Venipuncture In Children Research Articles

WITHDRAWN: EMLA and Amethocaine for reduction of children's pain associated with needle insertion.

Background Children often experience pain from needle insertion procedures; therefore, several topical anaesthetics have been developed. Objectives Compare the topical anaesthetics amethocaine and an eutectic mixture of local anaesthetics (EMLA) in terms of anaesthetic efficacy, ease of needle insertion and adverse events when used for intravenous cannulation and venipuncture in children. Search methods An exhaustive search that included over 30 databases and handsearching reference lists and journals. Selection criteria Randomized controlled trials (RCTs) were selected that compared EMLA and amethocaine for relieving children's pain from intravenous cannulation or venipuncture. Data collection and analysis Two review authors independently determined eligibility for inclusion by assessing trial quality. Details of eligible studies were summarized. One author was contacted for additional information. Information about adverse events was obtained from the text of the trial reports. Review Manager 4.2 was used to perform a meta‐analysis and compute relative risks (RR) with 95% confidence intervals (CI). Main results Six trials consisting of 534 children, three months to 15 years of age, were included in this review. A meta‐analysis was performed comparing amethocaine with EMLA on anaesthetic efficacy, ease of needle procedure and resultant skin changes. For anaesthetic efficacy, amethocaine significantly reduced the risk of pain compared to EMLA when all pain data were combined into a common pain metric (RR 0.78, 95% CI 0.62 to 0.98); when pain was self‐reported by children (RR 0.63, 95% CI 0.45 to 0.87); or when pain was observed by researchers (sensitivity analysis: RR 0.71, 95% CI 0.52 to 0.96). Compared to EMLA, amethocaine significantly reduced the risk of pain when drugs were applied for the following durations: for 30 to 60 minutes (RR 0.61, 95% CI 0.41 to 0.91); when applied according to manufacturer's instructions (sensitivity analysis: RR 0.64, 95% CI 0.46 to 0.89); and when applied for over 60 minutes (RR 0.70, 95% CI 0.51 to 0.96). Amethocaine was also significantly more efficacious than EMLA when used specifically for intravenous cannulation (RR 0.70, 95% CI 0.55 to 0.88). Insufficient data were available to compare anaesthetic efficacy for venipuncture. A comparison of amethocaine and EMLA for ease of a needle procedure was not significant; only one trial reported data that could be included. For skin changes, EMLA was favoured in the analysis of erythema (RR 14.83, 95% CI 2.28 to 96.36). Erythema was observed after use of amethocaine whereas blanching was observed after using EMLA. Adverse effects included itching and one case of conjunctival irritation. Authors' conclusions Although EMLA is an effective topical anaesthetic for children, amethocaine is superior in preventing pain associated with needle procedures.

Comparison between the Analgesic Effect of two Techniques on the Level of Pain Perception During venipuncture in Children up to 7 Years of Age: A Quasi-Experimental Study.

Distraction techniques are often provided by nurses, parents or child life specialists and help in pain alleviation during procedures. The use of non pharmacological procedures to cope with pain behaviour is less costly and most of these procedures can be administered by a nurse. Hence, the aim of the present study was to assess and compare the analgesic effect of holding the child by a family member versus holding the child by a family member along with an animation distraction intervention on the level of pain perception during venipuncture in children up to seven years of age. Purposive sampling technique was used to select 70 children admitted in paediatric ward of Guru Gobind Singh Medical Hospital, Faridkot, 35 children in each group viz. Group 1(child held by family member during venipuncture) and Group 2 (child held by family member along with an animation distraction during venipuncture) and video clippings were made for each subject in both groups. Standardized FLACC pain scale was used to assess the level of pain during venipuncture by seeing the video clips of procedure in both groups. Findings revealed that the mean pain score of Group 1 was 3.86 and that of Group 2 was 2.43. Findings revealed that in Group 1 majority 31(88.57%) got severe pain and none remained relaxed during venipuncture whereas in Group 2 majority 10(28.58%) got moderate pain, 09(25.71%) remained relaxed and only 07(20%) got severe pain. The comparison of mean pain score of both groups was checked statistically by computing independent t-test and the value of t comes out to be 7.199 with p-value 0.000*** which was found to be highly significant. The study concluded that when during painful procedures like venipuncture if children are given any non-pharmacological intervention like animated distraction along with their family member it helps in managing the pain. In other words, it distracts/diverts the child's attention from pain and results in better cooperation of child during procedure.

