The Art and Science of Infusion Nursing
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OPEN
Local anesthesia is used to relieve pain associated with intravenous (IV) cannulation and arterial blood gas (ABG) sampling in various countries. However, the use of pain management for these procedures is
given a low priority in many health institutions throughout Saudi Arabia, and there is a significant lack of recommen-dations regarding local anesthesia for these procedures. 1 , 2Therefore, adults and children are subjected to pain and the associated anxiety, which could otherwise be managed with the use of local anesthesia.
DEFINITIONS
Local anesthesia refers to the method of eliminating sen-sations in, or numbing, a specific part of the body for relieving the pain associated with invasive procedures. 3 , 4 It is typically administered through 1 of 2 routes: topical and parenteral. Topical local anesthesia is applied to the skin surface as creams, gels, sprays, and patches. Parenteral local anesthesia is administered as injections through intra-dermal or subcutaneous layers of the skin. 4
IV cannulation is an invasive procedure used for vascular access that requires the insertion of a catheter containing a needle to administer medications, fluids, and other ther-apeutic treatment. 5 ABG sampling is a test performed by inserting a needle into an artery to obtain blood samples; this is more painful than a venipuncture because of the need to insert the needle more deeply into highly inner-vated anatomical locations, such as the wrist, antecubital fossa, or groin. 6
OBJECTIVE
Pain related to needle punctures is associated with physical and psychosocial complications. Fear of procedures that use needles and the associated pain may lead to patients avoiding preventive health care. This may cause delays in the treatment of illnesses, which poses a long-term burden on the health care system and society. 7 The use of local anesthesia helps reduce patient distress at the time of the procedure, serves to facilitate needle insertion, and helps
ABSTRACT The use of local anesthetics to relieve pain associated with intravenous cannulation and arterial blood gas sampling is given low priority in many health institutions. This review sought to identify factors influencing nurses’ use of local anesthetics for these procedures. The Database Syntax Guide for Systematic Reviewers was used; health-relevant studies were critically assessed with appropriate Critical Appraisal Skills Programme tools. Significant factors influenc-ing the use of local anesthetics for parenteral procedures were identified, including the level of effectiveness among types of local anesthetics, the perceived benefits of facilitating needle insertions and patient satisfaction, the under-estimation of pain associated with needle punctures, time concerns, physician authorization, and costs. Key words: arterial blood gases , catheterization , factors , intravenous cannulation , local anesthesia , nurses , pain reduction
Author Affiliation: King Saud Medical City, Riyadh, Saudi Arabia.
Fatimah Yahya Alobayli, MSN, BSN, RN, is currently a PhD student in nursing science at University of Edinburgh, United Kingdom, supported by King Saud Medical City. Her nursing experience is clinically based, largely focused on critical care in Saudi Arabia. She has also gained profound experience from clin-ical placements in different settings during her overseas nursing studies in New Zealand (2011-2012) and Australia (2013-2014). Her current work focuses on evidence-based projects, including exploration of advanced practices to ease patient distress, reduce nurses’ workloads, and improve quality of care.
The author has no conflicts of interest to disclose .
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal .
Corresponding Author: Fatimah Yahya Alobayli, MSN, BSN, RN, Administrative Nurse Manager, King Saud Medical City, Ulaishah, Riyadh 12746, Saudi Arabia ( [email protected] ).
Factors Influencing Nurses’ Use of Local Anesthetics for Venous and Arterial Access
Fatimah Yahya Alobayli , MSN, BSN, RN
DOI: 10.1097/NAN.0000000000000316
92 Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. Journal of Infusion Nursing on behalf of the Infusion Nurses Society.
improve patient satisfaction and hospital experience.7-9 This review sought to identify factors influencing nurses’ use of local anesthesia for IV cannulation and ABG sampling.
METHODS
Article Search and Selection ProcessThe search process was performed in accordance with the Database Syntax Guide for Systematic Reviewers,10 which helped identify relevant articles in health-related databas-es. The databases searched included the Cumulative Index to Allied and Health Literature (CINAHL), MEDLINE, and PsycINFO. The main search terms were local anesthesia, pain reduction, intravenous cannulation, arterial blood gases, nurses, factors, and barriers. The search was limited to the English language and abstracts that contain the key-words local anesthesia. Titles and abstracts of articles that resulted from the search strategy were assessed for rele-vance to the research subject. As a result, 38 of the 54 arti-cles identified did not meet the aforementioned inclusion criteria and were excluded. In addition, the reference lists of the included articles were searched manually to identify additional studies. No studies were found that had been performed in Saudi Arabia regarding the use of local anes-thesia for IV cannulation or ABG sampling. Additionally, recent studies related to the use of local anesthesia for invasive procedures rarely involved nursing. Thus, articles published from 2005 onward that contained 2 or more of the search terms and that discussed important aspects relevant to the research topic were included. A total of 16 articles were included in this literature review.
Critical Appraisal of the StudiesArticles that met selection criteria for the literature review were critically assessed with the use of appraisal tools and programs and appropriate checklists. Most studies were trials that examined the effectiveness of local anesthesia for reducing the pain associated with venous and arterial access. All trial studies were critically assessed by using the relevant tool designed by the Critical Appraisal Skills Programme (CASP).11 Survey studies were assessed with the Critical Appraisal of a Survey checklist, produced by the Centre for Evidence-Based Management (CEBMa),12 and the included studies were evaluated by means of the CASP tool designed for systematic reviews.13 Critical appraisal tools were used for the articles, based on the suitability of screening ques-tions and similarity of study approaches. A critical analysis of each study was undertaken to identify and critique their purpose, method, findings, limitations, and significance (Appendix 1).14-27 The rigor of the reviewed studies was assessed through identification of limitations and strengths.
Thematic AnalysisThematic analysis helped organize and describe the data set of the research topic28 and allowed further scope beyond
evaluation of existing structural data. It enabled exploration of various aspects of the research topic in terms of factors that have an impact on the use of local anesthesia for procedural pain. After individual analyses of the studies, articles were grouped together based on recurrent themes that emerged from the findings (Appendix 2). Findings are presented with themes that were extracted from the reviewed articles.
RESULTS
Effectiveness of Local Anesthetics
Intradermal InjectionsThe effectiveness of local anesthesia injection types has been studied in terms of the reduction of the pain associat-ed with venipunctures. Matheson et al21 aimed to identify an effective method for reducing the pain associated with ABG sampling. The study compared 3 methods of analgesic administration at the site of arterial puncture (0.7 mL 1% lidocaine, 0.7 mL buffered 1% lidocaine, or 0.7 mL bacterio-static saline) to determine which method was most effec-tive at minimizing the pain associated with arterial needle puncture. The investigation involved a randomized, par-tially blinded, prospective study convenience sample of 40 hospitalized patients in the United States. The findings sug-gested that although lidocaine and buffered lidocaine were both effective for reducing pain associated with the ABG sampling procedure (P = .000 and P = .041, respectively), compared with bacteriostatic saline (P = .665), lidocaine alone resulted in the most significant reduction of pain.
Another study by McNaughton et al22 compared pain and anxiety associated with IV cannulation after pretreating patients with 1% subcutaneous buffered lidocaine, 4% lido-caine cream, or no local anesthesia. A randomized cross-over study of 70 participants (medical students or nurses) who participated in hospital workshops for IV insertion in the United States was conducted. Three IV cannulations were performed for each participant; each insertion was pretreated randomly with either no treatment, lidocaine cream, or buffered lidocaine. Participants were asked to report the level of pain, anxiety, and preference for the use of local anesthesia, for themselves and patients, on a 10-point numeric rating scale.
The study showed that pain and anxiety associated with IV cannulation were significantly minimized by using either type of local anesthesia. Buffered lidocaine injection reduced venipuncture pain more than lidocaine cream did, without affecting the success of insertion. There were no significant differences in anxiety scores between the use of lidocaine cream or injected buffered lidocaine. Seventy percent of the participants reported that they would always want buffered lidocaine in the future.
Similarly, Burke et al14 compared the efficacy of intrader-mal bacteriostatic normal saline with that of intradermal buffered lidocaine in providing local anesthesia to adult
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patients before IV catheterization. A randomized, dou-ble-blind, parallel-design, quasi-experimental study was conducted on 148 adult patients from the hospital’s same-day surgery unit. The study’s strength was that it tested 2 types of local anesthesia using the same route of adminis-tration, which eliminated other confounding variables. It was determined that intradermal buffered lidocaine was significantly superior to intradermal bacteriostatic normal saline for reducing IV catheterization pain (P = .007).
Hudson et al18 reviewed studies and recommendations related to the use of intradermal lidocaine to reduce pain during arterial punctures. The findings showed that the use of intradermal lidocaine before arterial puncture clearly decreased pain associated with the procedure and did not interfere with the success rate. Overall, intradermal lidocaine injection was more efficacious for reducing procedural pain among the types of local anesthesia tested in those studies.
Intradermal Needleless DeviceA needleless intradermal jet injector (eg, J-Tip; National Medical Products, Irvine, CA) is another type of local anes-thesia used to reduce pain associated with cannulation and ABG sampling. Hajiseyedjavady et al9 conducted a random-ized, controlled clinical trial to compare pain levels from ABG sampling performed with and without application of lidocaine through a jet injector. Forty-two alert and coop-erative volunteers who required ABG sampling as part of their pain management were recruited in the emergency department (ED) of the Imam-Reza Hospital in Tabriz, Iran.
Despite the small sample size, the study showed that the visual analog pain scale score during ABG sampling was con-siderably lower in the treatment group than in the control group. All residents reported ease of use for the lidocaine jet injection procedure (P < .05). Another study by Jimenez et al19 compared the effectiveness of administering 1% buffered lidocaine with a jet injector vs using a topical trans-dermal agent, such as a eutectic mixture of local anesthetics (eg, EMLA; AstraZeneca, Cambridge, United Kingdom) to facilitate IV cannulation and provide adequate analgesia before catheter placement. The study was a randomized, controlled trial of 116 young patients (7-19 years old) at the Children’s Hospital and Regional Medical Centre in Seattle, Washington. The findings showed a statistically significant difference (P = .0001) in the pain ratings during IV cannu-lation between the topical transdermal agent (median = 3) and the jet injector (median = 0), indicating that the jet injector group experienced less pain than the topical trans-dermal agent group.
Interestingly, the jet injector was well tolerated, and the children were not frightened by the “pop” sound produced by the device, in contrast to the researchers’ expectations. It was concluded that applying 1% buffered lidocaine through a jet injector before IV cannulation is not painful and has better anesthetic effectiveness than applying the topical transdermal agent.
In addition, Crowley et al8 conducted a comprehensive literature review to provide evidence-based information for
emergency nurses in terms of reducing pain and distress in pediatric patients undergoing minor invasive procedures in the ED. The study classified the outcomes according to lev-els of recommendation for practice: Level A, High; Level B, Moderate; and Level C, Weak or Not Recommended for Practice. All forms of lidocaine/tetracaine (amethocaine) injections were Level A. The form of lidocaine delivered in the needleless jet injection device was superior to other forms of local anesthesia (Level A).
Topical Local AnesthesiaTopical local anesthesia, such as creams, gels, sprays, and patches, are used to reduce pain associated with needle punctures. Hijazi et al17 examined the effectiveness and safety of a topical alkane vapocoolant spray in reducing pain associated with venous cannulation in adults in an ED. The study used a randomized, double-blind, placebo- controlled approach that involved 201 adult patients in the ED of a metropolitan hospital in Australia. A visual analog scale was used to assess cannulation pain and discomfort induced by the spray; this is a highly discriminant method of assessing pain.
The study showed that application of topical alkane vapocoolant spray less than 15 seconds before cannulation was successful in numbing the area and reducing pain. Median pain scores for IV cannulation in the control and intervention groups were 36 (19-51) mm and 12 (5-40) mm, respectively (P < .001); 59 (60%) and 33 (32%) patients, respectively, reported pain scores ≥ 30 mm (P < .001). The vapocoolant intervention was concluded to be effec-tive, safe, and acceptable for reducing pain associated with peripheral cannulation in adults in the ED.
Similarly, Page and Taylor25 compared the efficacy, acceptability, and safety of a topical vapocoolant alkane spray and 1% subcutaneous lidocaine for reducing pain from IV cannulation. They conducted a nonblinded, ran-domized, controlled trial on a convenience sample of 220 participants (adult and pediatric) from a metropolitan ED. The study findings suggested that although vapocoolant spray was less painful to administer, it was less effective for reducing pain associated with cannulation than lidocaine injection. Vapocoolant spray was associated with greater cannulation success (83.6% vs 67.3%; P = .005), required less time to administer (median 9.0 vs 84.5 seconds; P < .001), and was more convenient for staff (median 5 vs 4; P < .001), although the overall patient satisfaction scores were similar between the groups. They concluded that although lidocaine was superior, vapocoolant spray offered a useful alternative in the ED setting.
