Best Practice For IV
Insertion In Infants And
Children
Columbus State University
Team: Peds and IVs
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Justin Banister
Michael Chamberlain
Jacob Chauvin
Eric Hall
Kirsten Joiner
Darrell Mackenzie
Purpose
• To determine the best practice for the
use of a numbing device in reducing pain
and anxiety of infants and children
during peripheral IV insertion.
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Significance
• Reduction of pain and anxiety in
pediatric patients
• Increase first attempt IV insertion
success rates
• Conserve time, money, and resources
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PICO(T) Clinical Question
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P: Infants and Children
I: Pain/Anxiety reducing interventions
C: No intervention
O: Decreased pain and anxiety during
IV insertion
Interventions for
Pain/Anxiety:
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No Intervention
Distractions
Saline Wheal
ELA Max Cream
Sub-Q Lidocaine
Vapocoolant Spray
Jet Lidocaine Device
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The Use of No Intervention
• It will be the child and/or caregiver’s
choice as to whether the patient will
recieve any type of intervention for the
insertion of the IV.
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Distractions
• Bubbles
• Pinwheels
• Music
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http://www.ourwebpage.org/aircastles
andslides/bubbles_2zillions.jpg
Saline Wheal
• Bacteriostatic Normal Saline (BNS) compared to 1%
lidocaine and no anesthetic
• 27-gauge needle was used to intradermally inject 0.1
to 0.2 mL of BNS and 1% lidocaine
• 1 minute after the injection of the compound,
the IV was inserted into the vein.
•A modified visual analog scale was used for the
children to rate their preprocedural anxiety, pain
with intradermal injection, and pain with
cannulation
(Fein, Boardman, Stevenson, & Selbst, 1998)
Saline Wheal
•Pain Scale:
• No anesthesia: 41.0
• BNS: 9.0
• 1% Lidocaine: 10.0
•Significance:
•p = 0.006 - BNS vs no anesthesia
•p = 0.04 - lidocaine vs no anesthesia
•p = 0.57 - BNS vs lidocaine
(Fein, Boardman, Stevenson, & Selbst, 1998)
ELA-Max Cream
• A 4% lidocaine cream that features a liposomal
delivery system and is administered topically
after disinfection of insertion site.
• 2.5 g applied to the skin and covered with an
occlusive dressing (Tegaderm) overlying the IV
site 30 minutes before IV insertion
• It has been shown to effectively
reduce pain and distress associated
with venipuncture in children
(Luhmann, Hurt, Shootman, & Kennedy, 2004)
ELA-Max Cream
Benefits:
• No occlusive dressing needed per ELA-Max packaging
• Decreases pain and distress of IV insertion
Complications:
• Time constraints
• Child could touch and place cream in mouth
• If not covered by transparent dressing
Limitations:
• Study indicated a limitation was the skill to apply
cream
• Non-toxic and over the counter, but we
discourage ingesting
(Luhmann, Hurt, Shootman, & Kennedy, 2004)
Sub-Q Lidocaine
• 0.1 to 0.2 ml 1% buffered lidocaine administered
subcutaneously with a 30-gauge needle 5 minutes
before IV insertion
• Significantly reduces distress associated with
peripheral intravenous catheter
insertion in children
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(Luhmann, Hurt, Shootman, & Kennedy, 2004)
Sub-Q Lidocaine
Complications:
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Additional stick for the patient
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Skill of sub-q injection
http://www.travmed.com
(Luhmann, Hurt, Shootman, & Kennedy, 2004)
ELA-Max vs Sub-Q
Lidocaine
• No significant difference in pain
scores between the two methods:
• Pain: p = 0.19
• Anxiety: p = 0.18
(Luhmann, Hurt, Shootman, & Kennedy, 2004)
EMLA-Max vs Sub-Q Lidocaine
vs Intradermal Lidocaine
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Eutetic Mixture of Local Anesthetics
4 European studies
EMLA comparable to Sub-Q lidocaine
EMLA less effective than intradermal
lidocaine
(Delisa, Gans, & Walsh, 2005)
Vapocoolant Spray
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Sprayed directly onto skin from 3-9 inches away, or
can be used on a cotton ball and applied with
forceps.
Pain was reduced from a mean score of 56 - 37 per
color visual analog scale, p < 0.01
It was not specified in the study if disinfection of
the site was performed prior to or after the
vapocoolant spray was applied
(Farion, Splinter, Newbook, Gaboury, Splinter, 2008)
gebauerspainease.com
Vapocoolant Spray
• 50% of patients receiving vapocoolant spray
reported no pain compared to 32% in placebo
group, p = 0.01
• 85% first attempt cannulation success vs. 62.5% in
placebo group, p = 0.02
- Child life specialists ratings favored
vapocoolant vs. placebo
emedicine.medscape.com
(Farion, Splinter, Newbook, Gaboury, Splinter, 2008)
Vapocoolant Spray
- The study did not indicate the specific mechanism of
action that increased successful first attempts. It is
assumed that a reduction in pain, anxiety, and
movement of the patient contributed to this.
