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Guideline Summary
Guideline Title
Needle-related procedural pain in pediatric patients in the emergency department.
Bibliographic Source(s)
ENA Emergency Nursing Resources Development Committee. Needle-related procedural pain in pediatric patients in the emergency department. Des Plaines (IL): Emergency Nurses Association; 2010 Dec. 10 p.
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Conditions that require needle-related procedures in the emergency department

Guideline Category
Management
Prevention
Treatment
Clinical Specialty
Anesthesiology
Emergency Medicine
Nursing
Pediatrics
Intended Users
Advanced Practice Nurses
Nurses
Physicians
Guideline Objective(s)

To evaluate whether there is evidence of pain and distress reduction in pediatric patients who receive analgesic or anxiolytic intervention compared to those who do not during minor invasive procedures in the emergency department (ED)

Target Population

Pediatric patients undergoing needle-related procedures in the emergency department

Interventions and Practices Considered
  1. Biobehavioral interventions
    • Developmentally appropriate distraction
    • Coaching with distraction
    • Cognitive behavioral therapy
    • Hypnosis
    • Breathing exercises
    • Use of suggestion (not recommended)
    • Patient information/preparation (no recommendation)
  2. Dermal anesthetic preparations
    • Ethyl vinyl chloride
    • Pentafluoropropane and tetrafluoroethane
    • Lidocaine/tetracaine (amethocaine)
  3. Subdermal local anesthetic with needle-free delivery
  4. Local application of ice
  5. Pacifiers and sucrose
Major Outcomes Considered

Assessment of pain (self-report of pain intensity, behavioral reactions, physiological reactions)

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

Via a comprehensive literature search, all articles relevant to the topic were identified. The following databases were searched: PubMed, Google Scholar, CINAHL, Cochrane - British Medical Journal, Agency for Healthcare Research and Quality (AHRQ; www.ahrq.gov External Web Site Policy), and the National Guideline Clearinghouse (www.guideline.gov External Web Site Policy). Searches were conducted using the search terms "pediatrics," "procedural pain," "minor procedures," "emergency department," "intravenous cannulation," and "pain" using a variety of search combinations. Searches were limited to English language articles on human subjects from 2005 – October 2010. In addition, the reference list includes selected articles that were scanned for pertinent research findings. Research articles from emergency department settings, non-emergency department (ED) settings, position statements and guidelines from other sources were reviewed. Articles that met the following criteria were chosen to formulate the Emergency Nursing Resource (ENR): research studies, meta-analyses, systematic reviews, and existing guidelines relevant to the topic. Other types of article were also reviewed and provided as additional information.

Number of Source Documents

22 documents were included in the evidence tables.

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Grading the Levels of Evidence*

  1. Evidence from a systematic review or meta-analysis of all relevant randomized controlled trials or evidence-based clinical practice guidelines based on systematic reviews of randomized controlled trials (RCTs)
  2. Evidence obtained from at least one properly designed randomized controlled trial
  3. Evidence obtained from well-designed controlled trials without randomization
  4. Evidence obtained from well designed case control and cohort studies
  5. Evidence from systematic reviews of descriptive and qualitative studies
  6. Evidence from a single descriptive or qualitative study
  7. Evidence from opinion of authorities and/or reports of expert committees

Grading the Quality of the Evidence

  1. Acceptable Quality: No Concerns
  2. Limitations in Quality: Minor flaws or inconsistencies in the evidence
  3. Major Limitations in Quality: Many flaws and inconsistencies in the evidence
  4. Not Acceptable: Major flaws in the evidence

*Melnyk, B. M., & Fineout-Overholt, E. (2005). Evidence-based practice in nursing and healthcare: A guide to best practice. Philadelphia, PA: Lippincott, Williams, & Wilkins.

Methods Used to Analyze the Evidence
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

The Emergency Nursing Resource (ENR) authors used standardized worksheets, including Evidence-Appraisal Table Template, Critique Worksheet and AGREE Work Sheet, to prepare tables of evidence ranking each article in terms of the level of evidence, quality of evidence, and relevance and applicability to practice. Clinical findings and levels of recommendations regarding patient management were then made by the Emergency Nursing Resource Development Committee according to the ENA's classification of levels of recommendation for practice, which include: Level A High, Level B Moderate, Level C Weak or Not recommended for practice (see the "Rating Scheme for the Strength of the Evidence" field).