Mirzaei et al23 conducted a quasi-experimental study to compare the effect of transdermal cream, lidocaine spray, and ice packs on the intensity of pain experienced with arteriovenous cannulation in hemodialysis patients. The study involved 40 patients > 18 years old in Shahid Rahnemoon Hospital in Iran. Transdermal cream was found to be highly effective for reducing pain intensity compared with lidocaine spray and ice packs (P < .001). Similarly,
94 Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. Journal of Infusion Nursing on behalf of the Infusion Nurses Society.
findings from Crowley and colleagues’ literature review8 included classifications of topical anesthesia that were recommended for management of pain and distress associ-ated with venipuncture, in which vapocoolant spray in the form of ethylvinylchloride was Level C, and pentafluoropro-pane and tetrafluoroethane were Level B.
Papa and Zempsky24 surveyed 2187 nurses from 3 nursing societies in the United States to examine nurses’ attitudes and experiences regarding techniques used to manage venous access pain in pediatric patients. Although the study did not specify which types of topical anesthesia were used in those settings, the findings suggested that topical local anesthesia was considered more effective than nonpharmacological techniques, but was used less often because of concerns about its slow-acting nature. Most nurses (92%) agreed that an effective, fast-acting topical local anesthetic would benefit pediatric patients, their fam-ilies, and the nurses who treat them.
This review has presented common types of local anes-thesia that have been studied for their effectiveness in reducing pain associated with venous and arterial punc-tures. Evidence and recommendations presented in the reviewed studies show the efficacy of local anesthesia for minimizing procedural pain at different levels. Table 1 shows the levels of recommendations for those methods of local anesthesia, as well as some of their characteristics, according to the reviewed literature. Notably, the levels of effectiveness of those methods of local anesthesia in pain reduction, as well as their positive and negative character-istics, are important factors that can influence the use of local anesthesia by nurses.
Additional Strategies for Procedural Pain Management
Application of IceApplication of ice is another technique that can be used by nurses as an alternative method for reducing pain associ-ated with needle-related procedures. Haynes16 conducted a study that investigated whether precooling a puncture site with ice could reduce the pain associated with arterial puncture. A convenience sample of 80 adult outpatients
with a physician’s order for ABG sampling was obtained. The study used a prospective, stratified, randomized, con-trolled trial approach and showed significant reductions in pain in the treatment group (ice application) compared with the control group. This suggested that the application of ice is an effective alternative option for reducing pain associated with arterial puncture because it is noninvasive, nonpharmacologic, inexpensive, and readily available.
Similarly, a previous quasi-experimental study by Rostami et al26 was conducted with 80 children (6-12 years old) in an ED of a pediatric center in Ahwaz, Iran. The study aimed to determine the effect of local application of ice for 3 minutes before venipuncture on pain-related responses in school-aged children. They tested this hypothesis in relation to physiological and psychological variables and found no significant differences in physiological responses before and after procedures between the 2 groups (P = .07). However, behavioral and subjective responses before and after the procedure were lower in the test group (P = .0011 and P = .0097, respectively). The study conclud-ed that the application of ice to the skin before venipunc-ture can be an effective and safe intervention for reducing puncture-related pain.
In addition, Mirzaei et al23 showed that the ice method was effective in reducing pain intensity associated with arteriovenous cannulation in hemodialysis patients; how-ever, it was inferior to transdermal agents. Those previous findings are consistent with the classifications of pain management by Crowley et al8 regarding needle-related procedures recommended for practice, in which the local application of ice for reducing the pain and distress associ-ated with venipuncture was classified as Level B.
Behavioral InterventionBehavioral intervention is an area in nursing care that can be used effectively for pain management in needle-related procedures. Crowley et al8 reported classifications of pain management for needle-related procedures that were recommended for practice. The level of recommenda-tion for a behavioral intervention to reduce the pain and distress associated with venipuncture was classified as Level A because of sufficient evidence-based information
TABLE 1
Effectiveness of Local Anesthesia for Reducing Pain Associated With Venipuncture According to Reviewed LiteratureLocal Anesthetics Level of Recommendation Onset of Effect Disadvantages
Lidocaine jet injector (needleless) High Fast Makes “pop” sound
Intradermal lidocaine High Fast Additional needlestick needed
Intradermal buffered lidocaine High Fast Additional needlestick needed
Vapocoolant alkane spray Moderate Fast Inferior to lidocaine for pain reduction
Transdermal agent (topical mixture of lidocaine and prilocaine)
Moderate Slow acting Long wait time required to produce effect
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supporting the efficacy of cognitive behavioral therapy, breathing exercises, appropriate distractions, and hypnosis. However, Papa and Zempsky24 found that nonpharmacolog-ical techniques, although frequently used by nurses, were perceived by nurses as insufficient in alleviating procedural pain when used alone.
Other Benefits of Local Anesthesia
Facilitation of Successful Needle InsertionsThe use of local anesthesia facilitates successful IV can-nulation and ABG sampling because of the reduction of associated pain and anxiety, which helps patients remain still during the procedure. According to Hudson et al,18 the administration of local anesthesia for ABG sampling was helpful in increasing the success rates of gaining arterial access because it minimizes patient movement during the procedure. Similarly, Crowley et al8 evaluated the success rate of injection and topical anesthetics; all reviewed studies indicated that the success rates were enhanced by the administration of local anesthesia. Furthermore, the administration of topical anesthetics was associated with increased success rates of catheter insertions. Likewise, Hajiseyedjavady et al9 found that the use of jet injectors resulted in a marked reduction of the pain of arterial puncture and contributed to a greater success rate of ABG sampling. They stated that the ABG procedure frequently fails because of the deeper anatomical location of the artery, which causes more pain. This makes it difficult for the patient to hold still during the procedure, which com-plicates the performance of the practitioner. Therefore, Hajiseyedjavady et al9 believed that greater pain relief would lead to more successful sampling.
Improved SatisfactionThe use of local anesthesia for invasive procedures by nurses provides patients with optimal pain management, thus improving patients’ satisfaction and hospital experi-ence. This can have a positive impact on patients’ future well-being. Papa and Zempsky24 examined the impact of managing venous access pain in pediatric patients, accord-ing to the nurses’ perceptions. Ninety-six percent of nurses acknowledged that performing IV cannulation in a fearful and anxious child was challenging. Thus, most nurses (91%) agreed that better-quality pain control improved their sat-isfaction with their job performance, increased their overall job satisfaction (81%), increased positive relationships with patients and families (91%), and had a positive impact on the hospital experience of children and their families (97%).
Furthermore, McNaughton et al22 conducted a study on health care providers (ie, medical students and nurses). The researchers investigated whether participants would want local anesthesia for IV insertion for themselves and their patients. The study showed interesting outcomes, in that many participants were more influenced by personal experience to use local anesthesia for themselves and their patients in the future. In addition, an exploratory study
by Levitt and Ziemba-Davis20 explored the knowledge of patient preferences for pain control during IV cannulation. One aim was to measure patients’ rates of satisfaction with the treatments they chose. Only 4 patients chose the tradi-tional strategy of no pain management. In contrast, 86.6% of participants preferred pain control. All participants in all groups reported that patient involvement in decision making regarding pain management was very important. Patient satisfaction and staff convenience, including the convenience of nurses, regarding the use of local anes-thesia for invasive procedures were measured in some reviewed studies, and the outcomes were satisfactory.9,17,25
Factors Leading to the Low Use Rate of Local Anesthesia
Staff Members’ Underestimation of Procedural PainPain associated with a needle puncture can be perceived as insignificant by health care practitioners, which can hinder the use of local anesthetics by nurses and other health pro-fessionals. Sado and Deakin27 measured the prevalence of local anesthetic use for IV cannulation and ABG sampling by physicians. The authors stated that although many studies recommended the use of local anesthesia for these pro-cedures, previous surveys indicated that ward physicians were more likely than anesthetists to ignore such advice.
The authors sought to determine whether these differ-ences persist. A questionnaire was given to 178 anesthe-tists, physicians, and surgeons in 8 hospitals in the United Kingdom. Although the study was conducted 10 years ago, interestingly, the findings were consistent with the hypoth-esis of that study, in which 60% of anesthetists used local anesthesia for these procedures compared with 2% of ward physicians. Similarly, Hudson et al18 reviewed the literature and recommendations related to the use of intrader-mal lidocaine to decrease pain during arterial punctures. Although some articles reviewed in their study were old, they showed that, except among anesthesia providers, the use of a local anesthetic before arterial puncture was not universal. This is contrary to the standard of practice, which supports the use of local anesthetic to minimize arterial puncture pain. A number of false perceptions may hinder wider use of such anesthetics. Despite differences between physicians and nurses, certain beliefs and attitudes can con-tribute to a similar practice of disregarding the use of local anesthesia for invasive procedures. IV cannulation and ABG sampling, in particular, are performed by nurses in Saudi Arabia, and there is a lack of recommendations for using local anesthesia for these procedures in local practice.1,2
Staff Concerns About Time Taken in Administering Local AnesthesiaTime is a critical factor that can have an impact on nurses’ use of local anesthesia for invasive procedures. Nurses surveyed in a study by Papa and Zempsky24 reported that they used topical local anesthesia in only 29% of cases.
96 Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. Journal of Infusion Nursing on behalf of the Infusion Nurses Society.
One of the reasons most frequently identified was the slow onset of topical anesthetics, which is associated with treatment delays. Likewise, the findings of Czarnecki et al15 showed that the majority of nurses identified insufficient time to premedicate patients before procedures as one of the most common barriers to pediatric pain management. Furthermore, Hijazi et al17 and Page and Taylor25 stated that the application time of topical anesthesia, such as a transdermal agent (45 minutes), is often unacceptable in an acute care environment, where immediate cannulation is required. They studied the practicality of using vapocoolant spray as a fast-acting topical anesthetic in the ED and found that this spray could produce the desired effect within less than 15 seconds after application.17,25 In their literature review, Hudson et al18 suggested that the effectiveness of lidocaine ointment, amethocaine gels, and transdermal creams, as alternatives to intradermal lidocaine, is limited in critical settings because of the lengthy application time required (30-60 minutes) to produce a sufficient effect. The findings concluded that ABG analysis was required in less time than allowed by use of topical anesthetics. As a con-cern related to this issue, Hajiseyedjavady et al9 tested the efficacy of jet injectors for ABG sampling. The findings sug-gested that the jet injector was effective and beneficial in providing rapid anesthesia in less than 6 minutes. Similarly, Jimenez et al19 measured the time from application to can-nulation for both transdermal agents and the jet injector and found that transdermal agents required 69 minutes compared with 1.8 minutes for the jet injector group. Using the jet injector was recommended, especially in emergency or busy situations, when there is insufficient time for the transdermal agents to take effect.
Lack of Physician AuthorizationPhysicians’ orders regarding local anesthesia are an import-ant factor that can hinder use by nurses. A cross-sectional study conducted by Czarnecki et al15 identified barriers that were perceived to interfere with nurses’ abilities to provide optimal pain management in pediatric patients. A survey study was conducted on 272 nurses from the Children’s Hospital of Wisconsin. The most significant barriers iden-tified for optimal pediatric pain management included insufficient physicians’ orders for local anesthesia before procedures (mean 4.98, standard deviation [SD] 2.67; and mean 4.92, SD 2.81, respectively). Furthermore, Papa and Zempsky24 explored nurses’ perceptions of the impact of pain management in pediatric patients. ED nurses were most challenged in terms of pain control and most often resorted to nonpharmacological management. Papa and Zempsky24 stated that because of the rapid responses required in the ED, nurses working in the ED might be less likely to order pain control measures, which requires a phy-sician’s authorization, because of concerns regarding the consequent delay in treatment. Hudson et al18 agreed that the need for a physician’s order to administer local anesthe-sia before arterial access is a barrier that limits the use of
local anesthesia by nurses. Therefore, it was recommended that nurse managers establish standing orders to incorpo-rate the use of local anesthesia (subcutaneous lidocaine) as a standard protocol for obtaining blood samples for ABG analysis.18
The Cost of Local AnesthesiaCost is another factor that contributes to the availability of local anesthesia for nurses. In their review, Hudson et al18 compared the cost of local anesthesia methods and suggested that intradermal lidocaine is inexpensive com-pared with transdermal agents. Transdermal agent patches cost $7 per application, and lidocaine and syringes cost approximately 17 cents, so the additional lidocaine needed for basic ABG sampling requirements would cost less than 20 cents per procedure.18
In addition, Page and Taylor25 calculated the cost of vapocoolant spray and lidocaine subcutaneous injection per patient (in Australian dollars) from the vapocoolant spray retailer and hospital pharmacy department. The cost of 1 can of vapocoolant spray (250 g) was approximately $16.12 AU and provided 70 administrations. Notably, the authors did not state the price of lidocaine. However, although vapocoolant spray was less expensive than lido-caine, it was concluded that both agents were considered inexpensive.
