First do no harm: pain relief for the peripheral venous cannulation of adults, a systematic review and network meta-analysis

Abstract

BackgroundPeripheral venous cannulation is an everyday practice in hospitals, which many adults find painful. However, anaesthesia for cannulation is usually only offered to children. Inadequate pain relief is not only unpleasant for patients but may cause anxiety about further treatment and deter patients from seeking medical care in the future. The aim of this study is to discover the most effective local anaesthetic for adult peripheral venous cannulation and to find out how the pain of local anaesthetic application compares with that of unattenuated cannulation.MethodsThese aims are addressed through a systematic review, network meta-analysis and random-effects meta-analysis. Searching covered 12 databases including MEDLINE and EMBASE from 1990 to August 2015. The main included study design was RCTs. The primary outcome measure is self-reported pain, measured on a 100 mm visual analogue scale.ResultsThe systematic review found 37 includable studies, 27 of which were suitable for network meta-analysis and two for random-effects meta-analysis. The results of the network meta-analysis indicate that none of the 17 anaesthetic considered had a very high probability of being the most effective when compared to each other; 2 % lidocaine had the highest probability (44 %). When the anaesthetics were compared to no treatment, the network meta-analysis showed that again 2 % lidocaine was estimated to be the most effective (mean difference −25.42 (95 % CI −32.25, −18.57). Other members of the ‘caine’ family were also estimated to be more effective than no treatment as were Ametop®, EMLA® and Rapydan® patch. The meta-analysis compared the pain of anaesthetic application with the unattenuated pain of cannulation. This found that all applications of local anaesthetic were less painful than cannulation without local anaesthetic. In particular a 1 % lidocaine injection was estimated to be −12.97 (95 % CI −15.71, −10.24) points (100 mm VAS) less painful than unattenuated cannulation.ConclusionsThe pain of peripheral venous cannulation in adults can be successfully treated. The pain of application of any local anaesthetic is less than that of unattenuated cannulation. Local anaesthetic prior to cannulation should become normal practice and a marker of high quality care.Protocol registrationThe protocol for the larger study was registered with PROSPERO no. CRD42012002093.Electronic supplementary materialThe online version of this article (doi:10.1186/s12871-016-0252-8) contains supplementary material, which is available to authorized users.

Pain During Venous Cannulation

“…►Cite this as: Rüsch I nserting a cannula into a vein is a routine procedure, which in some patients may none the less cause discomfort (1,2). Surveys, editorials, and systematic reviews on this topic imply that local anesthesia is applied to the venipuncture sites on a regular basis in children, but this is handled rather inconsistently in adults (3)(4)(5)(6)(7). In a survey among anesthetists in the UK, the doctors reported that they administered a local anesthetic for venipuncture in cases where the cannula size exceeded 18 G. However, fewer than half of surgeons or specialists in internal medicine followed this practice (6).…”

“…By contrast, numerous studies have consistently found that intradermal or subcutaneous application of a local anesthetic-for example, lidocaine solution 1-2%-reduces puncture-related pain (1, 8-10, 14, 15). A recent network meta-analysis directly or indirectly compared lidocaine application with 16 further analgetic interventions before peripheral venipuncture and found that 2% lidocaine was most effective (5). However, this procedure is time-consuming (7); it can result in a higher rate of puncture failures (15,16), and of itself causes pain (8)(9)(10)16).…”

Prediction of Acute Postoperative Pain from Assessment of Pain Associated With Venous Cannulation

“…The region of cannulation also influences the pain intensity induced; for example, the antecubital fossa is associated with less pain than is the back of the hand . Nevertheless, many operators do not routinely offer pain relief because of time loss, considered lack of indication, belief that it makes the procedure more difficult, or peer pressure not to …”

“…11 Nevertheless, many operators do not routinely offer pain relief because of time loss, considered lack of indication, belief that it makes the procedure more difficult, or peer pressure not to. 10,12 It was recently shown that peripheral venous cannulation-induced pain (VCP) intensity can be used to predict the risk for postoperative pain in patients subjected to elective laparoscopic cholecystectomy. Patients scoring VCP at or above 2.0 VAS units had 3.4 times higher risk for moderate or severe postoperative pain.…”

Prevention of venipuncture pain in children: a comparative study of topical anesthetics

“…However, the waiting period to establish full analgesic effect is a significant barrier to their use, which has stimulated the development of new topical anesthetics and the revival of old ones, such as ethyl chloride. This anesthetic stopped being used after the development of new, safer drugs because of its possible adverse effects, but the controversy remains as to the use of ethyl chloride in clinical practice (Bond et al, 2016;Fossum, Love, & April, 2016;Hogan, Smart, Shah, & Taddio, 2014;Zempsky, 2008). This study aimed to compare the effectiveness of five topical anesthetics for preventing VP pain in children in an outpatient department of a pediatric hospital.…”