Survey of Interventions for Needle Procedures
Survey of Interventions for Needle Procedures
Needle procedures are a necessary component of the treatment of hospitalized children. However, for many children they can be both painful and distressing. There was concern among the nurses at our pediatric hospital that we were not adequately controlling pain from needle procedures. We were interested in obtaining more information about the incidence and types of needle procedures and the current use of topical analgesics. A survey was designed to describe the frequency, type, time to complete, and perceived ease of needle procedures. The use of topical anesthetics and other comfort measures was also examined. The most common needle procedures performed were venipunctures for blood work, followed by intravenous cannulations, capillary sticks, port-a-cath access, and intramuscular injections. In total, 387 procedures were performed over a 23-day period. The majority of the procedures were perceived as easy, and the modal time to complete the procedures was 5 minutes. A topical anesthetic was used for 74 procedures (i.e., 19%), and the majority of these procedures were performed on the medical day unit with oncology patients. Results of the survey provided information about the day-to-day practice of needle procedures in order to identify both the supports and the barriers to providing these procedures atraumatically. Examining needle procedures within a framework of atraumatic care broadened our perspective and enabled us to integrate the use of topical anesthetics as just one of a number of strategies to minimize the pain and distress associated with needle procedures.
Invasive procedures, particularly procedures that involve needles, can cause substantial anxiety and pain in a pediatric setting. Many children view receiving needles as one of the most traumatic aspects of being in the hospital (Cordoni & Cordoni, 2001; Cummings, Reid, Finley, McGrath, & Ritchie 1996). Parents rate needle procedures as the second-most-distressing event during their child's hospitalization, second only to waiting for their child during surgery (Caty, Ritchie, & Ellerton, 1989). The most frequent needle procedures that hospitalized children encounter include venipuncture for laboratory blood sampling, intravenous (IV) cannulation, and intramuscular injections. The amount of pain caused by these procedures varies across studies, and reports range from mild to severe (Arts et al., 1994; Eland, 1981; Goodenough et al., 1997; Fowler-Kerry & Lander, 1987; McGrath et al., 1990). On average, younger children experience more pain and anxiety than older children (Fowler-Kerry & Lander; Fradet, McGrath, Kay, Adams, & Luke 1990). For some individuals, a fear of needles persists into adulthood and may have lifelong negative repercussions, such as preventing them from donating blood (Oswalt & Napoliello, 1974) or precipitating fainting episodes in response to a needle (Pavlin, Links, Rapp, Nessley, & Keyes 1993).
Studies that predate the widespread use of conscious sedation for bone marrow aspirations and lumbar punctures indicate that children's pain and distress may escalate over time with successive procedures (Ellis & Spanos, 1994; Jay, Ozolins, Elliott, & Caldwell, 1983; Katz, Kellerman, & Siegel, 1980; Kellerman, Zeltzer, Ellenberg, & Dash, 1983). Furthermore, research suggests that if painful procedures are not adequately managed, children may suffer negative short- and long-term psychological effects, such as anticipatory nausea and vomiting, insomnia, eating problems, and treatment nonadherence (Ross & Ross, 1988; Walco, Cassidy, & Schechter, 1994; Weisman, Bernstein, & Schechter, 1998). Taken together, these studies highlight the importance of ensuring that children's distress during needle procedures is recognized and that efforts are made to control the pain and minimize the distress.
A significant development in minimizing children's pain and distress during needle procedures has been the dramatic increase in the use of topical anesthetics such as EMLA cream (eutectic mixture of local anesthetics; Astra Pharmaceutical Products) or Ametop Gel (Smith & Nephew). In many hospitals, it is standard practice to use some type of topical anesthetic for all procedures that involve needles (Finley, 2001). These products provide pain relief at the insertion point of the needle and are relatively inexpensive and easy to use (Fetzer, 2002; Taddio, Gurguis, & Koren, 2002). EMLA cream is a mixture of equal parts of 2.5% lidocaine and 2.5% prilocaine and is applied to the skin, then covered with an occlusive dressing and left in place for at least 60 minutes. The peak action for EMLA occurs at 2 hours and lasts for as long as 4 to 5 hours. A disadvantage of EMLA is that vasoconstriction of the vein has been documented, but this effect is reduced if the cream remains in place for longer than the minimum 60 minutes (Moureau & Zonderman, 2000). The most common side effects of EMLA include local skin reactions, such as itching or a minor skin rash, which quickly disappears when EMLA and the occlusive dressing are removed. Allergic reactions to EMLA are extremely rare, but mild systemic reactions have appeared in a small percentage of patients with known allergies to lidocaine. Ametop Gel (tetracaine 4%) provides analgesia similar to EMLA's but has the advantage of a more rapid onset of action. It works in about 30 to 45 minutes, lasts for 4 to 6 hours after a single application, and does not cause vasoconstriction. Ametop Gel is more expensive, at $2.97 per dose, than EMLA, at $1.31 per dose.