Jimenez et al19 also compared the cost of the jet injector vs transdermal agent per IV insertion in their institution. The cost of the jet injector was $2.10 compared with $2.80 for a transdermal agent. That study recommended the implementation of jet injector local anesthetic as a cost-effective alternative. In addition, Burke et al14 reported that use of a transdermal agent as a topical local anesthesia was inappropriate because of the cost.
DISCUSSION
As illustrated by this review, different forms of local anes-thesia exhibit different levels of effectiveness for reducing the pain associated with IV cannulation and ABG sampling. The level of efficacy of the medication is an important factor to consider when using local anesthesia to provide effective pain management for needle punctures. Other factors can influence nurses’ decisions regarding local anes-thesia use, such as the age of the patient, its practicality in specific clinical settings (critical or noncritical), and type of procedure performed (eg, gaining venous or arterial access). For example, topical anesthetics are commonly used for pediatric patients because children are more anx-ious and less tolerant of needle insertions compared with adult patients.7
According to studies included in this review, jet injection is highly recommended compared with other forms of local anesthesia because it is needleless and penetrates intrader-mally to produce fast-acting pain relief. It is also deemed
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safe and effective. This device works effectively in ABG sampling because the arterial access required is more inva-sive than gaining venous access, and the associated pain is greater. Furthermore, its cost is reasonable. Although McSwain and Yeager29 argued that the concept of this device has gained popularity, it is not yet broadly available.
Transdermal cream is effective for reducing procedural pain. However, it may not be practical in nursing practice because of its slow-acting effect, especially in situations where time is critical. Because of this, the use of fast-acting local anesthetic alternatives can influence nurses’ use of local anesthesia. This would help to eliminate barriers relat-ed to time concerns associated with treatment delay.
In addition, ice can be used by nurses as an alternative method to reduce procedural pain effectively (because it is noninvasive, nonpharmacological, inexpensive, and readily available) and when local anesthesia is not available or is not offered to patients in some settings. Behavioral inter-ventions, which can be partially effective, are often used by nurses to lessen pain associated with needle-related procedures. However, reliance on behavioral interventions alone to relieve pain associated with invasive procedures is insufficient. The use of local anesthesia should be incor-porated into these interventions to provide patients with optimal pain management.
Individuals who have experienced better pain manage-ment with local anesthesia for invasive procedures prefer to have local anesthesia in the future. This observation is important because it can affect future emotional and phys-ical well-being. Despite physicians’ orders that may limit the use of local anesthesia, nurses should take the initiative to help eliminate such barriers by negotiating with medical and nursing directors to establish standing orders or to develop appropriate protocols. Cost was also identified as an important factor that may encourage or hinder the use of local anesthesia.
A concern that may be perceived as a barrier to using local anesthesia injection by nurses is that its adminis-tration can affect successful insertion because it causes subcutaneous wheal formation, obscuring visibility of the blood vessel and subsequently increasing the difficulty of venipuncture. However, evidence from the reviewed studies disproved this. The rates of successful insertions with injectable local anesthesia were satisfactory in those studies. Another potential concern for nurses regarding the use of local anesthesia injections could be the exposure of patients to additional pain as a result of 2 needlesticks. The local anesthetic needlestick is less painful because of the small size of the needle used compared with the procedural needle insertion.27 Alternative modes of local anesthesia, which can be used according to their appropriateness for the situation, such as transdermal agents, vapocoolant sprays, and jet injectors, have been suggested.
Anecdotal evidence suggests that the lack of hospital policies or guidelines can be barriers to the use of local anesthesia for IV cannulation and ABG sampling. This is
the case in the largest tertiary care center in Riyadh, Saudi Arabia. In addition, lack of education or training in nursing education in Saudi Arabia hinders the use of local anesthe-sia for needlesticks. As a consequence, nursing practice is shaped by these factors. Pain relief for needle-related pro-cedures is underestimated in health care in Saudi Arabia, which affects the quality of care available to patients.
Implications for Nursing PracticeNo studies have been conducted in Saudi Arabia that sup-port the use of local anesthesia for venous and arterial needle punctures to date. The research findings presented in this article add to knowledge regarding factors that have an impact on the use of local anesthesia for vascular access. Identifying these factors from an international perspective provides a valuable understanding of the issue at a local level, which may help policy makers develop strategies to improve the quality of nursing practice. This review was undertaken to benefit society to improve the quality of health care and enhance patients’ satisfaction and hospital experience, as well as prevent physical, psychological, and economic concerns.
CONCLUSION
Factors that can have an impact on the use and availability of local anesthesia by nurses were identified in this review. These include (1) the level of effectiveness among types of local anesthesia; (2) underestimating pain associated with catheter insertion, time for administration, and onset of action, especially in critical settings; (3) lack of provider authorization; and (4) cost. The absence of hospital policies and a lack of education or training also influence the use of local anesthesia because nursing practice is shaped by these organizational guidelines. A core responsibility of nursing is to alleviate pain and advocate for patients’ best interests. This review informs stakeholders about the gap in nursing practice in Saudi Arabia as substantiated by the recommendations and evidence in the literature.
ACKNOWLEDGMENTS
The author would like to acknowledge the support provided by Flinders University in South Australia and the Research Centre at King Saud Medical City in Riyadh, Saudi Arabia. Special thanks to P.J. Parameaswari, PhD, for her constructive feedback.
REFERENCES
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2. Ministry of Health, General Directorate of Nursing. Manual of Nursing Policies and Procedures. Emergency Care. 2nd ed. https://www.moh.gov.sa/depts/NursingDepts/Policiesandprocedures/Inhospitals/Documents/ERDN.pdf. Accessed March 27, 2018.
98 Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. Journal of Infusion Nursing on behalf of the Infusion Nurses Society.
3. Logothesis DD. Local anesthesia in dental hygiene practice: an intro-duction. In: Nathe CN, ed. Local Anesthesia for the Dental Hygienist. St. Louis, MO: Elsevier/Mosby; 2016.
4. Malamed SF. Handbook of Local Anesthesia. Maryland Heights, MO: Mosby/Elsevier Health Sciences; 2014.
5. Phillips S, Collins M, Dougherty L, eds. Venepuncture and Cannulation. Chichester, UK: Wiley; 2011.
6. Yee K, Shetty AL, Lai K. ABG needle study: a randomised control study comparing 23G versus 25G needle success and pain scores. Emerg Med J. 2015;32(5):343-347.
7. McMurtry CM, Pillai Riddell R, Taddio A, et al. Far from “just a poke”: common painful needle procedures and the development of needle fear. Clin J Pain. 2015;31(10 suppl):S3-S11.
8. Crowley MA, Storer A, Heaton K, et al. Emergency nursing resource: needle-related procedural pain in pediatric patients in the emergency department. J Emerg Nurs. 2011;37(3):246-251.
9. Hajiseyedjavady H, Saeedi M, Eslami V, Shahsavarinia K, Farahmand S. Less painful arterial blood gas sampling using jet injection of 2% lidocaine: a randomized controlled clinical trial. Am J Emerg Med. 2012;30(7):1100-1104.
10. Damrell R. Database Syntax Guide for Systematic Reviews. Bedford Park, Australia: Flinders University Library; 2016.
11. Critical Appraisal Skills Programme. 11 questions to help you make sense of a trial. http://media.wix.com/ugd/dded87_40b9ff0bf53840478331 915a8ed8b2fb.pdf. Updated May 31, 2013. Accessed March 20, 2018.
12. Center for Evidence-Based Management. Critical appraisal of a cross-sectional study (survey). https://www.cebma.org/wp-content/uploads/Critical-Appraisal-Questions-for-a-Cross-Sectional-Study-july-2014.pdf. Accessed March 20, 2018.
13. Critical Appraisal Skills Programme. 11 questions to help you make sense of a review. http://media.wix.com/ugd/dded87_a02ff2e3445f4952992d5a96ca562576.pdf. Updated May 31, 2013. Accessed March 20, 2018.
14. Burke SD, Vercler SJ, Bye RO, Desmond PC, Rees YW. Local anesthesia before IV catheterization. Am J Nurs. 2011;111(2):40-47.
15. Czarnecki ML, Simon K, Thompson JJ, et al. Barriers to pediatric pain management: a nursing perspective. Pain Manag Nurs. 2011;12(3): 154-162.
16. Haynes JM. Randomized controlled trial of cryoanalgesia (ice bag) to reduce pain associated with arterial puncture. Resp Care. 2015;60 (1):1-5.
17. Hijazi R, Taylor D, Richardson J. Effect of topical alkane vapocoolant spray on pain with intravenous cannulation in patients in emergency departments: randomised double blind placebo controlled trial. BMJ. 2009;338:b215. doi:https://doi.org/10.1136/bmj.b215.
18. Hudson TL, Dukes SF, Reilly K. Use of local anesthesia for arterial punc-tures. Am J Crit Care. 2006;15(6):595-599.
19. Jimenez N, Bradford H, Seidel KD, Sousa M, Lynn AM. A comparison of a needle-free injection system for local anesthesia versus EMLA® for intra-venous catheter insertion in the pediatric patient. Anesth Analg. 2006; 102(2):411-414.
20. Levitt FC, Ziemba-Davis M. An exploratory study of patient prefer-ences for pain management during intravenous insertion: maybe we should sweat the small stuff. J Perianesth Nurs. 2013;28(4):223-232.
21. Matheson L, Stephenson M, Huber B. Reducing pain associated with arterial punctures for blood gas analysis. Pain Manag Nursing. 2014;15(3):619-624.
22. McNaughton C, Zhou C, Robert L, Storrow A, Kennedy R. A random-ized, crossover comparison of injected buffered lidocaine, lidocaine cream, and no analgesia for peripheral intravenous cannula insertion. Ann Emerg Med. 2009;54(2):214-220.
23. Mirzaei S, Javadi M, Eftekhari A, Hatami M, Hemayati R. Investigation of the effect of EMLA cream, lidocaine spray, and ice pack on the arte-riovenous fistula cannulation pain intensity in hemodialysis patients. Health Sci. 2018;7(2):51-57.
24. Papa A, Zempsky W. Nurse perceptions of the impact of pediatric peripheral venous access pain on nurse and patient satisfaction. Adv Emerg Nurs J. 2010;32(3):226-233.
25. Page DE, Taylor DM. Vapocoolant spray vs subcutaneous lidocaine injection for reducing the pain of intravenous cannulation: a random-ized, controlled, clinical trial. Br J Anaesth. 2010;105(4):519-525.
26. Rostami S, Salsali M, Keikhaee B, Moradi A. Effect of local refrigeration prior to venipuncture on pain related responses in school age chil-dren. Aust J Adv Nurs. 2006;24(2):51-55.
27. Sado DM, Deakin CD. Local anaesthesia for venous cannulation and arte-rial blood gas sampling: are physicians using it?J R Soc Med. 2005;98(4): 158-160.
28. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77-101.
29. McSwain SD, Yeager BE. Is there an easy, effective, efficient, and inex-pensive technique to reduce pain of arterial punctures?Resp Care. 2015; 60(1):141-143.
VOLUME 42 | NUMBER 2 | MARCH/APRIL 2019 journalofinfusionnursing.com 99
AP
PE
ND
IX 1
Lite
ratu
re R
evie
w
Aut
hor
and
Dat
eA
im/O
bjec
tive
Sam
ple
and
Sett
ing
Met
hods
and
M
etho
dolo
gyM
ajor
Fin
ding
sLi
mit
atio
ns a
nd R
igor
/Va
lidit
ySi
gnifi
canc
e to
the
Is
sue
Burk
e et
al,
2011
14Th
e pu
rpos
e of
the
stu
dy
was
to c
ompa
re t
he
effic
acy
of in
trad
erm
al
bact
erio
stat
ic n
orm
al
salin
e w
ith t
hat
of
intr
ader
mal
buf
fere
d lid
ocai
ne in
pro
vidi
ng
loca
l ane
sthe
sia
to
adul
t pa
tient
s be
fore
IV
cath
eter
izat
ion.
148
adul
ts (M
= 2
6,
F =
48
each
gro
up)
from
the
res
earc
h-er
’s ho
spita
l sam
e-da
y su
rger
y un
it
Qua
ntita
tive
Rand
omiz
ed,
doub
le-b
lind,
pa
ralle
l-des
ign,
qua
si-
expe
rimen
tal s
tudy
Intr
ader
mal
buf
fere
d lid
ocai
ne
was
dem
onst
rate
d to
be
sign
ifi-
cant
ly s
uper
ior
to in
trad
erm
al
bact
erio
stat
ic n
orm
al s
alin
e in
re
duci
ng t
he p
ain
of IV
cat
he-
teriz
atio
n (P
= .0
07).