- Nurses noticed an improvement of technical ease
when using the vapocoolant spray vs. placebo
- Results: Vapocoolant spray
effectively reduced pain and
increased first attempt cannulation
success rates in pediatric patients
(Farion, Splinter, Newhook, Gaboury, Splinter, 2008)
Vapocoolant Spray
Risks:
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Burning sensation produced when cooling
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Tissue Necrosis after 10 seconds
Benefits:
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Reduction in pain and associated anxiety
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Non-flammable, non-toxic, and Ozone friendly,
works instantly, costs around 50 cents per use
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Safe to use on pediatric patients
gebauerspainease.com
(Farion, Splinter, Newhook, Gaboury, Splinter, 2008)
Jet Lidocaine Device
• It does not contain any sharp needles, thus
reducing the risk of needle-stick injuries,
and can be safely discarded in to a normal
waste container
• Delivers medication into the epidermis in
0.2 seconds and takes approximately 1
minute to fully work
http://onlinelibrary.wiley.com/doi/10.1111/j.15532712.2009.00401.x/full
(Auerbach, Tunik, & Mojica, 2009)
Jet Lidocaine Device
• Study has shown that it provides greater
anesthesia than that of ELA-Max
• The J-Tip jet device is a cost effective device
at approximately $2/device; 1 use per device
• P<0.001
– Limitations
(Spanos, Booth, Koenig, Sikes, Gracely, & Kim, 2008)
Conclusion
• Recommend:
– Jet Lidocaine for efficacy
– Bacteriostatic normal saline for “biggest
bang for the buck”
Guideline procedure
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A nurse reviews the order.
Select a suitable vein
Disinfect site per hospital protocol
A numbing agent will be selected by the patient and/or caregiver and
applied per hospital protocol.
Guideline procedure
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Jet Lidocaine
• 0.2 mL of buffered 1% lidocaine injected via jet device at least
60 seconds before IV insertion attempt
ELA-Max Cream
• Applied to the skin and occluded with Tegaderm 30 minutes
before peripheral IV insertion attempt
Sub-q Lidocaine
• 30-gauge needle to subcutaneously inject 0.2 mL of buffered 1%
lidocaine 5 minutes before IV insertion attempt
• Vapocoolant Spray
• Administer Vapocoolant spray to IV insertion site within
60 seconds before IV insertion attempt
• Bacteriostatic normal saline (BNS)
• 27-gauge needle is used to inject 0.1 to 0.2 mL
intradermally of BNS 1 minute before IV insertion
attempt
• Insert IV per hospital protocol
Resources
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.
Delisa, J., Gans, B., & Walsh, N. (2005). Physical medicine and rehabilitation: Principles and
practice, volume 1. Philadelphia, PA: Lippincott, Williams, & Wilkins.
Farion, K, J., Splinter, K, L., Newhook, K., Gaboury, I., & Splinter, W, M. (2008). The effect of
vapocoolant spray on pain due to intravenous cannulation in children: a randomized
controlled trial. Canadian Medical Association Journal, 179(1):31-6.
Fein J. A., Boardman C. R., Stevenson S., & Selbst S. M. (1998). Saline with benzyl alcohol as
intradermal anesthesia for intravenous line placement in children. Pediatric Emergency
Care, 14(2), 119-122. Retrieved from http://journals.lww.com/peconline/pages/default.aspx
Resources
Larsen, P., Eldridge, D., Brinkley, J., Newton, D., Goff, D., Hartzog, T., et al. (2010).
Pediatric peripheral intravenous access: does nursing experience and
competence really make a difference?. Journal of Infusion Nursing, 33(4), 226-235.
Luhmann, J., Hurt, S., Shootman, M., & Kennedy, R. (2004). A Comparison of
buffered lidocaine versus ELA-Max before peripheral intravenous catheter
insertions in children. Pediatrics, 113(3 Part 1), e217-20.
Spanos, S., Booth, R., Koenig, H., Sikes, K., Gracely, E., & Kim, I. (2008). Jet injection
of 1% buffered lidocaine versus topical ELA-Max for anesthesia before
peripheral intravenous catheterization in children: a randomized controlled trial.
Pediatric Emergency Care, 24(8), 511-515.
Windle, P., Kwan, M., Warwick, H., Sibayan, A., Espiritu, C., & Vergara, J. (2006).
Comparison of bacteriostatic normal saline and lidocaine used as intradermal
anesthesia for the placement of intravenous lines. Journal of PeriAnesthesia
Nursing, 21(4), 251-258.
Thank
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