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

All members of the subgroup independently complete an exhaustive review of all identified literature, complete a separate evidence table for each topic (if possible), and then reconvene to reach consensus. Each subgroup prepares a description of the topic, definition, background, significance, and evidence table. The subgroup identifies and assigns preliminary scores for quality and strength of evidence, and describes conclusions based on the review of the body of evidence. The entire Committee reads the articles and reviews the evidence-appraisal tables for each topic and then finalizes implications for practice and the level of recommendation.

Rating Scheme for the Strength of the Recommendations

Levels of Recommendation for Practice

Level A Recommendations: High
  • Reflects a high degree of clinical certainty
  • Based on availability of high quality level I, II and/or III evidence available using Melnyk & Fineout-Overholt grading system* (see the "Rating Scheme for the Strength of the Evidence" field)
  • Based on consistent and good quality evidence; has relevance and applicability to emergency nursing practice
  • Is beneficial
Level B Recommendations: Moderate
  • Reflects moderate clinical certainty
  • Based on availability of Level III and/or Level IV and V evidence using Melnyk & Fineout-Overholt grading system* (see the "Rating Scheme for the Strength of the Evidence" field)
  • There are some minor flaws or inconsistencies in quality of evidence; has relevance and applicability to emergency nursing practice
  • Is likely to be beneficial
Level C Recommendations: Weak
  • Level V, VI and/or VII evidence available using Melnyk & Fineout-Overholt grading system* (see the "Rating Scheme for the Strength of the Evidence" field) - Based on consensus, usual practice, evidence, case series for studies of treatment or screening, anecdotal evidence, and/or opinion
  • There is limited or low quality patient-oriented evidence; has relevance and applicability to emergency nursing practice
  • Has limited or unknown effectiveness
Not Recommended for Practice
  • No objective evidence or only anecdotal evidence available; or the supportive evidence is from poorly controlled or uncontrolled studies
  • Other indications for not recommending evidence for practice may include:
    • Conflicting evidence
    • Harmfulness has been demonstrated
    • Cost or burden necessary for intervention exceeds anticipated benefit
    • Does not have relevance or applicability to emergency nursing practice
  • There are certain circumstances in which the recommendations stemming from a body of evidence should not be rated as highly as the individual studies on which they are based. For example:
    • Heterogeneity of results
    • Uncertainty about effect magnitude and consequences
    • Strength of prior beliefs
    • Publication bias

*Melnyk, B. M., & Fineout-Overholt, E. (2005). Evidence-based practice in nursing and healthcare: A guide to best practice. Philadelphia, PA: Lippincott, Williams, & Wilkins.

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
Internal Peer Review
Description of Method of Guideline Validation

The Institute for Emergency Nursing Research (IENR) Advisory Council reviews the final document for overall validity and provides feedback as appropriate using the Emergency Nursing Resource (ENR) Evaluation Worksheet. Reviews and feedback are sent to the subgroup to evaluate and incorporate, as appropriate. Emergency Nurses Association (ENA) staff creates the final products for publication with input from the Committee.

Recommendations

Major Recommendations

The grades of recommendations (A–C, Not Recommended), levels of evidence (I-VII), and quality of evidence (I-IV) are defined at the end of the "Major Recommendations" field.