Effects of Topical Anesthetic Cream on Pain at Venipuncture in Children.

PURPOSE: This study was done to evaluate the effectiveness of EMLA cream on pain related to venipuncture among children.METHODS: In this study, 48 children were evaluated using a sequential measurement for level of pain by Skin Conductance Level (SCL) based on Galvanic Skin Response (GSR), heart rate, and the Visual Analogue Scale (VAS) at four times.RESULTS: The maximum and mean of the SCL were each significantly different between the experimental and control groups and furthermore, the two were also significantly different among observed times. In addition there was a significant interaction between group and time. The children's perceived pain using VAS was not significantly different between the experimental and control groups. There was no significant difference in the heart rate between the experimental and control groups; however, the interaction between group and time was significant.CONCLUSION: In conclusion, applying topical anesthetic cream to the venipuncture site to reduce pain was effective among the children and therefore it is highly recommended that topical anesthetic cream be applied at the venipuncture site as a nursing intervention to reduce pain when a child has to undergo a venipuncture.

Kinderanästhesie - Der schwierige Venenzugang

Venipunctures in children are difficult. Some factors can hardly be influenced, for example, a well-developed subcutaneous fat tissue. Technical devices may help to identify invisible veins. With the help of ultrasound deep peripheral veins on the wrists and ankles can be presented and punctured. Stiff resistance of a child thwarts any successful puncture. Children should therefore be adequately sedated, if cannot be induced by mask. Missing practice venipuncture and inadequate knowledge of appropriate puncture sites can be met easily by practicing and reading.The possibility of intraosseous puncture today is standard of anesthesia care for children. Within in a few seconds, a secure access to the vein system can be created.

A Comparison of Amethocaine and Liposomal Lidocaine Cream as a Pain Reliever Before Venipuncture in Children

Although the use of anesthetic creams before intravenous (IV) insertion has been shown to be both safe and effective in decreasing pain during IV cannulation, the use of any single agent based on efficacy is not yet considered the standard of care in children. We sought to compare a commonly used preparation, 4% liposomal lidocaine (Maxilene), with 4% amethocaine (Ametop), a newer agent with reportedly good efficacy and an intrinsic vasodilatory effect. A total of 60 children aged 5 to 12 years were randomized to receive topically either 4% amethocaine or 4% liposomal lidocaine before IV cannulation. The primary outcome variable was the child's rating of pain using the Faces Pain Scale - Revised. Secondary outcomes included success rate on first IV cannulation attempt, cannulation difficulty ratings by the nurses, and adverse skin reactions. We found no statistically significant differences in self-reported scores in the Faces Pain Scale-Revised with the use of 4% amethocaine versus 4% lidocaine before IV cannulation. There was a trend toward fewer IV cannulation attempts in the 4% amethocaine group. Adverse skin reactions were uncommon, and there were no statistically significant differences between groups. This study demonstrates that there is no difference between 4% amethocaine and 4% liposomal lidocaine in reducing pain associated with IV cannulation in children. Amethocaine confers no advantage in improving IV cannulation success rate over lidocaine. Both agents are associated with few local adverse skin reactions.

Visualizing Veins With Near-Infrared Light to Facilitate Blood Withdrawal in Children

This study aims to evaluate for the first time the value of visualizing veins by a prototype of a near-infrared (NIR) vascular imaging system for venipuncture in children. An observational feasibility study of venipunctures in children (0-6 years) attending the clinical laboratory of a pediatric university hospital during a period of 2 months without (n = 80) and subsequently during a period of 1 month with a prototype of an NIR vascular imaging system (n = 45) was conducted. Failure rate (ie, more than 1 puncture) and time of needle manipulation were determined. With the NIR vascular imaging system, failure rate decreased from 10/80 to 1/45 (P = .05) and time decreased from 2 seconds (1-10) to 1 second (1-4, P = .07). This study showed promising results on the value of an NIR vascular imaging system in facilitating venipunctures.