Larg
e sa
mpl
e.Pr
actic
e se
ttin
g w
as n
ot
iden
tifie
d.A
skill
ed in
fusi
on n
urse
pe
rfor
med
the
pro-
cedu
re, w
hich
cou
ld
lead
to a
mis
sing
co
nfou
ndin
g va
riabl
e of
diff
eren
t ski
lls a
nd
expe
rienc
e of
a g
roup
of
pro
fess
iona
ls.
Two
type
s of
loca
l ane
s-th
esia
wer
e te
sted
us
ing
the
sam
e ro
ute
of a
dmin
istr
atio
n,
whi
ch e
limin
ated
oth
er
varia
bles
tha
t co
uld
affe
ct t
he o
utco
mes
.
Two
type
s of
loca
l ane
s-th
esia
wer
e te
sted
, w
hich
pro
vide
d a
use-
ful c
ompa
rison
am
ong
othe
r ty
pes
used
for
the
sam
e pu
rpos
e of
re
duci
ng p
roce
dura
l pa
in. T
his
can
help
de
term
ine
thei
r pr
acti-
calit
y an
d co
nven
ienc
e in
nur
sing
pra
ctic
e.
Crow
ley
et a
l, 20
118
The
purp
ose
of t
he s
tudy
w
as to
add
to t
he
deve
lopm
ent
of e
mer
-ge
ncy
nurs
ing
reso
urce
s ev
iden
ce-b
ased
info
r-m
atio
n re
gard
ing
pain
an
d di
stre
ss r
educ
tion
in p
edia
tric
pat
ient
s du
ring
min
or in
vasi
ve
proc
edur
es in
the
ED
.
Com
preh
ensi
ve li
tera
-tu
re r
evie
wTh
e au
thor
s us
ed s
tan-
dard
ized
wor
kshe
ets,
in
clud
ing
the
Evid
ence
-Ap
prai
sal T
able
Te
mpl
ate,
Crit
ique
W
orks
heet
, and
the
Ag
ree
Wor
kshe
et to
pr
epar
e ta
bles
of e
vi-
denc
e ra
nkin
g ea
ch
artic
le in
term
s of
the
le
vel o
f evi
denc
e, t
he
qual
ity o
f evi
denc
e,
and
its r
elev
ance
an
d ap
plic
abili
ty to
pr
actic
e.
Cate
gorie
s of
effe
ctiv
enes
s fo
r pa
in re
lief a
re ra
nked
as
follo
ws:
1. B
iobe
havi
oral
inte
rven
tions
. (L
evel
A: H
igh)
.2.
Der
mal
ane
sthe
tic: V
apoc
oola
nt
spra
y.i.
Ethy
l vin
yl c
hlor
ide
(Lev
el C
: W
eak)
. ii.
Pen
taflu
orop
ropa
ne a
nd
tetr
aflu
oroe
than
e (L
evel
B:
Mod
erat
e).
iii. A
ll tr
ansd
erm
al fo
rms
of
lidoc
aine
/tet
raca
ine
(am
etho
-ca
ine)
(Lev
el B
: Mod
erat
e).
3. S
ubde
rmal
loca
l ane
sthe
tic
with
nee
dlel
ess
deliv
ery
(eg,
jet
inje
ctio
n de
vice
) as
a de
liver
y m
etho
d fo
r lid
ocai
ne is
sup
erio
r to
oth
er fo
rms
of p
repa
ratio
n (L
evel
A: H
igh)
.4.
Loc
al a
pplic
atio
n of
ice
(Lev
el B
: M
oder
ate)
.5.
Pac
ifier
s an
d su
cros
e fo
r in
fant
s 0-
3 m
onth
s:i.
Paci
fiers
(Lev
el B
: Mod
erat
e).
ii. S
ucro
se (L
evel
C: W
eak)
.
Seco
ndar
y so
urce
.Pr
actic
e se
ttin
g w
as n
ot
iden
tifie
d.
Prov
ided
leve
ls o
f rec
-om
men
datio
ns fo
r di
ffere
nt t
ypes
of
pain
man
agem
ent
for
need
le-r
elat
ed
proc
edur
es in
chi
ldre
n ba
sed
on e
vide
nce
rank
ing,
whi
ch c
an
help
sup
port
the
st
udy
of t
heir
effe
c-tiv
enes
s. F
acto
rs t
hat
cont
ribut
ed to
suc
h co
nclu
sion
s in
thi
s st
udy
are
impo
rtan
t to
re
sear
ch b
ecau
se t
hey
can
influ
ence
the
use
of
loca
l ane
sthe
tics
by
nurs
es.
(con
tinue
s)
100 Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. Journal of Infusion Nursing on behalf of the Infusion Nurses Society.
AP
PE
ND
IX 1
Lite
ratu
re R
evie
w (
Cont
inue
d)
Aut
hor
and
Dat
eA
im/O
bjec
tive
Sam
ple
and
Sett
ing
Met
hods
and
M
etho
dolo
gyM
ajor
Fin
ding
sLi
mit
atio
ns a
nd R
igor
/Va
lidit
ySi
gnifi
canc
e to
the
Is
sue
Czar
neck
i et
al,
2011
15Th
e st
udy
aim
ed to
iden
-tif
y ba
rrie
rs p
erce
ived
as
inte
rfer
ing
with
RN
s’
abili
ty to
pro
vide
opt
i-m
al p
edia
tric
pai
n m
an-
agem
ent.
272
of 9
70 s
urve
ys
wer
e re
turn
ed fr
om
RNs
(F =
226
, M
= 6
)Ch
ildre
n’s
Hos
pita
l of
Wis
cons
in is
a p
edi-
atric
teac
hing
hos
pi-
tal i
n so
uthe
aste
rn
Wis
cons
in.
Qua
ntita
tive,
cr
oss-
sect
iona
l des
ign
The
5 m
ost
sign
ifica
nt b
arrie
rs
iden
tifie
d w
ere
insu
ffic
ient
or
ders
, ins
uffic
ient
phy
sici
an
orde
rs b
efor
e pr
oced
ures
, in
suff
icie
nt t
ime
to p
rem
edic
ate
patie
nts
befo
re p
roce
dure
s, t
he
perc
eptio
n th
at p
ain
man
age-
men
t by
med
ical
sta
ff is
a lo
w
prio
rity,
and
par
ents
’ rel
ucta
nce
to h
ave
patie
nts
rece
ive
pain
m
edic
atio
n.Ad
ditio
nal b
arrie
rs w
ere
iden
tifie
d th
roug
h na
rrat
ive
com
men
ts.
Larg
e sa
mpl
e si
ze.
Nur
ses
wer
e fr
om a
sin
gle
sett
ing.
The
stud
y pr
ovid
ed
deta
iled
desc
riptio
n of
da
ta.
The
maj
ority
of p
artic
-ip
ants
wer
e fe
mal
e,
whi
ch c
ould
sho
w b
ias
resp
onse
s; h
owev
er,
this
may
ref
lect
the
re
ality
of t
he n
ursi
ng
popu
latio
n, in
whi
ch
the
maj
ority
oft
en a
re
fem
ale.
Alth
ough
thi
s st
udy
is
limite
d to
ped
iatr
ics
and
is n
ot s
peci
fical
ly
abou
t lo
cal a
nes-
thet
ics,
it id
entif
ied
impo
rtan
t fa
ctor
s fr
om
nurs
es’ p
ersp
ectiv
es
that
are
bar
riers
to
optim
al p
ain
man
-ag
emen
t, w
hich
are
us
eful
to t
he r
esea
rch.
In
add
ition
, the
use
of
topi
cal a
nalg
esic
s fo
r pr
oced
ural
pai
n w
as
invo
lved
as
part
of t
his
stud
y, w
hich
is r
ele-
vant
to t
he r
esea
rch.
Hay
nes,
201
516Th
e st
udy
inve
stig
ated
w
heth
er a
pplic
atio
n of
ic
e to
the
pun
ctur
e si
te
coul
d re
duce
the
pai
n as
soci
ated
with
art
eria
l pu
nctu
re.
Conv
enie
nce
sam
ple
of 8
0 ad
ult
outp
a-tie
nts
with
a p
hy-
sici
an o
rder
for
an
ABG
test
Qua
ntita
tive,
pro
spec
tive,
st
ratif
ied,
rand
omiz
ed,
cont
rolle
d tr
ial
Sign
ifica
nt r
educ
tion
of p
ain
in t
he
trea
tmen
t gro
up c
ompa
red
with
th
e co
ntro
l gro
up. (
Mea
n vi
sual
an
alog
sca
le 1
3.8 ±
16.
9 vs
25
± 2
3 m
m, P
= .0
1; m
edia
n vi
sual
ana
log
scal
e 7
mm
, IQ
R 1.
5–19
vs
20 m
m; I
QR
4.5–
38.5
m
m, P
= .0
1).
Onl
y 3
subj
ects
wer
e un
able
to
tole
rate
3-m
in ic
e ap
plic
atio
n.
Rece
nt s
tudy
.Pr
actic
e se
ttin
g w
as n
ot
iden
tifie
d.A
sing
le p
hleb
otom
ist
drew
all
ABG
s, s
o th
ere
mig
ht b
e a
mis
sing
co
nfou
ndin
g va
riabl
e be
caus
e a
grou
p of
pr
ofes
sion
als
with
var
-io
us s
kills
and
exp
eri-
ence
was
not
invo
lved
.
Appl
icat
ion
of ic
e is
an
othe
r te
chni
que
that
can
be
used
by
RNs
as a
n al
tern
ativ
e fo
r pr
oced
ural
pai
n re
duct
ion
beca
use
it is
non
inva
sive
, non
-ph
arm
acol
ogic
, ine
x-pe
nsiv
e, a
nd r
eadi
ly
avai
labl
e, e
spec
ially
w
hen
loca
l ane
sthe
sia
is n
ot a
vaila
ble
or is
no
t of
fere
d to
pat
ient
s in
som
e se
ttin
gs.
(con
tinue
s)
VOLUME 42 | NUMBER 2 | MARCH/APRIL 2019 journalofinfusionnursing.com 101
AP
PE
ND
IX 1
Lite
ratu
re R
evie
w (
Cont
inue
d)
Aut
hor
and
Dat
eA
im/O
bjec
tive
Sam
ple
and
Sett
ing
Met
hods
and
M
etho
dolo
gyM
ajor
Fin
ding
sLi
mit
atio
ns a
nd R
igor
/Va
lidit
ySi
gnifi
canc
e to
the
Is
sue
Czar
neck
i et
al,
2011
15Th
e st
udy
aim
ed to
iden
-tif
y ba
rrie
rs p
erce
ived
as
inte
rfer
ing
with
RN
s’
abili
ty to
pro
vide
opt
i-m
al p
edia
tric
pai
n m
an-
agem
ent.
272
of 9
70 s
urve
ys
wer
e re
turn
ed fr
om
RNs
(F =
226
, M
= 6
)Ch
ildre
n’s
Hos
pita
l of
Wis
cons
in is
a p
edi-
atric
teac
hing
hos
pi-
tal i
n so
uthe
aste
rn
Wis
cons
in.
Qua
ntita
tive,
cr
oss-
sect
iona
l des
ign
The
5 m
ost
sign
ifica
nt b
arrie
rs
iden
tifie
d w
ere
insu
ffic
ient
or
ders
, ins
uffic
ient
phy
sici
an
orde
rs b
efor
e pr
oced
ures
, in
suff
icie
nt t
ime
to p
rem
edic
ate
patie
nts
befo
re p
roce
dure
s, t
he
perc
eptio
n th
at p
ain
man
age-
men
t by
med
ical
sta
ff is
a lo
w
prio
rity,
and
par
ents
’ rel
ucta
nce
to h
ave
patie
nts
rece
ive
pain
m
edic
atio
n.Ad
ditio
nal b
arrie
rs w
ere
iden
tifie
d th
roug
h na
rrat
ive
com
men
ts.
Larg
e sa
mpl
e si
ze.
Nur
ses
wer
e fr
om a
sin
gle
sett
ing.
The
stud
y pr
ovid
ed
deta
iled
desc
riptio
n of
da
ta.
The
maj
ority
of p
artic
-ip
ants
wer
e fe
mal
e,
whi
ch c
ould
sho
w b
ias
resp
onse
s; h
owev
er,
this
may
ref
lect
the
re
ality
of t
he n
ursi
ng
popu
latio
n, in
whi
ch
the
maj
ority
oft
en a
re
fem
ale.
Alth
ough
thi
s st
udy
is
limite
d to
ped
iatr
ics
and
is n
ot s
peci
fical
ly
abou
t lo
cal a
nes-
thet
ics,
it id
entif
ied
impo
rtan
t fa
ctor
s fr
om
nurs
es’ p
ersp
ectiv
es
that
are
bar
riers
to
optim
al p
ain
man
-ag
emen
t, w
hich
are
us
eful
to t
he r
esea
rch.
In
add
ition
, the
use
of
topi
cal a
nalg
esic
s fo
r pr
oced
ural
pai
n w
as
invo
lved
as
part
of t
his
stud
y, w
hich
is r
ele-
vant
to t
he r
esea
rch.
