A narrative review with practical advice on how to decrease pain and distress during venepuncture and peripheral intravenous cannulation

Establishing a plan to improve pediatric patient comfort during PIV insertions and blood specimen collection: a quality improvement effort

HIGHLIGHTS

Patient comfort during peripheral intravenous (PIV) insertion and specimen collection was increased. The authors extended the contingency plan implemented for PICC insertion to include PIV insertion and specimen collection. The authors met their goals by using quality improvement methodology. Prioritizing patient comfort often requires institutional culture change.

BACKGROUND

Needle procedures can cause pain and distress, especially in pediatric patients.1 Retrospective data collected at a freestanding pediatric facility revealed that approximately 30% of pediatric patients were not demonstrating sufficient levels of comfort during peripheral intravenous (PIV) catheter insertion and specimen collection (lab draws) even after successful implementation of comfort measures by the vascular access team (VAT) in an adjacent procedure (eg peripherally inserted central catheter placement). The current quality improvement project was implemented to support adaptation and expansion of previous lessons learned to PIVs and lab draws specifically.

DESIGN AND METHODS

The VAT used the Pediatric Sedation State Scale,2 a standardized assessment tool integrated into the electronic medical record, to assess procedural comfort during PIVs and lab draws from February 2021 through April 2023. A total of 24 134 patients aged 0 to 18 years were included in the data collection. Interventions were delivered concurrently and included (1) reeducation/ongoing support for implementation of the Comfort Promise3 measures, (2) the creation and implementation of advanced comfort options, and (3) culture change.

AIMS AND OBJECTIVES

The goal of the interventions was to improve the percentage of pediatric patients achieving adequate levels of comfort beginning at 68% in year 1 to 90% in year 2.

RESULTS

From February 2021 to April 2023, the VAT team was able to improve procedural comfort scores from 68% to 90% of pediatric patients with adequate comfort for lab draws and/or PIV insertions.

CONCLUSIONS

While standard comfort measures are a good first step in pain management during needle procedures, they are not sufficient for every pediatric patient. Nitrous, sedation, and the use of anxiolytics and analgesics can play an important role in reducing pain and anxiety during needle procedures and should be considered for patients not achieving adequate levels of comfort with standard comfort measures.

Efficacy of Buzzy Device Versus EMLA Cream for Reducing Pain During Needle-Related Procedures in Children: A Randomized Controlled Trial

OBJECTIVES

Several pain management tools exist but with limitations in their efficacy or applicability. The EMLA (eutectic mixture of local anesthetics) cream is currently used for pain relief for needle-related procedures; however, it needs a minimum of 30 to 45 minutes to be effective. The Buzzy is a device that generates vibrations with cold leading to quicker pain relief. Our aim was to evaluate the effect of the Buzzy device in pain and anxiety reduction compared with EMLA cream in children requiring intravenous cannulation or venepuncture.

METHODS

This was a randomized clinical trial comparing pain and anxiety reduction by Buzzy device with the standard care (EMLA cream) in children aged 2 to 14 years who required blood extraction or intravenous cannulation based on their clinical needs. Eligible patients were randomized to either Buzzy device as the intervention or EMLA cream as the control. The outcome measures were the degree of pain scores and anxiety ratings at different stages of the needle-related procedures.

RESULTS

A total of 300 patients with a mean age of 6.5 ± 3.1 years were enrolled. Baseline characteristics were similar between the Buzzy device and EMLA cream groups. The observed pain scores by research nurses and a parent were significantly lower in the EMLA group compared with the Buzzy device group; however, the pain scores by the self-assessment scale were not statistically significant with mean difference of -0.332, 95% confidence interval, -0.635 to -0.028 ( P = 0.062). The level of anxiety was significantly lower in EMLA compared with Buzzy device ( P = 0. 0.0001). Both staff and parents' satisfaction, success rate of cannulation, type of blood tests, and comment on the physician on the results were similar in both groups.

CONCLUSIONS

Pain and anxiety relief using the Buzzy device is not as effective as EMLA cream in children requiring venepuncture. However, rapid onset of action of the Buzzy device is valuable in decreasing waiting time in a busy emergency department.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT05354739.