463 Passive Distraction is the Only Determinant of Pain During Venous Blood Sampling in School Children in An Outpatient Clinic Setting

Introduction: Non-pharmacological interventions can be used to minimize discomfort, but data on the impact of non-pharmacological interventions on procedural pain in children are limited. We therefore evaluated the impact of distraction (TV watching) during elective venipuncture in children. Methods: 58 children (6-12 years) were asked to document pain perception (VASc score, cm) during venipuncture. Parents (VASp) and nurses (VASn) were also asked to quantify procedural pain as perceived by them. In 31 cases, the child was stimulated to watch a movie chosen by the child (passive distraction group). Characteristics and VASc scores between groups were compared (unpaired) and risk factors for increased VASc score (> 4) were entered in a multiple logistic model, interrater agreement (kappa) was used to compare VASc with VASp and VASn. Results: Median VASc was 2.2 (range 0-7.3), 11/58 children reported VASc >4 (2 in distraction group). Median VASc was lower in the distraction group (1.5 to 3.1, p 4. Median VASp and VASn were 2.5 and 2. Although correlations with VASc were 0.74 and 0.53, kappa-scores were fair (0.23 and 0.31). Conclusions: Although the median difference (1.5 vs 3.1) in VASc during distraction is limited, it does result in a significant decrease in VASc>4 observations. Interrater agreement was fair, confirming that hetero-evaluation of pain remains poor.

45: A Clinical Study to Evaluate the Efficacy of 4% Liposomal Lidocaine as Compared to Placebo for Pain Reduction of Nonemergent Venipuncture in Adults

There is a multitude of literature describing the benefits of topical anesthetics for pain reduction during venipuncture in children, but no study to date has shown a pain reduction from topical anesthetic use during venipuncture in adults. This study was a randomized, double-blind, placebo-controlled trial to assess the efficacy of an existing topical anesthetic- 4% liposomal lidocaine (LMX-4 ®) already in use for children, for pain relief in adult patients during non-emergent venipuncture procedures.

A needle-free powder lignocaine delivery system reduced the pain of venipuncture in children

W T Zempsky Dr W T Zempsky, Connecticut Children’s Medical Center, Hartford, CT, USA; wzempsk@ccmckids.org Does a needle-free powder lignocaine (lidocaine) delivery system reduce the pain of venipuncture in children?...

The influence of distraction on pain and anxiety during venipuncture in children aged between 8 and 11 years

Objective: As in adults, psychological factors such as stress, anxiety and the impact of the medical procedure may influence the experience of procedure pain in children. In this study we focused on pain during venipuncture in children. Anxiety seems to be an important predictor of the pain experience. Cognitive processes of anxiety, such as catastrophising and avoidance behaviour, can be influenced in various ways. One way of reducing pain and anxiety is distraction. Methods: A randomised and controlled experimental design study was conducted in a research population of 20 ambulatory patients aged between 8 and 11 years old, who were referred to the specialised department for child venipuncture at the University Hospital of Maastricht. Our distraction intervention was completing a find-the-hidden-items puzzle. Control patients did not receive any distraction. Results: Distraction did not reduce pain and anxiety in the experimental group as compared with the control group. Children with high anxiety reported more pain than children with low anxiety. The results for catastrophising showed the same trend as the low- and high-anxiety groups, but were not statistically significant. Distraction lowers anxiety in children who do not watch the venipuncture, but not in children who prefer to watch the venipuncture. Conclusion: Distraction can be an effective intervention to decrease pain and anxiety, when controlling for anxiety levels and eye orientation. (Netherlands Journal of Psychology, 63, 21-28.)

Effects of Distraction on Pain, Fear, and Distress During Venous Port Access and Venipuncture in Children and Adolescents With Cancer

This study evaluates the effect of self-selected distracters (ie, bubbles, I Spy: Super Challenger book, music table, virtual reality glasses, or handheld video games) on pain, fear, and distress in 50 children and adolescents with cancer, ages 5 to 18, with port access or venipuncture. Using an intervention-comparison group design, participants were randomized to the comparison group (n = 28) to receive standard care or intervention group (n = 22) to receive distraction plus standard care. All participants rated their pain and fear, parents rated participant fear, and the nurse rated participant fear and distress at 3 points in time: before, during, and after port access or venipuncture. Results show that self-reported pain and fear were significantly correlated (P = .01) within treatment groups but not significantly different between groups. Intervention participants demonstrated significantly less fear (P <.001) and distress (P = .03) as rated by the nurse and approached significantly less fear (P = .07) as rated by the parent. All intervention parents said the needlestick was better because of the distracter. The authors conclude that distraction has the potential to reduce fear and distress during port access and venipuncture.

