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Best Practices for Pain Reduction Associated with Venipuncture in Children University of Alaska Anchorage NS 400 Jennifer Crow, Dawn Reishus, Brenda (Cooper)

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Presentation on theme: "Best Practices for Pain Reduction Associated with Venipuncture in Children University of Alaska Anchorage NS 400 Jennifer Crow, Dawn Reishus, Brenda (Cooper)"— Presentation transcript:

1 Best Practices for Pain Reduction Associated with Venipuncture in Children University of Alaska Anchorage NS 400 Jennifer Crow, Dawn Reishus, Brenda (Cooper) McMillan, Char Corkery, Rachel Chesser

2 Conclusion Reduction of pain in children during venipuncture will help prevent increased pain and anxiety in future procedures. Pain control methods can be achieved through various inexpensive, non-invasive means. Further education and training is advised for nursing staff regarding pain reduction techniques for children. Databases Searched CINAHL Cochrane Google Scholar PsychINFO Summary of Evidence Sweet-tasting solutions significantly reduce pain of venipuncture in infants under 1 year of age (Gradin et al., 2002; Harrison et al., 2011). Amethocaine cream provided significant pain relief of venipuncture compared to EMLA cream in children 3 months - 15 years old (Lander & Weltman, 2006). Xylocaine topical spray significant reduced pain of venipuncture in neonates under 34 weeks gestation in addition to standard care (Chen et al., 2006). Jet delivery of lidocaine or a placebo provided superior pain relief to no pretreatment for children 5-18 years old (Auerbach et al., 2009). Children 6-12 years old self-reported less pain when distraction by flip-cards was used (Inal & Kelleci, 2011). External cold and vibration significantly reduced pain and anxiety in children ages 4-18 years old versus standard care (Baxter et al., 2011; Inal & Kelleci, 2012). Background Venipuncture is found to be a common cause of pain in children. (Inal & Kelleci, 2012) Venipuncture pain in children may lead to long term avoidance of seeking health care, immunizations, and donations. (Baxter et al., 2011) Searchable Question: What are best nursing practices to reduce the pain of venipuncture in children? Suggestions for Future Research Additional qualitative studies regarding various methods of pain reduction for venipuncture in children. Additional RCT studies to support use of sweet- tasting solutions for children over 1 year of age. Determine whether external cold and vibration devices could offer pain relief for more invasive procedures. Results Critical appraisal of the literature suggests that some form of pain control during venipuncture will be beneficial for children.

3 Research Question What are the best nursing practices to reduce the pain of venipuncture in children?

4 Background & Significance Venipuncture procedures are found to be a common cause of pain in children. (Inal & Kelleci, 2012) Venipuncture pain in children may lead to long-term negative effects later in life such as future avoidance of medical care, immunizations, and blood donations. (Baxter et al., 2011)

5 Topical Xylocaine Spray for Reducing the Pain of Venipuncture in Neonates (Chen, et al. 2006) Design: RCT, Level 2 Population: Newborn infants in the neonatal intensive care units with gestational age of more than 34 weeks (n=40) Sample: Purposive Sample/ Random Group Assignment Intervention: Administration of a 10% xylocaine solution pump spray applied topically before venipuncture. Findings: Infants in the study group had lower heart rate and less changes in oxygen saturations than infants in the control group. Strengths of the Study Financially feasible intervention RCT Weaknesses of the Study Small population Assumes that heart rate, respiratory rate and oxygen saturation are associated with pain.