Hay
nes,
201
516Th
e st
udy
inve
stig
ated
w
heth
er a
pplic
atio
n of
ic
e to
the
pun
ctur
e si
te
coul
d re
duce
the
pai
n as
soci
ated
with
art
eria
l pu
nctu
re.
Conv
enie
nce
sam
ple
of 8
0 ad
ult
outp
a-tie
nts
with
a p
hy-
sici
an o
rder
for
an
ABG
test
Qua
ntita
tive,
pro
spec
tive,
st
ratif
ied,
rand
omiz
ed,
cont
rolle
d tr
ial
Sign
ifica
nt r
educ
tion
of p
ain
in t
he
trea
tmen
t gro
up c
ompa
red
with
th
e co
ntro
l gro
up. (
Mea
n vi
sual
an
alog
sca
le 1
3.8 ±
16.
9 vs
25
± 2
3 m
m, P
= .0
1; m
edia
n vi
sual
ana
log
scal
e 7
mm
, IQ
R 1.
5–19
vs
20 m
m; I
QR
4.5–
38.5
m
m, P
= .0
1).
Onl
y 3
subj
ects
wer
e un
able
to
tole
rate
3-m
in ic
e ap
plic
atio
n.
Rece
nt s
tudy
.Pr
actic
e se
ttin
g w
as n
ot
iden
tifie
d.A
sing
le p
hleb
otom
ist
drew
all
ABG
s, s
o th
ere
mig
ht b
e a
mis
sing
co
nfou
ndin
g va
riabl
e be
caus
e a
grou
p of
pr
ofes
sion
als
with
var
-io
us s
kills
and
exp
eri-
ence
was
not
invo
lved
.
Appl
icat
ion
of ic
e is
an
othe
r te
chni
que
that
can
be
used
by
RNs
as a
n al
tern
ativ
e fo
r pr
oced
ural
pai
n re
duct
ion
beca
use
it is
non
inva
sive
, non
-ph
arm
acol
ogic
, ine
x-pe
nsiv
e, a
nd r
eadi
ly
avai
labl
e, e
spec
ially
w
hen
loca
l ane
sthe
sia
is n
ot a
vaila
ble
or is
no
t of
fere
d to
pat
ient
s in
som
e se
ttin
gs.
(con
tinue
s)
AP
PE
ND
IX 1
Lite
ratu
re R
evie
w (
Cont
inue
d)
Aut
hor
and
Dat
eA
im/O
bjec
tive
Sam
ple
and
Sett
ing
Met
hods
and
M
etho
dolo
gyM
ajor
Fin
ding
sLi
mit
atio
ns a
nd R
igor
/Va
lidit
ySi
gnifi
canc
e to
the
Is
sue
Haj
isey
edja
vady
et
al,
2012
9Th
e ai
m o
f the
stu
dy w
as
to c
ompa
re p
ain
leve
ls
from
ABG
sam
plin
g pe
r-fo
rmed
with
or
with
out
appl
icat
ion
of li
doca
ine
thro
ugh
an in
trad
erm
al
jet
inje
ctor
.
42 a
lert
and
coo
p-er
ativ
e vo
lunt
eers
re
quiri
ng A
BG s
am-
ple
as p
art
of t
heir
man
agem
ent
in
the
EDG
roup
A v
s G
roup
B
(M =
15
and
F =
6
vs M
= 1
0 an
d F =
11)
Imam
-Rez
a H
ospi
tal i
n Ta
briz
, Ira
n
Qua
ntita
tive,
rand
omiz
ed,
cont
rolle
d cl
inic
al t
rial
The
pain
vis
ual a
nalo
g sc
ale
scor
e du
ring
ABG
sam
plin
g w
as
cons
ider
ably
low
er in
gro
up A
co
mpa
red
with
gro
up B
(1.2
9 ±
0.
90 v
s 4.
19 ±
1.4
3; P
< .0
01).
The
num
ber
of a
ttem
pts
requ
ired
for
ABG
was
sig
nific
antly
low
er
in g
roup
A c
ompa
red
with
gr
oup
B (1
.29 ±
0.4
6 vs
2.1
±
0.12
; P =
.009
).Al
l res
iden
ts r
epor
ted
ease
of u
se
with
the
lido
cain
e je
t in
ject
ion
proc
edur
e (P
< .0
5).
Smal
l sam
ple.
The
cont
rol g
roup
re
ceiv
ed a
con
vent
iona
l m
etho
d of
mild
loca
l an
esth
esia
; how
ever
, it
was
not
exp
lain
ed w
hy
this
was
don
e.Co
ntra
dict
ory
info
rma-
tion
prov
ided
in t
he
abst
ract
abo
ut t
he
met
hod
(app
licat
ion
of
loca
l ane
sthe
sia
5 m
in
befo
re t
he p
roce
dure
).
Alth
ough
the
re w
as n
o nu
rsin
g in
volv
emen
t in
th
is s
tudy
in w
hich
ED
re
side
nts
perf
orm
ed
the
proc
edur
e, t
he
stud
y co
mpa
red
the
use
of a
jet
inje
ctor
de
vice
with
oth
er
type
s of
loca
l ane
s-th
esia
. Thi
s st
udy
has
rele
vant
asp
ects
th
at m
ay in
fluen
ce
the
use
of t
his
devi
ce
by n
urse
s, s
uch
as
adm
inis
trat
ion
time,
su
cces
sful
inse
rtio
n,
and
conv
enie
nce.
Hija
zi e
t al
, 20
0917
The
auth
ors
exam
ined
the
ef
fect
iven
ess
and
safe
ty
of u
sing
a to
pica
l alk
ane
vapo
cool
ant
spra
y in
re
duci
ng p
ain
asso
ciat
-ed
with
ven
ous
cann
ula-
tion
in a
dults
in E
Ds.
201
adul
t pa
tient
s in
th
e ED
of a
met
-ro
polit
an te
achi
ng
hosp
ital i
n Au
stra
lia
Qua
ntita
tive
appr
oach
Rand
omiz
ed d
oubl
e-
blin
d, p
lace
bo-
cont
rolle
d tr
ial
Med
ian
pain
sco
res
for
cann
ula-
tion
in t
he c
ontr
ol a
nd in
ter-
vent
ion
grou
ps w
ere
36 (1
9-51
) an
d 12
(5-4
0) m
m, r
espe
ctiv
ely
(P <
.001
), an
d 59
(60%
) and
33
(32%
) rep
orte
d pa
in s
core
s ≥
30
mm
(P <
.001
). Su
cces
s ra
tes
for
first
can
nula
tion
atte
mpt
did
not
diff
er b
etw
een
grou
ps (P
= .3
9).
39%
and
62%
pat
ient
s sa
id t
hey
wou
ld c
hoos
e th
e sp
ray
they
re
ceiv
ed fo
r an
alge
sia
in t
he
futu
re (P
= .0
02).
Topi
cal a
lkan
e va
poco
olan
t sp
ray
is e
ffect
ive,
saf
e, a
nd a
ccep
tabl
e in
red
ucin
g ca
nnul
atio
n pa
in
(less
tha
n 15
s o
f app
licat
ion)
in
adul
ts in
ED
.
Larg
e sa
mpl
e si
ze.
Pote
ntia
l con
foun
d-er
s w
ere
mea
sure
d to
ens
ure
accu
rate
ou
tcom
es.
Visu
al a
nalo
g sc
ale
was
us
ed, w
hich
is a
hig
hly
disc
rimin
ant
met
hod
of
asse
ssin
g pa
in.
Clea
r an
d de
taile
d in
for-
mat
ion
was
pro
vide
d th
at e
xpre
sses
rel
iabi
li-ty
of t
he s
tudy
.
Alth
ough
it w
as e
xclu
sive
to
onl
y 1
type
of l
ocal
an
esth
esia
, thi
s st
udy
help
s su
ppor
t th
e ev
i-de
nce
of v
apoc
oola
nt
spra
y ef
fect
iven
ess
in
redu
cing
pai
n as
so-
ciat
ed w
ith v
enou
s ca
nnul
atio
n.It
is a
lso
bene
ficia
l to
com
pare
with
oth
er
type
s of
loca
l ane
sthe
-si
a th
at a
re u
sed
for
the
sam
e pu
rpos
e to
ex
amin
e as
pect
s th
at
can
influ
ence
nur
ses’
us
e, s
uch
as le
vel o
f ef
fect
iven
ess
and
onse
t of
act
ion.
(con
tinue
s)
102 Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. Journal of Infusion Nursing on behalf of the Infusion Nurses Society.
AP
PE
ND
IX 1
Lite
ratu
re R
evie
w (
Cont
inue
d)
Aut
hor
and
Dat
eA
im/O
bjec
tive
Sam
ple
and
Sett
ing
Met
hods
and
M
etho
dolo
gyM
ajor
Fin
ding
sLi
mit
atio
ns a
nd R
igor
/Va
lidit
ySi
gnifi
canc
e to
the
Is
sue
Hud
son
et a
l, 20
0618
The
purp
ose
of t
he s
tudy
w
as to
rev
iew
rec
om-
men
datio
ns a
nd s
tudi
es
rela
ted
to t
he u
se o
f in
trad
erm
al li
doca
ine
to d
ecre
ase
pain
dur
ing
arte
rial p
unct
ures
.
Lite
ratu
re r
evie
wA
syst
emat
ic c
om-
pute
rized
sea
rch
of M
EDLI
NE
(198
0-Ja
nuar
y 20
06)
Exce
pt a
mon
g an
esth
esia
pro
-vi
ders
, the
use
of a
loca
l ane
s-th
esia
bef
ore
arte
rial p
unct
ure
is n
ot u
nive
rsal
, con
trar
y to
th
e st
anda
rd o
f pra
ctic
e. A
nu
mbe
r of
fals
e pe
rcep
tions
m
ay p
reve
nt w
ider
use
of s
uch
anes
thet
ics.
Seco
ndar
y so
urce
.Pr
actic
e se
ttin
g w
as n
ot
iden
tifie
d.
Alth
ough
the
rev
iew
sp
ecifi
ed 1
typ
e of
lo
cal a
nest
hesi
a an
d so
me
revi
ewed
art
icle
s ar
e co
nsid
ered
old
, it
expl
ored
man
y fa
ctor
s th
at c
an in
fluen
ce t
he
use
of lo
cal a
nest
hesi
a by
nur
ses,
suc
h as
st
anda
rd o
f pra
ctic
e,
effe
ctiv
enes
s of
intr
a-de
rmal
lido
cain
e, to
pi-
cal a
nest
hesi
a, b
arrie
rs
of u
se, e
ffect
on
succ
essf
ul in
sert
ion,
an
d co
st.
Jimen
ez e
t al
, 20
0619
The
stud
y ai
med
to c
om-
pare
the
effe
ctiv
enes
s of
1%
buf
fere
d lid
ocai
ne
with
an
intr
ader
mal
je
t in
ject
or v
s a
topi
cal
tran
sder
mal
age
nt, (
eg,
EMLA
) to
faci
litat
e IV
ca
nnul
atio
n an
d pr
ovid
e ad
equa
te a
nalg
esia
be
fore
IV p
lace
men
t.
116
youn
g pa
tient
s (7
-19
y ol
d)To
pica
l tra
nsde
rmal
ag
ent
grou
p =
59
Intr
ader
mal
jet
inje
c-to
r gr
oup =
57
Child
ren’
s H
ospi
tal a
nd
Regi
onal
Med
ical
Ce
nter
in S
eatt
le,
Was
hing
ton
Qua
ntita
tive
Rand
omiz
ed, c
ontr
olle
d tr
ial
Ther
e w
as a
sig
nific
ant
diffe
renc
e in
pai
n ra
tings
(P =
.000
1)
durin
g IV
can
nula
tion
betw
een
the
topi
cal t
rans
derm
al a
gent
(m
edia
n =
3) a
nd t
he in
trad
er-
mal
jet
inje
ctor
(med
ian =
0).
84%
of p
atie
nts
repo
rted
no
pain
at
the
tim
e of
the
intr
ader
mal
je
t in
ject
or li
doca
ine
appl
ica-
tion
com
pare
d w
ith 6
1% in
the
to
pica
l tra
nsde
rmal
age
nt g
roup
at
the
tim
e of
dre
ssin
g re
mov
al
(P =
.004
).N
o di
ffere
nces
wer
e fo
und
in
the
num
ber
of a
ttem
pts
for
IV
cann
ulat
ion.
Intr
ader
mal
jet
inje
ctor
app
lica-
tion
of 1
% b
uffe
red
lidoc
aine
be
fore
IV c
annu
latio
n is
not
pa
infu
l and
has
bet
ter
anes
thet
-ic
effe
ctiv
enes
s co
mpa
red
with
a
topi
cal t
rans
derm
al a
gent
.
