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Best Practice For IV Insertion In Infants And Children

Best Practice For IV Insertion In Infants And Children. Columbus State University. Team: Peds and IVs. Justin Banister Michael Chamberlain Jacob Chauvin Eric Hall Kirsten Joiner Darrell Mackenzie. Purpose.

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Best Practice For IV Insertion In Infants And Children

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  1. Best Practice For IV Insertion In Infants And Children Columbus State University

  2. Team: Peds and IVs • Justin Banister • Michael Chamberlain • Jacob Chauvin • Eric Hall • Kirsten Joiner • Darrell Mackenzie

  3. 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. http://mystuffspace.com/graphic/happy-baby.jpg

  4. Significance • Reduction of pain and anxiety in pediatric patients • Increase first attempt IV insertion success rates • Conserve time, money, and resources http://www.skywriting.net

  5. PICO(T) Clinical Question • P: Infants and Children • I: Pain/Anxiety reducing interventions • C: No intervention • O: Decreased pain and anxiety during IV insertion

  6. Interventions for Pain/Anxiety: • No Intervention • Distractions • Saline Wheal • ELA Max Cream • Sub-Q Lidocaine • Vapocoolant Spray • Jet Lidocaine Device http://www.thrivingpets.com http://4.bp.blogspot.com

  7. 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. http://www.frickart.org

  8. Distractions • Bubbles • Pinwheels • Music http://www.picturesofbabies.net/ http://www.ourwebpage.org/aircastlesandslides/bubbles_2zillions.jpg

  9. 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)

  10. 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)

  11. 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)

  12. 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)

  13. 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 (Luhmann, Hurt, Shootman, & Kennedy, 2004) http://imghost.indiamart.com

  14. Sub-Q Lidocaine Complications: • Additional stick for the patient • Skill of sub-q injection (Luhmann, Hurt, Shootman, & Kennedy, 2004) http://www.travmed.com

  15. 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)

  16. EMLA-Max vs Sub-Q Lidocaine vs Intradermal Lidocaine • Eutetic Mixture of Local Anesthetics • 4 European studies • EMLA comparable to Sub-Q lidocaine • EMLA less effective than intradermal lidocaine (Delisa, Gans, & Walsh, 2005)

  17. Vapocoolant Spray • Sprayeddirectlyontoskinfrom 3-9 inchesaway, or can be usedon a cottonball and appliedwithforceps. • Painwasreducedfrom a mean score of 56 - 37 per color visual analogscale, p < 0.01 • Itwasnotspecified in thestudyifdisinfection of thesitewasperformed prior toorafterthevapocoolant spray wasapplied (Farion, Splinter, Newbook, Gaboury, Splinter, 2008) http://images.mooremedical.com gebauerspainease.com

  18. 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 (Farion, Splinter, Newbook, Gaboury, Splinter, 2008) • emedicine.medscape.com

  19. 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)

  20. Vapocoolant Spray Risks: • Burning sensation produced when cooling • Tissue Necrosis after 10 seconds Benefits: • Reduction in pain and associated anxiety • Non-flammable, non-toxic, and Ozone friendly, works instantly, costs around 50 cents per use • Safe to use on pediatric patients (Farion, Splinter, Newhook, Gaboury, Splinter, 2008) gebauerspainease.com

  21. 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 (Auerbach, Tunik, & Mojica, 2009) http://onlinelibrary.wiley.com/doi/10.1111/j.1553-2712.2009.00401.x/full

  22. 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)

  23. Conclusion • Recommend: • Jet Lidocaine for efficacy • Bacteriostatic normal saline for “biggest bang for the buck”

  24. Guideline procedure • 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.

  25. Guideline procedure • 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

  26. 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

  27. 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.

  28. Thank You!! http://wawmptacouncil.info/ http://www.cs.cmu.edu/~christel/MM_MSEC/Ozarks/Missouri.html

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