Ramaz Mitaishvili, MD
Private Practice of Pediatric
Global Health University
of Southern California
Glendale, CA
GUIDLINE FOR ATRAUMATIC SKIN/VESSEL PUNCTURES
To reduce the pain associated with heel, finger, venous, or arterial punctures:
Apply EMLA topically over site if time permits (at least 60 minutes). To remove
the Tegaderm dressing atraumatically, grasp opposite sides of the film and pull
sides away from each other to stretch and loosen the film. After the film begins
to loosen, grasp the other two sides of the film and pull. Use Numby Stuff
(iontophoresis) over site if time permits (8 – 20 minutes depending on amount
of current), a vapocoolant spray, or use buffered lidocaine (injected intradermally
near vein with 30-gauge needle) to numb skin.
Use nonpharmacologic methods of pain and anxiety control (e.g., ask child to take a deep breath when the needle is inserted and again when the needle is withdrawn; have child exhale a large breath or blow bubbles to "blow hurt away";
ask child to count slowly and then faster and louder if pain is felt). Keep all equipment out of sight until used. Enlist parent's presence and/or assistance if they wish to participate. Restrain child only as needed to perform the procedure safely; use "therapeutic hugging" — the use of a secure, comfortable holding position, usually a sitting position, that provides close physical contact with the parent or other trusted caregiver.
Allow skin preparation to dry completely before penetrating skin. Use smallest
gauge needle, i.e., 25 gauge, that permits free flow of blood; 27 gauge can be
used for obtaining 1 to 1.5 ml of blood and for prominent veins. Avoid IV in
dominant hand or hand child uses to suck thumb. Use automatic lancet device
for precise puncture depth of finger or heel; press device lightly against skin and
avoid steadying finger against a hard surface. Emphasize that blood entering syringe
or tube does not hurt and reassure young children that you did not "take their
blood" away and that they have a lot more inside. Place small bandage over
puncture site to make removal easy and less painful and to reassure young children that "their blood will not leak out."*
Have a "two-try" only policy to reduce excessive insertion attempts — two operators each have two insertion attempts; if not successful after 4 punctures, consider alternative venous access, such as peripherally inserted central catheter (PICC);
have policy for identifying children with difficult access and appropriate interventions, i.e., most experienced operator for first attempt .**
For multiple blood samples:
Use an intermittent infusion device ("saline or heparin lock") to collect
additional samples from existing intravenous line; consider peripherally inserted central catheters (PICC) lines early, not as a last resort. Preferably, use saline flush for
catheter larger than 24 gauge (less painful, compatible with drugs, and less costly).
Coordinate care to allow several tests to be performed on one blood sample
using micromethods of testing.
Anticipate tests (i.e., drug levels, chemistry, immunoglobulin levels) and ask laboratory to save blood for additional testing.
For heel lancing in newborns:
Heel lancing has been shown to be more painful than venipuncture (Larsson and others, 1998); consider venipuncture when amount of blood from heel would require much squeezing, e.g., genetic screening tests.
Effectiveness of EMLA is controversial, although use of 0.5 gm for 30 minutes four times a day in preterm infants was found to be safe (Essink-Tebbes and others, 1999).
Place diapered newborn against mother's bare chest in skin-to-skin contact 10-15 min. before and during heel lance (Gray, Watt, and Blass, 2000). During procedure, allow newborn to suck a pacifier coated with a slurry of sugar and water: to make an approximate 24% sucrose solution, add 1 teaspoon of table sugar to 4 teaspoons of sterile water. Use this solution to coat the pacifier repeatedly or administer 2 ml to the tongue 2 minutes before the procedure (Blass and Watt, 1999).
* Contrary to popular belief, a study of children ages 3 to 6 years found that asking them not to look at the "finger stick" to avoid the sight of blood or applying a decorated bandage did not lessen their rating of pain intensity (Johnston CC, Stevens B, and Arbess G: The effect of the sight of blood and use of decorative adhesive bandages on pain intensity ratings by preschool children, J Pediatr Nurs 8(3):147-151, 1993).
** For an example of one hospital's guidelines for reducing excessive IV insertion attempts, see Catudal, J: Pediatric IV therapy: actual practice, J Venous Access Devices 4(1):27-29, Spring 1999.