Larg
e sa
mpl
e.La
ck o
f con
trol
gro
up w
as
not
expl
aine
d in
the
st
udy.
Blin
ding
of s
tudy
per
son-
nel w
as n
ot p
rovi
ded.
This
stu
dy is
use
ful t
o th
e re
sear
ch to
pic
beca
use
it te
sted
an
intr
ader
-m
al je
t in
ject
or lo
cal
anes
thet
ic a
gain
st a
to
pica
l tra
nsde
rmal
ag
ent
to m
easu
re t
he
effe
ctiv
enes
s be
twee
n bo
th, a
nd it
mea
sure
d re
leva
nt a
spec
ts, s
uch
as s
ucce
ssfu
l ins
er-
tion
rate
, tim
e, a
nd
conv
enie
nce.
It a
lso
test
ed t
he h
ypot
hesi
s th
at c
hild
ren
wou
ld
be fr
ight
ened
by
the
pop
soun
d, y
et t
he
oppo
site
was
pro
ven.
Al
l of t
hese
res
ults
ar
e fa
ctor
s th
at c
ould
in
fluen
ce t
he u
se o
f lo
cal a
nest
hetic
s by
nu
rses
.
(con
tinue
s)
VOLUME 42 | NUMBER 2 | MARCH/APRIL 2019 journalofinfusionnursing.com 103
AP
PE
ND
IX 1
Lite
ratu
re R
evie
w (
Cont
inue
d)
Aut
hor
and
Dat
eA
im/O
bjec
tive
Sam
ple
and
Sett
ing
Met
hods
and
M
etho
dolo
gyM
ajor
Fin
ding
sLi
mit
atio
ns a
nd R
igor
/Va
lidit
ySi
gnifi
canc
e to
the
Is
sue
Levi
tt a
nd
Ziem
ba-D
avis
, 20
1320
The
purp
ose
of t
his
stud
y w
as to
exp
lore
kno
wl-
edge
abo
ut p
atie
nt
pref
eren
ces
for
pain
co
ntro
l dur
ing
perip
her-
al v
enou
s ca
nnul
atio
n.Sp
ecifi
c ai
ms
wer
e to
(1
) elu
cida
te p
atie
nts’
de
sire
to b
e in
volv
ed
in d
ecis
ions
abo
ut p
ain
man
agem
ent;
(2) d
eter
-m
ine
whe
ther
pat
ient
s ha
ve a
pre
fere
nce
for
diffe
rent
pai
n m
anag
e-m
ent
stra
tegi
es; (
3)
dete
rmin
e pa
tient
sat
-is
fact
ion
with
the
pai
n m
anag
emen
t ch
oice
; an
d (4
) rec
ord
pain
ra
tings
and
sat
isfa
ctio
n w
ith IV
inse
rtio
n.
30 p
atie
nts
recr
uite
d fr
om a
ref
erra
l hos
-pi
tal i
n th
e U
nite
d St
ates
Qua
ntita
tive
appr
oach
.Ex
plor
ator
y st
udy.
Patie
nts
wer
e as
ked
to
answ
er s
ome
ques
-tio
ns b
efor
e an
d af
ter
the
proc
edur
e.Th
ree
grou
ps: i
ntra
der-
mal
lido
cain
e, g
uide
d im
ager
y, a
nd n
o in
terv
entio
n.
Four
pat
ient
s ch
ose
the
trad
ition
al
stra
tegy
of n
o pa
in c
ontr
ol. I
n co
ntra
st, 8
6.6%
of p
artic
ipan
ts
pref
erre
d to
hav
e pa
in c
ontr
ol.
The
stud
y fo
und
that
pai
n in
the
in
trad
erm
al li
doca
ine
grou
p w
as
sign
ifica
ntly
low
er.
All p
artic
ipan
ts in
the
3 g
roup
s re
port
ed t
hat
the
patie
nt’s
invo
lvem
ent
in d
ecis
ion
mak
ing
rega
rdin
g pa
in m
anag
emen
t is
ve
ry im
port
ant.
Rece
nt s
tudy
.Sm
all s
ampl
e si
ze.
Stud
y m
etho
dolo
gy w
as
uncl
ear.
Lack
of b
lindi
ng a
nd e
qual
tr
eatm
ent
limit
its r
eli-
abili
ty.
Rand
omiz
atio
n to
gro
ups
was
not
pos
sibl
e be
caus
e pa
rtic
ipan
t ch
oice
s ab
out
pain
m
anag
emen
t st
rate
-gi
es w
ere
a ke
y st
udy
outc
ome.
Des
pite
lim
itatio
ns,
this
stu
dy is
use
ful
beca
use
it ex
plor
ed
the
impo
rtan
ce o
f pai
n m
anag
emen
t st
rate
-gi
es fo
r IV
inse
rtio
n fr
om p
atie
nts’
per
-sp
ectiv
es. I
n ad
ditio
n,
its im
plic
atio
ns fo
r nu
rsin
g pr
actic
e ar
e pa
rtic
ular
ly r
elev
ant
to
the
conc
erns
out
lined
in
thi
s ar
ticle
.
Mat
heso
n et
al,
2014
21Th
e st
udy
aim
ed to
com
-pa
re s
tand
ard
prac
tice
and
3 m
etho
ds o
f ana
l-ge
sic
infil
trat
ion
(0.7
mL
1% li
doca
ine,
0.7
mL
buffe
red
1% li
doca
ine,
or
0.7
mL
bact
erio
stat
ic
salin
e to
det
erm
ine
if 1
met
hod
was
mor
e su
c-ce
ssfu
l tha
n th
e ot
hers
at
red
ucin
g pa
in a
ssoc
i-at
ed w
ith A
BG s
ampl
ing.
Conv
enie
nce
sam
ple
of 4
0 ho
spita
lized
pa
tient
s at
OSF
Sa
int
Anth
ony
Med
ical
Cen
ter,
in
Rock
ford
, Illi
nois
Qua
ntita
tive,
rand
omiz
ed,
part
ially
blin
ded,
pro
-sp
ectiv
e de
sign
Com
parin
g th
e no
nint
erve
ntio
n gr
oup
with
the
3 in
terv
entio
ns
show
ed t
hat
the
buffe
red
(P =
.0
41) a
nd p
lain
lido
cain
e (P
=
.000
) ind
uced
sig
nific
antly
less
ar
teria
l pun
ctur
e pa
in t
han
the
noni
nter
vent
iona
l gro
up, b
ut
ther
e w
as n
o st
atis
tical
sig
nifi-
canc
e w
ith t
he u
se o
f bac
terio
-st
atic
sal
ine
(P =
.665
).O
vera
ll, p
lain
lido
cain
e w
as t
he
inte
rven
tion
that
res
ulte
d in
sig
-ni
fican
t re
duct
ion
of p
ain.
Rece
nt s
tudy
.Sm
all s
ampl
e si
ze a
nd
part
ial r
ando
miz
atio
n.Pa
tient
s w
ere
trea
ted
equa
lly.
All A
BGs
wer
e dr
awn
by 1
re
sear
cher
; out
com
es
coul
d be
affe
cted
if d
if-fe
rent
leve
ls o
f ski
ll an
d ex
perie
nce
of a
gro
up
of h
ealth
pro
fess
iona
ls
wer
e in
volv
ed.
Base
d on
pat
ient
s fr
om a
si
ngle
set
ting.
The
stud
y is
use
ful t
o su
ppor
t ef
fect
iven
ess
of lo
cal a
nest
hesi
a fo
r pr
oced
ural
pai
n. It
is
also
rel
evan
t to
the
st
udy
topi
c, a
s th
e re
sear
cher
is a
nur
se
who
has
als
o ex
eri-
men
ted
with
way
s to
re
duce
pai
n as
soci
ated
w
ith a
rter
ial p
unct
ure
for
ABG
sam
plin
g.
(con
tinue
s)
104 Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. Journal of Infusion Nursing on behalf of the Infusion Nurses Society.
AP
PE
ND
IX 1
Lite
ratu
re R
evie
w (
Cont
inue
d)
Aut
hor
and
Dat
eA
im/O
bjec
tive
Sam
ple
and
Sett
ing
Met
hods
and
M
etho
dolo
gyM
ajor
Fin
ding
sLi
mit
atio
ns a
nd R
igor
/Va
lidit
ySi
gnifi
canc
e to
the
Is
sue
McN
augh
ton
et a
l, 20
0922
The
stud
y ai
med
to c
om-
pare
pai
n an
d an
xiet
y as
soci
ated
with
IV c
an-
nula
tion
afte
r pr
etre
at-
ing
patie
nts
with
1%
su
bcut
aneo
us b
uffe
red
lidoc
aine
, 4%
lido
cain
e cr
eam
, or
no a
pplic
atio
n of
loca
l ane
sthe
sia.
70 m
edic
al s
tude
nt
and
nurs
e vo
lun-
teer
s w
ho p
artic
-ip
ated
in h
ospi
tal
wor
ksho
ps fo
r IV
in
sert
ion
in t
he
Uni
ted
Stat
es
Qua
ntita
tive,
rand
omiz
ed,
cros
sove
rPa
in a
nd a
nxie
ty a
ssoc
iate
d w
ith
IV c
annu
latio
n w
as s
igni
fican
tly
min
imiz
ed b
y th
e us
e of
lido
-ca
ine
crea
m o
r in
ject
ed b
uff-
ered
lido
cain
e.Th
ere
was
no
sign
ifica
nt d
if-fe
renc
e in
anx
iety
sco
res
in
patie
nts
rece
ivin
g lid
ocai
ne
crea
m a
nd t
hose
inje
cted
with
bu
ffere
d lid
ocai
ne.
70%
of s
ubje
cts
repo
rted
tha
t th
ey w
ould
alw
ays
requ
est
buff-
ered
lido
cain
e in
the
futu
re.
Man
y pa
rtic
ipan
ts w
ere
influ
ence
d by
the
ir po
sitiv
e pe
rson
al e
xpe-
rienc
es in
rec
eivi
ng lo
cal a
nes-
thes
ia a
s a
reas
on to
adm
inis
ter
it to
the
ir pa
tient
s.
The
sam
ple
was
bia
sed
to
heal
th p
rofe
ssio
nals
, w
hich
mig
ht a
ffect
the
va
lidity
of t
he fi
nd-
ings
in te
rms
of t
heir
know
ledg
e ab
out
loca
l an
esth
esia
.Th
ey w
ere
not
blin
ded,
an
d a
plac
ebo
was
no
t us
ed b
ecau
se o
f th
e cl
aim
of e
thic
al
cons
ider
atio
n.
The
stud
y is
rel
evan
t to
th
e re
sear
ch to
pic,
in
whi
ch it
sup
port
s th
e ef
fect
iven
ess
of lo
cal
anes
thes
ia fo
r re
duc-
ing
pain
and
anx
iety
as
soci
ated
with
IV c
an-
nula
tion.
Inte
rest
ingl
y,
the
stud
y sh
ows
that
pe
rson
al e
xper
ienc
es
of p
artic
ipan
ts h
ave
influ
ence
d th
eir
per-
cept
ion
tow
ard
usin
g lo
cal a
nest
hesi
a in
the
fu
ture
for
them
selv
es
and
thei
r pa
tient
s.
Ther
efor
e, p
erso
nal
expe
rienc
e co
uld
be a
fa
ctor
tha
t in
fluen
ces
nurs
es’ u
se o
f loc
al
anes
thes
ia.
Mirz
aei e
t al
, 20
1823
The
aim
of t
he s
tudy
was
to
inve
stig
ate
the
effe
ct
of to
pica
l tra
nsde
rmal
cr
eam
, lid
ocai
ne s
pray
, an
d ic
e on
art
erio
ve-
nous
can
nula
tion
pain
in
tens
ity in
hem
odia
lysi
s pa
tient
s.
40 h
emod
ialy
sis
patie
nts >
18
y ol
d w
ith a
rter
iove
nous
fis
tula
Shah
id R
ahne
moo
n H
ospi
tal i
n Ya
zd,
Iran
Qua
ntita
tive,
qua
si-
expe
rimen
tal
The
redu
ctio
n in
mea
n pa
in in
ten-
sity
was
sig
nific
antly
gre
ater
w
ith to
pica
l tra
nsde
rmal
cre
am
com
pare
d w
ith li
doca
ine
spra
y an
d ic
e (P
< .0
01).
The
pain
sco
re w
as a
lso
sign
ifi-
cant
ly d
iffer
ent
befo
re in
terv
en-
tion
and
afte
r ap
plic
atio
n of
the
3
inte
rven
tions
(P <
.001
).Th
e st
udy
conc
lude
d th
at a
ll 3
met
hods
of i
nter
vent
ion
wer
e ef
fect
ive
in r
educ
ing
pain
in
tens
ity, w
ith to
pica
l tra
ns-
derm
al c
ream
exe
rtin
g th
e gr
eate
st e
ffect
in d
ecre
asin
g th
e pu
nctu
re-r
elat
ed m
ean
pain
in
tens
ity o
f art
erio
veno
us fi
stu-
la c
annu
latio
n.