The use of a topical anesthetic was not mandatory for needle procedures at this hospital, and there was a perception among the nurses that needle pain was not adequately controlled and that topical anesthesia was not being used in a systematic manner. Two recent studies conducted within our hospital indicated that procedural pain, and in particular needle pain and associated anxiety, warranted closer examination. In the first study (Ellis et al., 2002), the pain intensity of a variety of procedures including needles was described as part of a hospitalwide pain prevalence survey that included 237 medical and surgical patients. Procedural pain ratings were obtained from either the child or the parent immediately after a potentially painful procedure. The average procedural pain rating was 4.38/10 (SD = 3.7), which is indicative of moderate pain. In a more recent study (Ellis et al. 2004), nurses' attitudes about procedural pain were assessed, and although they strongly agreed that nurses could make a difference in how children coped with painful events, they agreed only somewhat that they adequately prepared children and parents for painful procedures. Taken together these two findings indicated that the management of procedural pain in our hospital at least warranted further investigation and potentially intervention, including changes in institutional policies, to improve practice.
An obvious direction would be the development of a policy that required the use of topical anesthetic for all needle procedures. However, questions were raised as to whether this approach was necessary for all procedures, noting that such a policy has financial and human resource implications. In addition, anecdotal evidence suggested that for a few children, EMLA actually added to their distress. For these children, the application and removal of the occlusive dressing was perceived as a traumatic aspect of the needle procedure. Similarly, Cohen and colleagues (1999) reported high distress scores in an EMLA group compared with a group receiving standard care and distraction and suggested that waiting for 60 minutes before inserting the needle might increase anticipatory anxiety.
A detailed examination of the issue was undertaken before a decision about a policy to require a topical anesthetic for all needle procedures. This naturalistic study was designed to capture typical practice as it happens and not to alter it in any way for the purposes of the study. The objectives of the study were (a) to describe the frequency and types of needle procedures performed over a 5-day period; (b) to describe the current use and perceived effectiveness of EMLA and Ametop Gel; (c) to describe the use of nonpharmacologic comfort measures during needle procedures; and (d) to describe the time to complete and the perceived ease of needle procedures. The goal of the study was to provide data that would inform the development of a policy with regard to the use of EMLA or Ametop Gel in conjunction with nonpharmacologic measures to manage needle pain.
Needle procedures are a necessary component of the treatment of hospitalized children. However, for many children they can be both painful and distressing. There was concern among the nurses at our pediatric hospital that we were not adequately controlling pain from needle procedures. We were interested in obtaining more information about the incidence and types of needle procedures and the current use of topical analgesics. A survey was designed to describe the frequency, type, time to complete, and perceived ease of needle procedures. The use of topical anesthetics and other comfort measures was also examined. The most common needle procedures performed were venipunctures for blood work, followed by intravenous cannulations, capillary sticks, port-a-cath access, and intramuscular injections. In total, 387 procedures were performed over a 23-day period. The majority of the procedures were perceived as easy, and the modal time to complete the procedures was 5 minutes. A topical anesthetic was used for 74 procedures (i.e., 19%), and the majority of these procedures were performed on the medical day unit with oncology patients. Results of the survey provided information about the day-to-day practice of needle procedures in order to identify both the supports and the barriers to providing these procedures atraumatically. Examining needle procedures within a framework of atraumatic care broadened our perspective and enabled us to integrate the use of topical anesthetics as just one of a number of strategies to minimize the pain and distress associated with needle procedures.
Invasive procedures, particularly procedures that involve needles, can cause substantial anxiety and pain in a pediatric setting. Many children view receiving needles as one of the most traumatic aspects of being in the hospital (Cordoni & Cordoni, 2001; Cummings, Reid, Finley, McGrath, & Ritchie 1996). Parents rate needle procedures as the second-most-distressing event during their child's hospitalization, second only to waiting for their child during surgery (Caty, Ritchie, & Ellerton, 1989). The most frequent needle procedures that hospitalized children encounter include venipuncture for laboratory blood sampling, intravenous (IV) cannulation, and intramuscular injections. The amount of pain caused by these procedures varies across studies, and reports range from mild to severe (Arts et al., 1994; Eland, 1981; Goodenough et al., 1997; Fowler-Kerry & Lander, 1987; McGrath et al., 1990). On average, younger children experience more pain and anxiety than older children (Fowler-Kerry & Lander; Fradet, McGrath, Kay, Adams, & Luke 1990). For some individuals, a fear of needles persists into adulthood and may have lifelong negative repercussions, such as preventing them from donating blood (Oswalt & Napoliello, 1974) or precipitating fainting episodes in response to a needle (Pavlin, Links, Rapp, Nessley, & Keyes 1993).