Analgesic effect of watching TV during venipuncture

Aims: To assess the analgesic effect of passive or active distraction during venipuncture in children. Methods: We studied 69 children aged 7–12 years undergoing venipuncture. The children were randomly divided...

Iatrogenic Brachial and Femoral Artery Complications Following Venipuncture in Children

Catheter- or noncatheter-related peripheral arterial complications such as arterial pseudoaneurysm, embolus, or arteriovenous fistula may be seen in the pediatric age group. The most common etiologies defined for arterial complications are peripheral arterial puncture performed for a routine arterial blood gas analysis, arterial catheters placed for invasive monitorization of children, or catheterization performed for diagnostic purposes through the peripheral arterial system, most commonly the femoral artery. Nine children with peripheral arterial complications, whose ages varied between 2 months and 2.5 years, were enrolled in this study. All patients were treated surgically. Following physical examination, Doppler ultrasonography, computed tomography angiography, magnetic resonance angiography, or digital subtraction angiography were used as diagnostic tools. We studied thrombophilic panels preoperatively. Six patients had brachial artery pseudoaneurysms that developed accidentally during venipuncture, I had a brachial arteriovenous fistula that developed after an accidental brachial artery puncture during routine peripheral blood analysis. In the remaining 2 patients, peripheral arterial embolic events were detected. One had a left brachial arterial embolus and the other had a sudden onset right femoral artery embolus that was detected via diagnostic interventions. No morbidity such as amputation, extremity loss, or mortality occurred due to the arterial events or surgery. All patients were discharged from the hospital in good clinical condition. In all patients, follow-up at 3 or 6 months revealed palpable peripheral artery pulsations of the ulnar and radial arteries at wrist level. Because the incidence of peripheral arterial complications is relatively low in children compared to adults, the diagnostic and therapeutic approaches are extrapolated from the adult guidelines. We proposed that early diagnosis and surgical approach prevented the complications from further developing in the affected extremity in these particular cases.

Tips for venipuncture in children

Tips for venipuncture in children

Randomized, double-blind, placebo-controlled study of ALGRX 3268: A topical lidocaine delivery system for topical anesthesia prior to venipuncture in children

ALGRX 3268 is a needle-free product that accelerates lidocaine into the skin under pressure of helium gas to provide topical anesthesia within 1 minute. In this single center, randomized, double-blind, placebo controlled trial, ALGRX 3268 (0.5 mg lidocaine delivered at 20 bar) or matching placebo was administered to 306 children ages 3–18 prior to venipuncture. Pain was assessed by children after ALGRX 3268 administration and after venipuncture performed at the back of the hand. Pain assessment was performed 2–3 minutes after venipuncture.

A Comparison of Distraction Strategies for Venipuncture Distress in Children

To compare the effects of two pediatric venipuncture distress-management distraction strategies that differed in the degree to which they required children's interaction. Eighty-eight 1- to 7-year-old children receiving venipuncture were randomly assigned to one of three treatment conditions: interactive toy distraction, passive movie distraction, or standard care. Distress was examined via parent, nurse, self-report (children over 4 years), and observational coding. Engagement in distraction was assessed via observational coding. Children in the passive condition were more distracted and less distressed than children in the interactive condition. Although children in the interactive condition were more distracted than standard care children, there were no differences in distress between these groups. Despite literature that suggests that interactive distraction should lower distress more than passive distraction, results indicate that a passive strategy might be most effective for children's venipuncture. It is possible that children's distress interfered with their ability to interact with the distractor.