Curr
ent
stud
ySm
all s
ampl
e si
zeLa
ck o
f ran
dom
izat
ion
This
is a
rece
nt s
tudy
co
mpa
ring
3 ty
pes
of
loca
l ane
sthe
sia—
a to
pica
l tra
nsde
rmal
ag
ent,
lidoc
aine
spr
ay,
and
ice—
test
ed o
n ar
terio
veno
us c
annu
la-
tion
for
hem
odia
lysi
s.Th
e st
udy
prov
ided
a
usef
ul c
ompa
rison
of
diffe
rent
type
s of
loca
l an
esth
esia
use
d fo
r th
e sa
me
purp
ose
of
redu
cing
pro
cedu
ral
pain
. Thi
s ca
n he
lp
dete
rmin
e th
eir p
ract
i-ca
lity
and
conv
enie
nce
with
in n
ursi
ng p
ract
ice.
(con
tinue
s)
VOLUME 42 | NUMBER 2 | MARCH/APRIL 2019 journalofinfusionnursing.com 105
AP
PE
ND
IX 1
Lite
ratu
re R
evie
w (
Cont
inue
d)
Aut
hor
and
Dat
eA
im/O
bjec
tive
Sam
ple
and
Sett
ing
Met
hods
and
M
etho
dolo
gyM
ajor
Fin
ding
sLi
mit
atio
ns a
nd R
igor
/Va
lidit
ySi
gnifi
canc
e to
the
Is
sue
McN
augh
ton
et a
l, 20
0922
The
stud
y ai
med
to c
om-
pare
pai
n an
d an
xiet
y as
soci
ated
with
IV c
an-
nula
tion
afte
r pr
etre
at-
ing
patie
nts
with
1%
su
bcut
aneo
us b
uffe
red
lidoc
aine
, 4%
lido
cain
e cr
eam
, or
no a
pplic
atio
n of
loca
l ane
sthe
sia.
70 m
edic
al s
tude
nt
and
nurs
e vo
lun-
teer
s w
ho p
artic
-ip
ated
in h
ospi
tal
wor
ksho
ps fo
r IV
in
sert
ion
in t
he
Uni
ted
Stat
es
Qua
ntita
tive,
rand
omiz
ed,
cros
sove
rPa
in a
nd a
nxie
ty a
ssoc
iate
d w
ith
IV c
annu
latio
n w
as s
igni
fican
tly
min
imiz
ed b
y th
e us
e of
lido
-ca
ine
crea
m o
r in
ject
ed b
uff-
ered
lido
cain
e.Th
ere
was
no
sign
ifica
nt d
if-fe
renc
e in
anx
iety
sco
res
in
patie
nts
rece
ivin
g lid
ocai
ne
crea
m a
nd t
hose
inje
cted
with
bu
ffere
d lid
ocai
ne.
70%
of s
ubje
cts
repo
rted
tha
t th
ey w
ould
alw
ays
requ
est
buff-
ered
lido
cain
e in
the
futu
re.
Man
y pa
rtic
ipan
ts w
ere
influ
ence
d by
the
ir po
sitiv
e pe
rson
al e
xpe-
rienc
es in
rec
eivi
ng lo
cal a
nes-
thes
ia a
s a
reas
on to
adm
inis
ter
it to
the
ir pa
tient
s.
The
sam
ple
was
bia
sed
to
heal
th p
rofe
ssio
nals
, w
hich
mig
ht a
ffect
the
va
lidity
of t
he fi
nd-
ings
in te
rms
of t
heir
know
ledg
e ab
out
loca
l an
esth
esia
.Th
ey w
ere
not
blin
ded,
an
d a
plac
ebo
was
no
t us
ed b
ecau
se o
f th
e cl
aim
of e
thic
al
cons
ider
atio
n.
The
stud
y is
rel
evan
t to
th
e re
sear
ch to
pic,
in
whi
ch it
sup
port
s th
e ef
fect
iven
ess
of lo
cal
anes
thes
ia fo
r re
duc-
ing
pain
and
anx
iety
as
soci
ated
with
IV c
an-
nula
tion.
Inte
rest
ingl
y,
the
stud
y sh
ows
that
pe
rson
al e
xper
ienc
es
of p
artic
ipan
ts h
ave
influ
ence
d th
eir
per-
cept
ion
tow
ard
usin
g lo
cal a
nest
hesi
a in
the
fu
ture
for
them
selv
es
and
thei
r pa
tient
s.
Ther
efor
e, p
erso
nal
expe
rienc
e co
uld
be a
fa
ctor
tha
t in
fluen
ces
nurs
es’ u
se o
f loc
al
anes
thes
ia.
Mirz
aei e
t al
, 20
1823
The
aim
of t
he s
tudy
was
to
inve
stig
ate
the
effe
ct
of to
pica
l tra
nsde
rmal
cr
eam
, lid
ocai
ne s
pray
, an
d ic
e on
art
erio
ve-
nous
can
nula
tion
pain
in
tens
ity in
hem
odia
lysi
s pa
tient
s.
40 h
emod
ialy
sis
patie
nts >
18
y ol
d w
ith a
rter
iove
nous
fis
tula
Shah
id R
ahne
moo
n H
ospi
tal i
n Ya
zd,
Iran
Qua
ntita
tive,
qua
si-
expe
rimen
tal
The
redu
ctio
n in
mea
n pa
in in
ten-
sity
was
sig
nific
antly
gre
ater
w
ith to
pica
l tra
nsde
rmal
cre
am
com
pare
d w
ith li
doca
ine
spra
y an
d ic
e (P
< .0
01).
The
pain
sco
re w
as a
lso
sign
ifi-
cant
ly d
iffer
ent
befo
re in
terv
en-
tion
and
afte
r ap
plic
atio
n of
the
3
inte
rven
tions
(P <
.001
).Th
e st
udy
conc
lude
d th
at a
ll 3
met
hods
of i
nter
vent
ion
wer
e ef
fect
ive
in r
educ
ing
pain
in
tens
ity, w
ith to
pica
l tra
ns-
derm
al c
ream
exe
rtin
g th
e gr
eate
st e
ffect
in d
ecre
asin
g th
e pu
nctu
re-r
elat
ed m
ean
pain
in
tens
ity o
f art
erio
veno
us fi
stu-
la c
annu
latio
n.
Curr
ent
stud
ySm
all s
ampl
e si
zeLa
ck o
f ran
dom
izat
ion
This
is a
rece
nt s
tudy
co
mpa
ring
3 ty
pes
of
loca
l ane
sthe
sia—
a to
pica
l tra
nsde
rmal
ag
ent,
lidoc
aine
spr
ay,
and
ice—
test
ed o
n ar
terio
veno
us c
annu
la-
tion
for
hem
odia
lysi
s.Th
e st
udy
prov
ided
a
usef
ul c
ompa
rison
of
diffe
rent
type
s of
loca
l an
esth
esia
use
d fo
r th
e sa
me
purp
ose
of
redu
cing
pro
cedu
ral
pain
. Thi
s ca
n he
lp
dete
rmin
e th
eir p
ract
i-ca
lity
and
conv
enie
nce
with
in n
ursi
ng p
ract
ice.
(con
tinue
s)
AP
PE
ND
IX 1
Lite
ratu
re R
evie
w (
Cont
inue
d)
Aut
hor
and
Dat
eA
im/O
bjec
tive
Sam
ple
and
Sett
ing
Met
hods
and
M
etho
dolo
gyM
ajor
Fin
ding
sLi
mit
atio
ns a
nd R
igor
/Va
lidit
ySi
gnifi
canc
e to
the
Is
sue
Papa
and
Ze
mps
ky,
2010
24
The
purp
ose
of t
he s
tudy
w
as to
exa
min
e nu
rses
’ at
titud
es to
war
d an
d ex
perie
nce
with
ven
ous
acce
ss p
ain
in p
edia
tric
pa
tient
s, a
nd t
heir
per-
cept
ions
of t
he v
alue
of
curr
ent
tech
niqu
es u
sed
for
man
agin
g su
ch p
ain.
2187
nur
ses
who
wer
e m
embe
rs o
f 3 n
urs-
ing
soci
etie
s ba
sed
in t
he U
nite
d St
ates
: th
e Em
erge
ncy
Nur
ses
Asso
ciat
ion,
th
e In
fusi
on N
urse
s So
ciet
y, a
nd t
he
Soci
ety
of P
edia
tric
N
urse
s
Qua
ntita
tive
Web
-bas
ed s
urve
yRe
spon
dent
s in
dica
ted
that
inse
rtin
g an
IV c
athe
ter i
n a
fear
ful,
anxi
ous
child
was
cha
lleng
ing
(96%
).N
onph
arm
acol
ogic
tech
niqu
es
wer
e fr
eque
ntly
use
d bu
t wer
e pe
rcei
ved
as in
suffi
cien
t for
alle
-vi
atin
g pa
in w
hen
used
alo
ne.
Topi
cal l
ocal
ane
sthe
tics
wer
e de
emed
mor
e ef
fect
ive,
but
are
us
ed le
ss o
ften
.M
ost
resp
onde
nts
agre
ed t
hat
impr
oved
pai
n m
anag
emen
t en
hanc
es t
heir
satis
fact
ion
with
th
eir
job
perf
orm
ance
(91%
), in
crea
ses
job
satis
fact
ion
(81%
), in
crea
ses
posi
tive
rela
tions
hip
with
pat
ient
s an
d fa
mili
es
(91%
), an
d po
sitiv
ely
impa
cts
the
hosp
ital e
xper
ienc
e fo
r ch
il-dr
en a
nd t
heir
fam
ilies
(97%
).M
ost n
urse
s (9
2%) a
gree
d th
at
an e
ffect
ive,
fast
-act
ing,
topi
cal
loca
l ane
sthe
tic w
ould
ben
efit
pedi
atric
pat
ient
s, th
eir
fam
ilies
, an
d th
e nu
rses
who
trea
t the
m.
Larg
e, r
epre
sent
ativ
e sa
mpl
e.W
ritte
n la
ngua
ge is
ver
y cl
ear.
Det
aile
d pr
ovis
ion
of
data
.It
did
not
spec
ify w
hich
ty
pes
of to
pica
l ane
s-th
esia
are
use
d in
th
ose
sett
ings
.
Alth
ough
it o
nly
focu
sed
on p
edia
tric
set
tings
, th
e st
udy
iden
tifie
d so
me
impo
rtan
t fa
c-to
rs t
hat
can
hind
er
the
use
of to
pica
l loc
al
anes
thet
ics
for
IV c
an-
nula
tion
from
the
per
-sp
ectiv
es o
f the
nur
ses
who
per
form
ed t
hese
pr
oced
ures
, whi
ch
supp
orts
the
res
earc
h to
pic.
Page
and
Tay
lor,
2010
25Th
e st
udy’
s ai
m w
as to
co
mpa
re t
he e
ffic
acy,
ac
cept
abili
ty, a
nd s
afet
y of
a to
pica
l vap
ocoo
lant
al
kane
spr
ay a
nd 1
%
plai
n su
bcut
aneo
us li
do-
cain
e in
red
ucin
g pa
in
from
IV c
annu
latio
n.
Conv
enie
nce
sam
ple
of 2
20 a
dult
and
pedi
atric
pa
rtic
ipan
ts in
a
met
ropo
litan
ED
Qua
ntita
tive,
non
blin
ded,
ra
ndom
ized
con
trol
led
tria
l
Ove
rall,
vap
ocoo
lant
spr
ay w
as
less
pai
nful
to a
dmin
iste
r bu
t le
ss e
ffect
ive
in d
ecre
asin
g ca
n-nu
latio
n pa
in t
han
lidoc
aine
. Va
poco
olan
t sp
ray
was
ass
ocia
t-ed
with
gre
ater
can
nula
tion
succ
ess
(83.
6% v
s 67
.3%
; P =
.005
), le
ss t
ime
to a
dmin
-is
ter
(med
ian
9.0
vs 8
4.5
s;
P <
.001
), an
d m
ore
staf
f co
nven
ienc
e (m
edia
n 5
vs 4
; P <
.001
) tha
n lid
ocai
ne.
Ove
rall
patie
nt s
atis
fact
ion
scor
es
wer
e si
mila
r.Va
poco
olan
t sp
ray
offe
rs a
use
ful
alte
rnat
ive
in t
he E
D s
ettin
g.
Larg
e, m
ixed
sam
ple
of
adul
ts a
nd c
hild
ren.
Equa
l allo
catio
n of
110
pa
rtic
ipan
ts fo
r ea
ch
grou
p fo
r a
tota
l of 2
20
part
icip
ants
.Pr
ovid
ed c
lear
and
ric
h de
tails
of i
nfor
mat
ion.
Prac
tice
loca
tion
was
not
id
entif
ied.
