po

rted

with

evi

denc

e.

This

stu

dy is

use

ful

beca

use

the

mai

n co

ncep

t is

rel

evan

t to

the

res

earc

h to

pic

of t

his

artic

le. W

hile

nu

rses

in S

audi

Ara

bia

are

perf

orm

ing

thes

e pr

oced

ures

, thi

s ar

ti-cl

e in

par

ticul

ar m

ay

assi

st in

iden

tifyi

ng

som

e fa

ctor

s th

at le

ad

to s

imila

r pr

actic

e of

di

sreg

ardi

ng t

he u

se

of lo

cal a

nest

hesi

a by

ph

ysic

ians

for

thes

e pr

oced

ures

.

Abbr

evia

tions

: ABG

, art

eria

l blo

od g

as; E

D, e

mer

genc

y de

part

men

t; F

, fem

ale;

IQR,

inte

rqua

rtile

rang

e; IV

, int

rave

nous

; M, m

ale;

RN

, reg

iste

red

nurs

e.

APPENDIX 2

Themes From the LiteratureThemes Element Sources

Effectiveness of local anesthesia; total articles = 11

Intradermal injections Matheson et al, 201421

McNaughton et al, 200922

Burke et al, 201114

Hudson et al, 200618

Intradermal needleless device Crowley et al, 20118

Hajiseyedjavady et al, 20129

Jimenez et al, 200619

Topical anesthetics Hijazi et al, 200917

Papa and Zempsky, 201024

Crowley et al, 20118

Page and Taylor, 201025

Mirzaei et al, 201823

Other strategies for procedural pain manage-ment; total articles = 5

Application of ice Haynes, 201516

Crowley et al, 20118

Rostami et al, 200626

Mirzaei et al, 201823

Behavioral intervention Papa and Zempsky, 201024

Crowley et al, 20118

Other benefits of local anesthesia; total articles = 9

Successful insertion Hudson et al, 200618

Crowley et al, 20118

Hajiseyedjavady et al, 20129

Jimenez et al, 200619

Improve satisfaction Hijazi et al, 200917

Papa and Zempsky, 201024

Page and Taylor, 201025

Hajiseyedjavady et al, 20129

Levitt and Ziemba-Davis, 201320

McNaughton et al, 200922

Barriers of low use of local anesthesia; total articles = 9

Underestimation of procedural pain Sado and Deakin, 200527

Czarnecki et al, 201115

Time concerns Hijazi et al, 200917

Page and Taylor, 201025

Papa and Zempsky, 201024

Hudson et al, 200618

Czarnecki et al, 201115

Hajiseyedjavady et al, 20129

Jimenez et al, 200619

Drug preorder Hudson et al, 200618

Papa and Zempsky, 201024

Czarnecki et al, 201115

Cost Hudson et al, 200618

Page and Taylor, 201025

Burke et al, 201114

Jimenez et al, 200619