A Randomized Controlled Trial to Evaluate S-Caine Patch™ for Reducing Pain Associated with Vascular Access in Children

A randomized, double-blinded trial was performed to evaluate the efficacy and safety of the S-Caine Patch (ZARS, Inc., Salt Lake City, UT), a eutectic mixture of lidocaine and tetracaine, for pain relief during venipuncture in children. With institutional review board approval, parental consent, and patient assent, 64 children who were scheduled for medically indicated vascular access at two centers were randomly assigned (2:1) to receive either an S-Caine Patch or a placebo patch for 20 min before venipuncture procedures. The primary outcome measure was the child's rating of pain during venipuncture using the Oucher pain scale. Additional measures of efficacy included the blinded investigator's and an independent observer's four-point categorical scores. Variables were compared between treatments using Mantel-Haenszel summary chi-square tests or Pearson chi-square tests. The S-Caine Patch produced significantly greater pain relief compared with placebo (median Oucher scores of 0 vs. 60; P < 0.001). Fifty-nine percent of the children in the S-Caine Patch group reported no pain compared with 20% of the children in the placebo patch group. The investigator estimated that 76% of the children in the S-Caine Patch group experienced no pain during venipuncture versus 20% in the placebo patch group (P = 0.001). Independent observer ratings also favored the S-Caine Patchtrade mark (P < 0.001). Mild skin erythema (< 38%) and edema (< 2%) occurred with similar frequencies between the groups. This study demonstrated that a 20-min application of the S-Caine Patch is effective in lessening pain associated with venipuncture procedures. Adverse events after S-Caine Patch application were mild and transient.

Family Presence During Invasive Procedures and Resuscitation in the Emergency Department: A Review of the Literature

Family Presence During Invasive Procedures and Resuscitation in the Emergency Department: A Review of the Literature

Prediction of outcome: The procedural pain attitudes scale: Relations among parent attitudes, parent anxiety, and child pain

Healthy children endure a number of painful medical procedures (e.g., immunizations, venipunctures). In order to develop effective pain management interventions, it is important to consider factors that relate to the variability in children's pain experience. One such variable might be parents' attitudes about pediatric procedural pain. The current study uses a newly developed scale to examine relations among these attitudes, parent anxiety, and child venipuncture pain. Eighty-eight 1- to 7-year-old children received venipucture as part of pre-surgery testing. Parent procedural pain attitudes were measured using the Procedural Pain Attitudes Scale (PPAS), a 7-item scale designed for this study. Child pain was assessed via self-report, parent-report, nurse-report, and an observational scale. In addition, parent general anxiety was evaluated with the State-Trait Anxiety Inventory (STAI), and parent procedural anxiety was assessed with self-report and nurse-report. The PPAS demonstrated good internal consistency (cronbach's alpha .75). Parent scores on the PPAS negatively correlated with all measures of children's venipuncture pain, parent state and trait anxiety, and nurse report of parent procedural anxiety. However, parents' self-report of anxiety was not associated with their PPAS scores. The PPAS is a brief scale with clinical and research utility. Although further validation is necessary, this initial study indicates that it is strongly associated with children's procedural distress and parent anxiety. Thus, the PPAS might serve as an effective screening tool to identify children at risk for negative procedural experiences and parents in need of intervention. Future work should seek to determine whether children's procedural pain impacts parents' attitudes, whether attitudes influence children' experiences, or whether a third variable is driving the relations.

Methaemoglobin formation after the use of EMLA cream in term neonates

EMLA cream 5% (a eutectic mixture of lidocaine and prilocaine) is a topical anaesthetic that has become widely used to minimize pain from venipuncture in children. It has not, however, been recommended in neonates owing to the potential risk of methaemoglobinaemia induced by prilocaine. The aim of this study was to establish the safety of 1 g EMLA cream 5% used on intact skin in term neonates. Forty‐seven neonates, aged 0‐3 months, with a postconceptual age of ≥37 weeks and a body weight between 2.8 and 5.7 kg, were included in a double‐blind, randomized, placebo‐controlled study. After baseline observations a total dose of 1.0 g EMLA/placebo was applied to two sites (0.5 g site−1) for 60‐70 min. Venous methaemoglobin (metHb) levels were determined in each patient at baseline and at three randomly assigned times, 0.5‐18h after application. Following application of the cream, the mean metHb levels were 1.17% (range 0.50‐2.53) in the EMLA group and 0.96% (range 0.50‐1.53) in the placebo group. The metHb concentrations were significantly higher in the EMLA group in the intervals from 3.5 to 13 h after application than in the placebo group, but were well below potentially harmful levels. Based on these results, a 1‐h application of 1 g EMLA cream is safe when used on the intact skin of term neonates below 3 months of age.