Lack
of c
ontr
ol g
roup
was
no
t ex
plai
ned.
Stud
y w
as n
ot b
linde
d.
Two
type
s of
loca
l ane
s-th
esia
wer
e st
udie
d,
whi
ch p
rovi
ded
a us
e-fu
l com
paris
on a
mon
g ot
her
type
s of
loca
l an
esth
esia
use
d fo
r th
e sa
me
purp
oses
as
this
stu
dy.
Mos
t im
port
ant,
it p
oint
-ed
at
cont
ribut
ing
fac-
tors
tha
t ca
n in
fluen
ce
the
use
of lo
cal a
nes-
thes
ia b
y nu
rses
, suc
h as
suc
cess
ful I
V in
ser-
tion,
adm
inis
trat
ion
time,
and
sat
isfa
ctio
n,
whi
ch h
elps
sup
port
th
is r
esea
rch
stud
y.
(con
tinue
s)
106 Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. Journal of Infusion Nursing on behalf of the Infusion Nurses Society.
AP
PE
ND
IX 1
Lite
ratu
re R
evie
w (
Cont
inue
d)
Aut
hor
and
Dat
eA
im/O
bjec
tive
Sam
ple
and
Sett
ing
Met
hods
and
M
etho
dolo
gyM
ajor
Fin
ding
sLi
mit
atio
ns a
nd R
igor
/Va
lidit
ySi
gnifi
canc
e to
the
Is
sue
Rost
ami e
t al
, 20
0626
The
aim
of t
he s
tudy
was
to
det
erm
ine
the
effe
ct
of lo
cal a
pplic
atio
n of
ice
for
3 m
in p
rior
to v
enip
unct
ure
on
pain
-rel
ated
res
pons
es
in s
choo
l-age
d ch
ildre
n.
80 c
hild
ren
(6-1
2 y
old)
in a
ped
iatr
ic
emer
genc
y de
part
-m
ent
of a
ped
iatr
ic
cent
er, i
n Ah
waz
, Ira
n
Qua
ntita
tive
Qua
si-e
xper
imen
tal
No
sign
ifica
nt d
iffer
ence
in p
hys-
iolo
gica
l res
pons
es b
efor
e an
d af
ter
the
proc
edur
e be
twee
n th
e 2
grou
ps (P
= .0
7).
How
ever
, beh
avio
ral a
nd s
ub-
ject
ive
resp
onse
s be
fore
and
af
ter
the
proc
edur
e w
ere
low
er
in t
he te
st g
roup
(P =
.001
1 an
d P =
.009
7, r
espe
ctiv
ely)
.Th
e st
udy
conc
lude
d th
at t
he
appl
icat
ion
of ic
e to
ski
n pr
ior
to v
enou
s pu
nctu
re c
an b
e an
ef
fect
ive
and
safe
inte
rven
tion
for
redu
cing
rel
ated
pai
n.
Clea
r an
d ac
cura
te m
ea-
sure
men
ts p
rovi
ded
Lack
of r
ando
miz
atio
n an
d bl
indi
ng
Appl
icat
ion
of ic
e is
an
othe
r te
chni
que
that
can
be
used
by
nurs
es a
s an
alte
r-na
tive
for
proc
edur
-al
pai
n re
duct
ion
beca
use
it is
non
in-
vasi
ve, n
onph
arm
a-co
logi
c, in
expe
nsiv
e,
and
read
ily a
vaila
ble,
es
peci
ally
whe
n lo
cal
anes
thes
ia is
not
ava
il-ab
le o
r no
t of
fere
d to
pa
tient
s in
som
e se
t-tin
gs. T
his
stud
y is
als
o be
nefic
ial t
o co
mpa
re
with
sim
ilar
stud
ies
cond
ucte
d on
adu
lts
for
the
sam
e pu
rpos
e.
Sado
and
Dea
kin,
20
0527
This
stu
dy m
easu
red
the
prev
alen
ce o
f the
use
of
loca
l ane
sthe
sia
for
veno
us c
annu
latio
n an
d AB
G s
ampl
ing
by
phys
icia
ns.
178
anes
thet
ists
, and
m
edic
al a
nd s
urgi
cal
phys
icia
ns in
8 h
os-
pita
ls in
the
Uni
ted
King
dom
Qua
ntita
tive
Dat
a co
llect
ed t
hrou
gh a
pr
inte
d qu
estio
nnai
re
60%
of a
nest
hetis
ts w
ere
usin
g lo
cal a
nest
hesi
a fo
r th
ese
pro-
cedu
res
com
pare
d w
ith 2
% o
f w
ard
phys
icia
ns.
Larg
e sa
mpl
e.Th
e st
udy
was
con
duct
ed
10 y
ago
.Th
e st
udy
has
been
cite
d m
ultip
le t
imes
.Br
ief d
escr
iptio
n pr
ovid
ed
in t
he s
tudy
.Fa
ctor
s re
leva
nt to
the
is
sue
wer
e di
scus
sed
base
d on
obs
ervi
ng
and
talk
ing
to d
octo
rs,
but
they
wer
e no
t su
p-po
rted
with
evi
denc
e.
This
stu
dy is
use
ful
beca
use
the
mai
n co
ncep
t is
rel
evan
t to
the
res
earc
h to
pic
of t
his
artic
le. W
hile
nu
rses
in S
audi
Ara
bia
are
perf
orm
ing
thes
e pr
oced
ures
, thi
s ar
ti-cl
e in
par
ticul
ar m
ay
assi
st in
iden
tifyi
ng
som
e fa
ctor
s th
at le
ad
to s
imila
r pr
actic
e of
di
sreg
ardi
ng t
he u
se
of lo
cal a
nest
hesi
a by
ph
ysic
ians
for
thes
e pr
oced
ures
.
Abbr
evia
tions
: ABG
, art
eria
l blo
od g
as; E
D, e
mer
genc
y de
part
men
t; F
, fem
ale;
IQR,
inte
rqua
rtile
rang
e; IV
, int
rave
nous
; M, m
ale;
RN
, reg
iste
red
nurs
e.
VOLUME 42 | NUMBER 2 | MARCH/APRIL 2019 journalofinfusionnursing.com 107
AP
PE
ND
IX 1
Lite
ratu
re R
evie
w (
Cont
inue
d)
Aut
hor
and
Dat
eA
im/O
bjec
tive
Sam
ple
and
Sett
ing
Met
hods
and
M
etho
dolo
gyM
ajor
Fin
ding
sLi
mit
atio
ns a
nd R
igor
/Va
lidit
ySi
gnifi
canc
e to
the
Is
sue
Rost
ami e
t al
, 20
0626
The
aim
of t
he s
tudy
was
to
det
erm
ine
the
effe
ct
of lo
cal a
pplic
atio
n of
ice
for
3 m
in p
rior
to v
enip
unct
ure
on
pain
-rel
ated
res
pons
es
in s
choo
l-age
d ch
ildre
n.
80 c
hild
ren
(6-1
2 y
old)
in a
ped
iatr
ic
emer
genc
y de
part
-m
ent
of a
ped
iatr
ic
cent
er, i
n Ah
waz
, Ira
n
Qua
ntita
tive
Qua
si-e
xper
imen
tal
No
sign
ifica
nt d
iffer
ence
in p
hys-
iolo
gica
l res
pons
es b
efor
e an
d af
ter
the
proc
edur
e be
twee
n th
e 2
grou
ps (P
= .0
7).
How
ever
, beh
avio
ral a
nd s
ub-
ject
ive
resp
onse
s be
fore
and
af
ter
the
proc
edur
e w
ere
low
er
in t
he te
st g
roup
(P =
.001
1 an
d P =
.009
7, r
espe
ctiv
ely)
.Th
e st
udy
conc
lude
d th
at t
he
appl
icat
ion
of ic
e to
ski
n pr
ior
to v
enou
s pu
nctu
re c
an b
e an
ef
fect
ive
and
safe
inte
rven
tion
for
redu
cing
rel
ated
pai
n.
Clea
r an
d ac
cura
te m
ea-
sure
men
ts p
rovi
ded
Lack
of r
ando
miz
atio
n an
d bl
indi
ng
Appl
icat
ion
of ic
e is
an
othe
r te
chni
que
that
can
be
used
by
nurs
es a
s an
alte
r-na
tive
for
proc
edur
-al
pai
n re
duct
ion
beca
use
it is
non
in-
vasi
ve, n
onph
arm
a-co
logi
c, in
expe
nsiv
e,
and
read
ily a
vaila
ble,
es
peci
ally
whe
n lo
cal
anes
thes
ia is
not
ava
il-ab
le o
r no
t of
fere
d to
pa
tient
s in
som
e se
t-tin
gs. T
his
stud
y is
als
o be
nefic
ial t
o co
mpa
re
with
sim
ilar
stud
ies
cond
ucte
d on
adu
lts
for
the
sam
e pu
rpos
e.
Sado
and
Dea
kin,
20
0527
This
stu
dy m
easu
red
the
prev
alen
ce o
f the
use
of
loca
l ane
sthe
sia
for
veno
us c
annu
latio
n an
d AB
G s
ampl
ing
by
phys
icia
ns.
178
anes
thet
ists
, and
m
edic
al a
nd s
urgi
cal
phys
icia
ns in
8 h
os-
pita
ls in
the
Uni
ted
King
dom
Qua
ntita
tive
Dat
a co
llect
ed t
hrou
gh a
pr
inte
d qu
estio
nnai
re
60%
of a
nest
hetis
ts w
ere
usin
g lo
cal a
nest
hesi
a fo
r th
ese
pro-
cedu
res
com
pare
d w
ith 2
% o
f w
ard
phys
icia
ns.
Larg
e sa
mpl
e.Th
e st
udy
was
con
duct
ed
10 y
ago
.Th
e st
udy
has
been
cite
d m
ultip
le t
imes
.Br
ief d
escr
iptio
n pr
ovid
ed
in t
he s
tudy
.Fa
ctor
s re
leva
nt to
the
is
sue
wer
e di
scus
sed
base
d on
obs
ervi
ng
and
talk
ing
to d
octo
rs,
but
they
wer
e no
t su
p-po
rted
with
evi
denc
e.
This
stu
dy is
use
ful
beca
use
the
mai
n co
ncep
t is
rel
evan
t to
the
res
earc
h to
pic
of t
his
artic
le. W
hile
nu
rses
in S
audi
Ara
bia
are
perf
orm
ing
thes
e pr
oced
ures
, thi
s ar
ti-cl
e in
par
ticul
ar m
ay
assi
st in
iden
tifyi
ng
som
e fa
ctor
s th
at le
ad
to s
imila
r pr
actic
e of
di
sreg
ardi
ng t
he u
se
of lo
cal a
nest
hesi
a by
ph
ysic
ians
for
thes
e pr
oced
ures
.
Abbr
evia
tions
: ABG
, art
eria
l blo
od g
as; E
D, e
mer
genc
y de
part
men
t; F
, fem
ale;
IQR,
inte
rqua
rtile
rang
e; IV
, int
rave
nous
; M, m
ale;
RN
, reg
iste
red
nurs
e.
APPENDIX 2
Themes From the LiteratureThemes Element Sources
Effectiveness of local anesthesia; total articles = 11
Intradermal injections Matheson et al, 201421
McNaughton et al, 200922
Burke et al, 201114
Hudson et al, 200618
Intradermal needleless device Crowley et al, 20118
Hajiseyedjavady et al, 20129
Jimenez et al, 200619
Topical anesthetics Hijazi et al, 200917
Papa and Zempsky, 201024
Crowley et al, 20118
Page and Taylor, 201025
Mirzaei et al, 201823
Other strategies for procedural pain manage-ment; total articles = 5
Application of ice Haynes, 201516
Crowley et al, 20118
Rostami et al, 200626
Mirzaei et al, 201823
Behavioral intervention Papa and Zempsky, 201024
Crowley et al, 20118
Other benefits of local anesthesia; total articles = 9
Successful insertion Hudson et al, 200618
Crowley et al, 20118
Hajiseyedjavady et al, 20129
Jimenez et al, 200619
Improve satisfaction Hijazi et al, 200917
Papa and Zempsky, 201024
Page and Taylor, 201025
Hajiseyedjavady et al, 20129
Levitt and Ziemba-Davis, 201320
McNaughton et al, 200922
Barriers of low use of local anesthesia; total articles = 9
Underestimation of procedural pain Sado and Deakin, 200527
Czarnecki et al, 201115
Time concerns Hijazi et al, 200917
Page and Taylor, 201025
Papa and Zempsky, 201024
Hudson et al, 200618
Czarnecki et al, 201115
Hajiseyedjavady et al, 20129
Jimenez et al, 200619
Drug preorder Hudson et al, 200618
Papa and Zempsky, 201024
Czarnecki et al, 201115
Cost Hudson et al, 200618
Page and Taylor, 201025
Burke et al, 201114
Jimenez et al, 200619