Acceptability of a novel device to improve child patient experience during venepuncture for blood sampling: Intervention with 'MyShield'

This study aimed to explore the acceptability of a novel device ('MyShield'): a device used for distraction during clinical procedures. It is a cardboard cuff, designed to fit around the arm, either above the elbow or around the wrist and used to hide the procedure from view. This device was tested in practice, to establish acceptability to children, parents and clinical staff. Fifty-eight children tried 'MyShield' during a venepuncture procedure. Feedback from 54 children, 58 parents/carers and 16 clinical staff was collected using surveys and interviews. In 24 cases, observational data were also collected. A large majority of children (94%, n = 51) and parents (96%, n = 56) reported a positive experience when using 'MyShield'; saying they would likely use it again. Potential of 'MyShield' in promoting parent/clinician interaction with the child was highlighted. Data suggests that 'MyShield' may be a useful device for children undergoing venepuncture, when used in conjunction with standard care, and subject to individual preferences and choice. Further work is required to establish mechanism of action and whether use of 'MyShield' has any impact across a range of short- and long-term outcome measures relating to patient experience and effectiveness.

Active production of music as distraction for venipuncture in children and adolescents: a randomized clinical trial

More than 50% of children report considerable pain during venipuncture or intravenous cannulation. Despite the tools and techniques may be employed to reduce pain and distress in everyday clinical practice, the care offered is frequently insufficient. Music's potential effect in healthcare settings has received increasing attention. This study aimed to verify if the active production of music with a Leap Motion Controller could help decreasing pain and distress during venipuncture in children and adolescents. We conducted an open-label randomized controlled clinical trial with parallel arms. Children aged 8 to 17 were enrolled at the blood-drawing center of the Institute for Maternal and Child Health IRCCS Burlo Garofolo of Trieste, Italy. We hypothesized that in order to demonstrate an adequate improvement in the pain score in the intervention group, at least 200 children, 100 in each group, were needed, with alpha 5% and 1-beta 80%. Differences between the groups were evaluated with the nonparametric Mann-Whitney U-test. The subjects were randomly assigned either to the active production of music group or to the standard of care group. The primary outcome was the median self-reported procedural pain score between experimental and standard of care group. Secondary outcomes were: the median pain and distress scores according to parental judgment and operators' judgment between the experimental and control group. Three hundred subjects entered the study and were randomized, 150 in the active production of music group and 150 in the standard of care group. Median self-reported pain scores were 1 (0-2) in the active production of music group and 2 (1-2) in the standard of care group and this difference was statistically significant (p = 0.0016). Median procedural distress was 1 (0-3) in the active production of music group and 3 (1-6) in the standard of care group, according to parental judgment, and this difference was statistically significant (p = 0.0000016).

CONCLUSION

This research showed that the active production of music is a valuable distraction technique to decrease venipuncture related pain and distress in children and adolescents.

TRIAL REGISTRATION

The study protocol was registered with ClinicalTrial.gov (June 28[th] 2022, NCT05441241) before the start of the subjects' enrolment.

WHAT IS KNOWN

• The benefits of music on pain and anxiety are well known and have been tested during different painful procedures. • The effect of active production of music has never been tested in children during venipuncture.

WHAT IS NEW

• In our study median self-reported pain scores and median procedural distress, according to parental judgment, were lower in the active production of music group than in the standard of care group and these differences were statistically significant.

The effect of buzzy and cold spray on pain, anxiety, and fear of children during venipuncture in pediatric emergency department in Turkey; A randomized controlled study

PURPOSE

It was aimed to evaluate the efficacy of Buzzy and cold spray in reducing pain, anxiety, and fear of children during venipuncture in the emergency department (ED).

METHODS

This study is an experimental, parallel-group (intervention-control), randomized controlled, single-blind design. The study was conducted with 161 children aged 5-12 years in pediatric ED. Data were collected by the 'Personal Information Form', 'Wong Baker-Facial Expression Rating Scale', 'Child Anxiety Statement Scale', and 'Child Fear Inventory'. Data were analyzed with descriptive statistics, Mann Whitney U test, Kruskal Wallis H test, and Intraclass Correlation.

RESULTS

Descriptive features of the children were homogeneous. 'Wong Baker-Facial Expression Rating Scale', 'Child Anxiety Statement Scale', and 'Child Fear Scale' score averages of the children in the control group were higher than the children in the Buzzy group and the cold spray group (p < 0.001). The pain scores of the Buzzy group were higher than those in the cold spray group (p < 0.001). The anxiety and fear mean scores of the children in the Buzzy and cold spray groups were similar (p > 0.05).

CONCLUSION

It was determined that Buzzy and cold spray were more effective than standard care in reducing the level of pain, anxiety, and fear in children ages 5-12 years during venipuncture in the pediatric emergency. The cold spray was more effective in reducing pain than Buzzy.