6 A Randomized, Double-blind Controlled Study of Jet Lidocaine Compared to Jet Placebo for Pain Relief in Children Undergoing Needle Insertion in the Emergency Department (Auerbach et al. 2009) Design: RCT, Double Blind Study, Level 2 Population: Children ages of 5-18 at a pediatric hospital requiring acute needle insertion (venipuncture or peripheral venous cannulation) (n=197) Sample: Convenience Sample/ Random Group Assignment Intervention: Pretreatment with jet delivered lidocaine (n=75) or a with jet-delivered placebo 60 seconds before undergoing needle insertion. (n=75) Findings: The mean needle insertion pain score for both the jet lidocaine and the jet placebo groups were lower than the needle insertion pain scores for the no device group. Weaknesses of the Study Pain scores are subjective Parental presence or lack of was not documented for each patient Nonintervention group was smaller than the intervention groups Variations in providers skills could impact the study. Strengths of the Study RCT, Double-blind study Financially feasible intervention Large sample size Patients reported pain levels using a CAS tool

7 Pain reduction at venipuncture in newborns: oral glucose compared with local anesthetic cream (Gradin et. al, 2002) Design: Experimental-controlled randomized double blind Population: 201 Newborns Interventions: Newborns receiving glucose prior to venipuncture Findings: Significantly fewer scored as having pain (19.3%) compared to EMLA group (41.7%) Strengths of the Study Decreased wait time Easy to use RCT Large sample size Financially possible.. Weaknesses of the Study Habituation to glucose Difficult to measure pain Effectiveness applies to newborns only Unknown reason why glucose works best

8 Using non-nutritive sucking and oral glucose solution with neonates to relieve pain: A randomized controlled trial (Liu et. al, 2010) Design: Randomized, parallel group controlled trial Population: 105 neonates at least 32 weeks gestational Interventions: Newborns receiving glucose prior to venipuncture Findings: Glucose group and non nutritive sucking group had significantly lower pain scores than control group Weaknesses of the Study Limited generalizability No use of double blind Strengths of the Study Use of NIPS RCT Relevance to Clinical Practice

9 Sweet tasting solutions for reduction of needle-related procedural pain in children aged one to 16 years. (Harrison et al., 2011) f Design: Systematic Review of RCTs, Level I Evidence Population: 4 studies and 330 children 12 months to 16 years of age Intervention: The use of sweet tasting solutions in children over one year of age during venipuncture. Findings: Sweet tasting solutions did not show a reduction in pain with needle related proceedures in children 12 months to 16 years of age. Strengths of the Study High Level Cochrane Review Weaknesses of the Study Conflicting Studies Requires more well-conducted RCTs with larger sample sizes

10 Distracting children during blood draw: Looking through distraction cards (Inal & Kelleci, 2012) Design: RCT, Level II Population: Children 6 – 12 years (n=123) Sample: Convenience Sample, Random Group Assignment Intervention: Flippits® Distraction Cards during blood draw procedures Findings: Children receiving intervention self-reported and were observed to have less pain and anxiety Strengths of the Study RCT, large sample Financially feasible Weaknesses of the Study Not suitable for children with neurologic, visual, or auditory deficits Effectiveness after multiple uses with one child are unclear

11 EMLA and Amethocaine for reduction of childrens pain associated with needle insertion (Review) (Lander, Weltman, & So, 2010) Design: Systematic Review of RCT, Level I Population: 6 trials of 534 children 3 months to 15 years of age Intervention: Compared EMLA to Amethocaine in reduction of pain associated with venipuncture Findings: Amethocaine significantly reduced risk of pain when compared with EMLA Strengths of the Study High-level Cochrane review Exhaustive database search and hand- search of reference lists and journals Weaknesses of the Study Some of the trials used scales that had not been properly analyzed

12 An Integration of Vibration and Cold Relieves Venipuncture Pain in a Pediatric Emergency Department (Baxter et al., 2011) Design: RCT, Level II Population: Children 4-18 years (n=81) Sample: Convenience Sample/Random Group Assignment Intervention: The use of both cold & vibration during venipuncture Findings: Children in the device group had significantly lower pain by parent report and the observational scale than children in the standard care group Strengths of the Study RCT Quick-acting option vs. topical analgesics Low cost ($0.09 per attempt) Weaknesses of the Study Small Sample Subjects & coders not blinded to intervention groups No control for placebo effects