Studies that predate the widespread use of conscious sedation for bone marrow aspirations and lumbar punctures indicate that children's pain and distress may escalate over time with successive procedures (Ellis & Spanos, 1994; Jay, Ozolins, Elliott, & Caldwell, 1983; Katz, Kellerman, & Siegel, 1980; Kellerman, Zeltzer, Ellenberg, & Dash, 1983). Furthermore, research suggests that if painful procedures are not adequately managed, children may suffer negative short- and long-term psychological effects, such as anticipatory nausea and vomiting, insomnia, eating problems, and treatment nonadherence (Ross & Ross, 1988; Walco, Cassidy, & Schechter, 1994; Weisman, Bernstein, & Schechter, 1998). Taken together, these studies highlight the importance of ensuring that children's distress during needle procedures is recognized and that efforts are made to control the pain and minimize the distress.
A significant development in minimizing children's pain and distress during needle procedures has been the dramatic increase in the use of topical anesthetics such as EMLA cream (eutectic mixture of local anesthetics; Astra Pharmaceutical Products) or Ametop Gel (Smith & Nephew). In many hospitals, it is standard practice to use some type of topical anesthetic for all procedures that involve needles (Finley, 2001). These products provide pain relief at the insertion point of the needle and are relatively inexpensive and easy to use (Fetzer, 2002; Taddio, Gurguis, & Koren, 2002). EMLA cream is a mixture of equal parts of 2.5% lidocaine and 2.5% prilocaine and is applied to the skin, then covered with an occlusive dressing and left in place for at least 60 minutes. The peak action for EMLA occurs at 2 hours and lasts for as long as 4 to 5 hours. A disadvantage of EMLA is that vasoconstriction of the vein has been documented, but this effect is reduced if the cream remains in place for longer than the minimum 60 minutes (Moureau & Zonderman, 2000). The most common side effects of EMLA include local skin reactions, such as itching or a minor skin rash, which quickly disappears when EMLA and the occlusive dressing are removed. Allergic reactions to EMLA are extremely rare, but mild systemic reactions have appeared in a small percentage of patients with known allergies to lidocaine. Ametop Gel (tetracaine 4%) provides analgesia similar to EMLA's but has the advantage of a more rapid onset of action. It works in about 30 to 45 minutes, lasts for 4 to 6 hours after a single application, and does not cause vasoconstriction. Ametop Gel is more expensive, at $2.97 per dose, than EMLA, at $1.31 per dose.
The use of a topical anesthetic was not mandatory for needle procedures at this hospital, and there was a perception among the nurses that needle pain was not adequately controlled and that topical anesthesia was not being used in a systematic manner. Two recent studies conducted within our hospital indicated that procedural pain, and in particular needle pain and associated anxiety, warranted closer examination. In the first study (Ellis et al., 2002), the pain intensity of a variety of procedures including needles was described as part of a hospitalwide pain prevalence survey that included 237 medical and surgical patients. Procedural pain ratings were obtained from either the child or the parent immediately after a potentially painful procedure. The average procedural pain rating was 4.38/10 (SD = 3.7), which is indicative of moderate pain. In a more recent study (Ellis et al. 2004), nurses' attitudes about procedural pain were assessed, and although they strongly agreed that nurses could make a difference in how children coped with painful events, they agreed only somewhat that they adequately prepared children and parents for painful procedures. Taken together these two findings indicated that the management of procedural pain in our hospital at least warranted further investigation and potentially intervention, including changes in institutional policies, to improve practice.
An obvious direction would be the development of a policy that required the use of topical anesthetic for all needle procedures. However, questions were raised as to whether this approach was necessary for all procedures, noting that such a policy has financial and human resource implications. In addition, anecdotal evidence suggested that for a few children, EMLA actually added to their distress. For these children, the application and removal of the occlusive dressing was perceived as a traumatic aspect of the needle procedure. Similarly, Cohen and colleagues (1999) reported high distress scores in an EMLA group compared with a group receiving standard care and distraction and suggested that waiting for 60 minutes before inserting the needle might increase anticipatory anxiety.
A detailed examination of the issue was undertaken before a decision about a policy to require a topical anesthetic for all needle procedures. This naturalistic study was designed to capture typical practice as it happens and not to alter it in any way for the purposes of the study. The objectives of the study were (a) to describe the frequency and types of needle procedures performed over a 5-day period; (b) to describe the current use and perceived effectiveness of EMLA and Ametop Gel; (c) to describe the use of nonpharmacologic comfort measures during needle procedures; and (d) to describe the time to complete and the perceived ease of needle procedures. The goal of the study was to provide data that would inform the development of a policy with regard to the use of EMLA or Ametop Gel in conjunction with nonpharmacologic measures to manage needle pain.
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