PRACTICE IMPLICATIONS

Nurses can use Buzzy and cold sprays to manage the fear, anxiety, and pain associated with venipuncture.

Adolescents' pain and distress during peripheral intravenous cannulation in a paediatric emergency setting

The objective of the study is to investigate pain and distress experienced by a group of adolescents and children during peripheral intravenous cannulation in a paediatric emergency department. This cross-sectional study was performed between November 2019 and June 2020 at the paediatric emergency department of the Institute for Maternal and Child Health of Trieste, Italy. Eligible subjects were patients between 4 and 17 years old undergoing intravenous cannulation, split into three groups based on their age: adolescents (13-17 years), older children (8-12 years), and younger children (4-7 years). Procedural distress and pain scores were recorded through validated scales. Data on the use of topical anaesthesia, distraction techniques, and physical or verbal comfort during procedures were also collected. We recruited 136 patients: 63 adolescents, 48 older children, and 25 younger children. There was no statistically significant difference in the median self-reported procedural pain found in adolescents (4; IQR = 2-6) versus older and younger children (5; IQR = 2-8 and 6; IQR = 2-8, respectively). Furthermore, no significant difference was observed in the rate of distress between adolescents (79.4%), older (89.6%), and younger (92.0%) children. Adolescents received significantly fewer pain relief techniques.Conclusion: This study shows that adolescents experience similar pain and pre-procedural distress as younger children during peripheral intravenous cannulation. What is Known: • Topical and local anaesthesia, physical and verbal comfort, and distraction are useful interventions for pain and anxiety management during intravenous cannulation in paediatric settings. • No data is available on pain and distress experienced by adolescents in the specific setting of the emergency department. What is New: • Adolescents experienced high levels of pre-procedural distress in most cases and similar levels of pain and distress when compared to younger patients • The number of pain relief techniques employed during procedures was inversely proportional to patient's age, topical or local anaesthesia were rarely used.

Effects of Green Color Exposure on Stress, Anxiety, and Pain during Peripheral Intravenous Cannulation in Dental Patients Requiring Sedation

Intravenous cannulation is an invasive procedure that causes stress, anxiety, and pain for many patients. A recent animal study found that exposure to green light induced antinociceptive and anxiolytic effects. This study examined whether green color exposure reduced stress, anxiety, and pain during peripheral intravenous cannulation (PIC) for sedation in dental patients. In this controlled clinical trial, 24 patients (mean age 40.9 years) were randomized to wear clear glasses or green-colored glasses for 15 min before PIC on two separate days in a cross-over manner. The primary outcome measures were salivary alpha-amylase (sAA) activity and stress-related hemodynamic changes, and the secondary outcome measures were the visual analog scale anxiety (VAS-A) and pain (VAS-P) scores during PIC. The sAA level in the clear group significantly increased during PIC compared with baseline, but did not increase in the green group. Median VAS-P scores during PIC were lower in the green group than in the clear group (VAS-P, 17.0 vs. 50.0). Green color exposure with glasses significantly reduced stress and pain during PIC without any adverse effects. This simple, safe, and effective method may be useful during painful medical procedures.

Effectiveness of animal-assisted therapy on pain in children: A systematic review and meta-analysis

Aims

Animal-assisted therapy (AAT) relieves pain by creating a relaxed and comfortable environment to reduce anxiety in children. Yet little is known about its effects on pain in children. This study aims to systematically evaluate the effects of AAT on pain in children.

Methods

Eight databases including PubMed, Cochrane Library, Web of Science, CINAHL Complete, Chinese Biomedical Database (CBM), Weipu Database (VIP), China Knowledge Resource Integrated Database (CNKI) and Wanfang Database were retrieved, and all randomized controlled trials or controlled clinical trial using AAT on children’s pain were recruited from inception to October 2019. Two reviewers independently screened literature, extracted data and assessed the risk of bias of the included studies. RevMan 5.3 software was employed for meta-analysis.

Results

Seven published studies containing 4 RCTs and 3 CCTs were included for the systematic review. The results of meta-analysis showed that AAT could reduce children’s pain when compared with the control group [MD = −0.53, 95% CI (−0.77, −0.30), P < 0.00001].

Conclusion

Current evidence shows that AAT can relieve pain in children to some extent. Considering the limited quality and quantity of the available studies, more high quality studies should be performed to verify the above conclusion.