Description of Decision Options/Interventions and the Level of Recommendation

Conclusions and recommendations about management of pain and distress associated with venipuncture, intravenous (IV) cannulation, and immunization in pediatric patients in the emergency department:

  1. Biobehavioral Interventions
    • There is sufficient evidence to support the efficacy of developmentally appropriate distraction, coaching with distraction, cognitive behavioral therapy, hypnosis and breathing exercises (Level A: Highly Recommended) in reducing pain and distress.
    • The use of suggestion to reduce pain and distress is not an effective method (Not Recommended for practice).
    • There is not sufficient information to make a recommendation regarding the effectiveness of patient information/preparation in decreasing pain and distress.
  2. Dermal Anesthetic Preparations: Vapocoolant
    • Ethyl vinyl chloride may be effective in relieving pain associated with venipuncture (Level C: Weak).
    • Pentafluoropropane and tetrafluoroethane (Pain Ease®) induced a moderate reduction in pain in patients undergoing IV cannulation (6-12 years of age) (Level B: Moderate).
    • All transdermal forms of lidocaine/tetracaine (amethocaine) are effective in reducing pain associated with IV cannulation, venipuncture, and immunization (Level A: High). Preparation in the form of cream and patches tended to take longer (e.g., 60 minutes or more) to exact effect, which makes them less feasible to use in the ED environment.
  3. Subdermal Local Anesthetic with Needle-Free Delivery
    • The use of a needleless injection device (e.g., J-Tip®) as a delivery method for lidocaine is superior to other forms of preparation when rapid local anesthesia is desired (Level A: High).
  4. Local Application of Ice
    • Local application of ice decreased the pain and distress associated with venipuncture (Level B: Moderate).
  5. Pacifiers and Sucrose
    • Pacifiers are effective analgesia for infants 0 to 3 months of age undergoing venipuncture (Level B: Moderate).
    • Evidence suggests that sucrose is beneficial as a form of analgesia in children from zero - three months of age; no benefit has been demonstrated for children older than three months. (Level C: Weak).

Definitions:

Levels of Recommendation for Practice

Level A Recommendations: High
  • Reflects a high degree of clinical certainty
  • Based on availability of high quality level I, II and/or III evidence available using Melnyk & Fineout-Overholt grading system* (see the "Rating Scheme for the Strength of the Evidence" field)
  • Based on consistent and good quality evidence; has relevance and applicability to emergency nursing practice
  • Is beneficial
Level B Recommendations: Moderate
  • Reflects moderate clinical certainty
  • Based on availability of Level III and/or Level IV and V evidence using Melnyk & Fineout-Overholt grading system* (see the "Rating Scheme for the Strength of the Evidence" field)
  • There are some minor flaws or inconsistencies in quality of evidence; has relevance and applicability to emergency nursing practice
  • Is likely to be beneficial
Level C Recommendations: Weak
  • Level V, VI and/or VII evidence available using Melnyk & Fineout-Overholt grading system* (see the "Rating Scheme for the Strength of the Evidence" field) - Based on consensus, usual practice, evidence, case series for studies of treatment or screening, anecdotal evidence, and/or opinion
  • There is limited or low quality patient-oriented evidence; has relevance and applicability to emergency nursing practice
  • Has limited or unknown effectiveness
Not Recommended for Practice
  • No objective evidence or only anecdotal evidence available; or the supportive evidence is from poorly controlled or uncontrolled studies
  • Other indications for not recommending evidence for practice may include:
    • Conflicting evidence
    • Harmfulness has been demonstrated
    • Cost or burden necessary for intervention exceeds anticipated benefit
    • Does not have relevance or applicability to emergency nursing practice
  • There are certain circumstances in which the recommendations stemming from a body of evidence should not be rated as highly as the individual studies on which they are based. For example:
    • Heterogeneity of results
    • Uncertainty about effect magnitude and consequences
    • Strength of prior beliefs
    • Publication bias

Grading the Levels of Evidence*

  1. Evidence from a systematic review or meta-analysis of all relevant randomized controlled trials or evidence-based clinical practice guidelines based on systematic reviews of randomized controlled trials (RCTs)
  2. Evidence obtained from at least one properly designed randomized controlled trial
  3. Evidence obtained from well-designed controlled trials without randomization
  4. Evidence obtained from well designed case control and cohort studies
  5. Evidence from systematic reviews of descriptive and qualitative studies
  6. Evidence from a single descriptive or qualitative study
  7. Evidence from opinion of authorities and/or reports of expert committees

Grading the Quality of the Evidence

  1. Acceptable Quality: No Concerns
  2. Limitations in Quality: Minor flaws or inconsistencies in the evidence
  3. Major Limitations in Quality: Many flaws and inconsistencies in the evidence
  4. Not Acceptable: Major flaws in the evidence

*Melnyk, B. M., & Fineout-Overholt, E. (2005). Evidence-based practice in nursing and healthcare: A guide to best practice. Philadelphia, PA: Lippincott, Williams, & Wilkins.

Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of evidence supporting the recommendations is specifically stated for each recommendation (see the "Major Recommendations" field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Reduction of needle-related procedural pain and distress

Potential Harms

Not stated

Contraindications

Contraindications

Contraindications are specific to medication or device. The product literature should be consulted.

Qualifying Statements

Qualifying Statements
  • The Emergency Nurses Association's (ENA’s) Emergency Nursing Resources (ENRs) are developed by ENA members to provide emergency nurses with evidence-based information to utilize and implement in their care of emergency patients and families. Each ENR focuses on a clinical or practice-based issue, and is the result of a review and analysis of current information believed to be reliable. As such, information and recommendations within a particular ENR reflect the current scientific and clinical knowledge at the time of publication, are only current as of their publication date, and are subject to change without notice as advances emerge.
  • In addition, variations in practice, which take into account the needs of the individual patient and the resources and limitations unique to the institution, may warrant approaches, treatments and/or procedures that differ from the recommendations outlined in the ENRs. Therefore, these recommendations should not be construed as dictating an exclusive course of management, treatment or care, nor does the use of such recommendations guarantee a particular outcome. ENRs are never intended to replace a practitioner's best judgment based on the clinical circumstances of a particular patient or patient population. ENRs are published by ENA for educational and informational purposes only, and ENA does not approve or endorse any specific methods, practices, or sources of information. ENA assumes no liability for any injury and/or damage to persons or property arising out of or related to the use of or reliance on any ENR.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Living with Illness
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness
Safety

Identifying Information and Availability

Bibliographic Source(s)
ENA Emergency Nursing Resources Development Committee. Needle-related procedural pain in pediatric patients in the emergency department. Des Plaines (IL): Emergency Nurses Association; 2010 Dec. 10 p.
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2010 Dec
Guideline Developer(s)
Emergency Nurses Association - Professional Association
Source(s) of Funding

Emergency Nurses Association

Guideline Committee

2010 ENA Emergency Nursing Resources Development Committee

Composition of Group That Authored the Guideline

Committee Members: Melanie A. Crowley, MSN, RN, CEN; Andrew Storer, DNP, RN, CRNP; Karen Heaton, PhD, FNP-BC, CEN; Mary Kathryn Naccarato, MSN, RN, CEN, HCRM; Jean A. Proehl, MN, RN, CEN, CPEN, FAEN; Jason D. Moretz, BSN, RN, CEN, CTRN; Suling Li, PhD, RN

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from the Emergency Nurses Association Web site External Web Site Policy.

Availability of Companion Documents

The following are available:

  • ENA Clinical Guidelines for Emergency Nursing Practice Committee. Guidelines for the development of clinical practice guidelines. Des Plaines (IL): Emergency Nurses Association; 2011 Dec. 30 p. Electronic copies: Available in Portable Document Format (PDF) from the Emergency Nurses Association Web site External Web Site Policy.
  • CPG evidence table: needle-related procedural pain in pediatric patients in the emergency department. Des Plaines (IL): Emergency Nurses Association; 2010 Dec. 19 p. Electronic copies: Available in Portable Document Format (PDF) from the Emergency Nurses Association Web site External Web Site Policy.
  • CPG other resources table: needle-related procedural pain in pediatric patients in the emergency department. Des Plaines (IL): Emergency Nurses Association; 2010 Dec. 8 p. Electronic copies: Available in Portable Document Format (PDF) from the Emergency Nurses Association Web site External Web Site Policy.
Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on July 15, 2011. The information was verified by the guideline developer on August 18, 2011.

Copyright Statement

This summary is based on the original guideline, which is subject to the guideline developer's restrictions.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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