I believe pain management is so important, so overlooked, yet such an incredible tool to help patients, that I’ve decided to post a portion of the IV Video Course here to make it accessible to everyone. This should give you some insight into pain control when inserting an IV, and serve as a sample of what the course is like. If your hospital doesn’t have a policy regarding pain management for venipuncture, hopefully this will inspire some of you to advocate for your patients and bring it up to your administrators. You can look up a lot of the research behind these statements in the 2021 INS Standards of practice. This section is in The IV Video Course, Pediatric Venipuncture, and Ultrasound IV Insertion. Below is the full video and the transcript directly from the course. Enjoy, and I hope everyone finds something useful!
Reducing Pain
Pain management is a severely underutilized strategy for IV insertion in the adult population.
Since pain is such a strong factor in conditioning, it can actually cause PTSD-like symptoms in some people, particularly those who are frequently in the hospital for chronic conditions. We of course won’t be able to implement these strategies in emergent situations, but when we do have the time, we need to do everything we can to reduce the pain associated with venipuncture in order to prevent these stress responses. Minimizing pain has also been shown to lead to quicker, more successful IV insertions and blood draws, reduces anxiety in those who have a fear of needles, and of course increases patient satisfaction.
Topical anesthetics like EMLA, LMX or AMETOP can be used to numb the area to be used for venipuncture. Clinical studies have shown LMX and AMETOP to be more effective than EMLA, and LMX doesn’t cause the mild vasoconstriction that EMLA can, though most facilities only have EMLA. Start by looking for appropriate vessels and choose 2 sites to apply anesthetic, just in case you need to make a second attempt. Apply the cream and cover with a transparent dressing for 30-45 minutes. This should result in effective numbing of the area for up to 6 hours.
If we want something with a much quicker onset, intradermal lidocaine has been shown to be effective, but can cause vasoconstriction in some cases, and the pain of lidocaine injection often outweighs the benefit of it. You can find buffered lidocaine, which doesn’t cause the typical burning sensation because the pH is balanced, but it has a much shorter shelf life so many facilities won’t carry it or compound it in the pharmacy for the purpose of pain control as it’s not cost effective.
Bacteriostatic saline injection also has a numbing effect with little pain associated with administration, though some patients may have allergies or reactions to either of these medications. Always check with patients and make sure they don’t have allergies or previous reactions to any medication you plan to use for pain reduction, and always obtain the necessary orders before administration.
To administer an intradermal anesthetic, first apply your tourniquet, find your vein, and mark its location. Remove the tourniquet and cleanse the site. Draw your medication up in a 1ml syringe with a small needle. 27 gauge or smaller is best as our goal is to minimize pain, a tuberculin syringe works well for this. You’ll typically only need about .1ml, though your orders or policies may vary.
Stretch the skin tight under your site, being careful not to contaminate it. Insert your needle at 5-15 degrees, just under the first few layers of skin right next to the vein, being very careful not to enter the vein. Slowly inject your medication until a “wheel” forms, then remove your needle, activate the safety and dispose of your sharps. You can now perform your venipuncture. You should enter the skin within the area of the injection, about ¼”-1/2” for best pain relief.
There are also needleless options that use a propellant to create a jet of medication that enters the skin. They’re a great option for intradermal pain reduction, though they’re not very cost effective so your facility may not carry them.
