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Guidelines 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and anxiety control (e.g., ask child to take a deep breath when the needle is inserted and again when the needle is withdrawn; have child exhale a large breath or blow bubbles to "blow hurt away"; ask child to count slowly and then faster and louder if pain is felt).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.

References

Blass EM, Watt L: Suckling-and sucrose-induced analgesia in human newborns, Pain 83(3):611-623, 1999.

Essink-Tebbes CM and others: Safety of lidocaine-prilocaine cream application four times a day in premature neonates: A pilot study, Eur J Pediatr 158(5):421-423, 1999.

Gray L, Watt L, and Blass EM: Skin-to-skin contact is analgesic in healthy newborns, Pediatrics 105(1):110-111, 2000. (www.pediatrics.org/cgi/content/full/105/1/E14)

Larsson BA and others: Venipuncture is more effective and less painful than heel lancing for blood tests in neonates, Pediatrics 101(5):882-886, 1998.

Additional Information

Notes about obtaining blood samples in children: needle size and saving blood

A Cooling Spray (Fluori-Methane) Reduces Immunization Injection Pain

Use of Buffered Xylocaine for Venipuncture

Guidelines for Using EMLA

Saline Versus Heparin Flush for Peripheral Intermittent IV Infusions in Children

Selected Bibliography and Notes: Atraumatic Care

March 15, 2002

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