Docstoc

Best Practices for Pain Reduction Associated with

Document Sample
Best Practices for Pain Reduction Associated with Powered By Docstoc
					    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
            Searchable Question: What are best nursing practices to reduce the pain of venipuncture in children?




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

  What are the best nursing

practices to reduce the pain of

  venipuncture in children?
 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)
         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                               Weaknesses of the Study

    •    Financially feasible intervention               •    Small population

    •    RCT                                             •    Assumes that heart rate, respiratory rate and oxygen

                                                             saturation are associated with pain.
    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.

    Strengths of the Study                                 Weaknesses of the Study

•    RCT, Double-blind study                               •    Pain scores are subjective
•    Financially feasible intervention                     •    Parental presence or lack of was not documented for each
•    Large sample size                                          patient
•    Patients reported pain levels using a CAS tool        •    Nonintervention group was smaller than the intervention
                                                                groups
                                                           •    Variations in provider’s skills could impact the study.
     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                      Weaknesses of the Study

   •       Decreased wait time                 •    Habituation to glucose

   •       Easy to use                         •    Difficult to measure pain

   •       RCT                                 •    Effectiveness applies to newborns only

   •       Large sample size                   •    Unknown reason why glucose works best

   •       Financially possible.

       .
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


       Strengths of the Study                         Weaknesses of the Study

   •    Use of NIPS                               •    Limited generalizability

   •    RCT                                       •    No use of double blind

   •    Relevance to Clinical Practice
  Sweet tasting solutions for reduction of needle-related
    procedural pain in children aged one to 16 years.
                                         (Harrison et al., 2011)

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.
                                                   f




          Strengths of the Study                           Weaknesses of the Study

      •    High Level Cochrane Review                  •    Conflicting Studies

                                                       •    Requires more well-conducted RCTs with

                                                           larger sample sizes
    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
                                             Weaknesses of the Study
          Strengths of the Study
                                         •    Not suitable for children with neurologic, visual,
    •      RCT, large sample
                                             or auditory deficits
    •      Financially feasible
                                         •    Effectiveness after multiple uses with one child are

                                             unclear
EMLA and Amethocaine for reduction of children’s
  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                            Weaknesses of the Study

     •   High-level Cochrane review                    •   Some of the trials used scales that had

     •   Exhaustive database search and hand-              not been properly analyzed

         search of reference lists and journals
     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                             Weaknesses of the Study

      •   RCT                                            •   Small Sample

      •   Quick-acting option vs. topical analgesics     •   Subjects & coders not blinded to intervention groups

      •   Low cost ($0.09 per attempt)                   •   No control for placebo effects
   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                                              Weaknesses of the Study

 • RCT                                                                • Not double-blind

 • Quick-acting option vs. topical analgesics                         • No control for placebo effects

 • Large sample size                                                  • Nurses not randomly selected

 • Pain & anxiety levels not assess by researcher to limit bias
    Stake Holders
Ø Nurses
Ø Certified Nursing Assistants
Ø Phlebotomists
Ø Intravenous Access Team
Ø Facility Administration/Accounting
          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.
 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).
 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).
   Summary of Evidence
Amethocaine cream provided significant
pain relief of venipuncture compared to
EMLA cream in children 3 months - 15
                years old.
           (Lander & Weltman, 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)
            Results

 Critical appraisal of the literature
  suggests that some form of pain
control during venipuncture will be
       beneficial for children.
           Implementation
Create EBP quality intervention teams


        Provide training for staff regarding pain
                     relief methods



            Implement protocol for venipuncture pain
                            relief
             Evaluation
Assess pain using hospital approved
            pain scales

     Document pain response to used
             intervention

           Periodic review of documentation
           regarding response to intervention
                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.
                                                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), 388-393. doi:10.1111/j.1553-2712.2009.00401.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),

               1151-1156.

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), 38-41.

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), 1053-1057.

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
                                                  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), 210-219.

               doi:10.1111/j.1440-172X.2012.02016.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), 339-345. doi:10.1097/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.: CD004236. DOI:

               10.1002/14651858.CD004236.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), 1604-1611.

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:0
posted:7/2/2014
language:English
pages:24