13 Relief of Pain During Blood Specimen Collection in Pediatric Patients (Inal & Kelleci, 2012) Design: RCT, Level II Population: Children 6-12 years (n=120) Sample: Convenience Sample/Random Group Assignment Intervention: using the Buzzy or cold & vibration applied to the site of insertion during venipuncture Findings: Children in the device group had significantly lower pain (p<0.001) and anxiety (p<0.001) Strengths of the Study RCT Quick-acting option vs. topical analgesics Large sample size Pain & anxiety levels not assess by researcher to limit bias Weaknesses of the Study Not double-blind No control for placebo effects Nurses not randomly selected

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

15 Future Research Additional qualitative studies regarding various methods of pain reduction for venipuncture in children. Additional RCT studies to support use of sweet-tasting solutions for children over 1 year of age. Determine whether external cold and vibration devices could offer pain relief for more invasive procedures.

16 Summary of Evidence Xylocaine topical spray significantly reduced the pain of venipuncture in neonates under 34 weeks gestation in addition to standard care. (Chen et al., 2006) Sweet-tasting solutions significantly reduce the pain of venipuncture in infants under one year of age. (Gradin et al., 2002; Harrison et al., 2011).

17 Summary of Evidence Children 6-12 years old self-reported less pain when distraction by flip- cards was used (Inal & Kelleci, 2011). External cold and vibration significantly reduced pain and anxiety in children ages 4-18 years old versus standard care (Baxter et al., 2011; Inal & Kelleci, 2012).

18 Summary of Evidence Jet delivery of lidocaine or a placebo provided superior pain relief to no pretreatment for children 5-18 years old. (Auerbach et al., 2009) Amethocaine cream provided significant pain relief of venipuncture compared to EMLA cream in children 3 months - 15 years old. (Lander & Weltman, 2006)

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

20 Implementation Create EBP quality intervention teams Provide training for staff regarding pain relief methods Implement protocol for venipuncture pain relief

21 Evaluation Assess pain using hospital approved pain scales Document pain response to used intervention Periodic review of documentation regarding response to intervention

22 Conclusion Pain control methods can be achieved through various inexpensive, non- invasive means. Further education and training is advised for nursing staff regarding pain reduction techniques for children. Reduction of pain in children during venipuncture will help prevent increased pain and anxiety in future procedures.

23 References Auerbach, M., Tunik, M., & Mojica, M. (2009). A randomized, double-blind controlled study of jet lidocaine compared to jet placebo for pain relief in children undergoing needle insertion in the emergency department. Academic Emergency Medicine, 16(5), doi: /j x Baxter, A., Cohen, L., McElvery, H., Lawson, M., & von Baeyer, C. (2011). An integration of vibration and cold relieves venipuncture pain in a pediatric emergency department. Pediatric Emergency Care, 27(12), Chen, H., Tzeng, C., Liu, W., Huang, Y., & Chen, Y. (2006). Topical xylocaine spray for reducing the pain of venipuncture in neonates. Clinical Neonatology, 13(2), Gradin, M., Eriksson, M., Holmqvist, G., Holstein, Å., & Schollin, J. (2002). Pain reduction at venipuncture in newborns: oral glucose compared with local anesthetic cream. Pediatrics, 110(6 part 1), Harrison D., Yamada J., Adam-Webber T., Ohlsson A., Beyene J., & Stevens B. Sweet tasting solutions for reduction of needle-related procedual pain in children aged one to 16 years. cochrane review 2011, Issue 10

24 References Inal, S., & Kelleci, M. (2012). Distracting children during blood draw: Looking through distraction cards is effective in pain relief of children during blood draw. International Journal Of Nursing Practice, 18(2), doi: /j X x İnal, S., & Kelleci, M. (2012). Relief of Pain During Blood Specimen Collection in Pediatric Patients. MCN: The American Journal Of Maternal Child Nursing, 37(5), doi: /NMC.0b013e31825a8aa Lander JA, Weltman BJ, So SS. EMLA and Amethocaine for reduction of children's pain associated with needle insertion. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD DOI: / CD pub2. Liu, M., Lin, K., Chou, Y., & Lee, T. (2010). Using non-nutritive sucking and oral glucose solution with neonates to relieve pain: A randomized controlled trial. Journal Of Clinical Nursing, 19(11-12),


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