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Corresponding author: Timothy L. Hudson, RN,MS, MED, US Army, Fort Bragg, NC 28307 (e-mail: timothy.hudson{at}us.army.mil).
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Abstract |
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• Objective To review the recommendations and studies related to the use of intradermal lidocaine to decrease pain during arterial punctures.
• Methods Articles were identified by doing a systematic computerized search of MEDLINE (1980 to January 2006) to evaluate articles and reference lists of articles and a manual search of the references listed in original and review articles. English-language articles that evaluated any aspect of pain related to arterial puncture and cannulation, pain related to and methods of introducing lidocaine subcutaneously, and perceptions and use of local anesthesia for arterial or intravenous punctures were reviewed.
• Results Except among anesthesia providers, the use of a local anesthetic before arterial puncture is not universal, contrary to the standard of practice. A number of false perceptions may prevent wider use of such anesthetics.
• Conclusion Before a plan for behavior modification or policy change is recommended for use of local anesthesia to decrease pain associated with arterial puncture, further research must be done to determine nurses’ perceptions of use, actual practice, and currently established local policies.
An undesirable characteristic of an arterial puncture is the pain experienced by the patient during the procedure.1 In an attempt to eliminate or at least minimize pain associated with obtaining arterial blood samples, local anesthetization of the puncture site should be performed.2 In this article we review the recommendations and studies related to the use of intradermal lidocaine to decrease pain during arterial punctures. We also provide a series of questions that may be useful in identifying barriers to the use of this evidence-based practice.
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Professional Standards |
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. A similar procedure is found in Emergency Nursing Procedures.3 The British Thoracic Society and the Association of Respiratory Technicians and Physiologists also recommend the use of local anesthesia before arterial puncture.4
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| Local anesthesia should be used before arterial puncture.
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Except for intravenous therapy, arterial access is the most common invasive procedure performed on critically ill patients.5 Arterial puncture is a source of pain and discomfort in critical care.1 Although pain cannot be completely eliminated during invasive procedures such as obtaining blood from an artery, pain should be minimized. In a study6 of 100 intensive care patients, punctures to obtain samples for ABG analysis were the No. 1 factor "that moderately or severely worried patients," and 48% of these patients’ unpleasant experiences were associated with arterial blood sampling.6 Obtaining samples for ABG analysis was ranked higher than endotracheal suctioning as an unpleasant experience and was identified separately from regular "pain," which was ranked third. It is noteworthy that the pain related to arterial puncture is of such intensity that patients place it in a separate and higher category of discomfort than other types of pain in the intensive care unit.
The standard of practice for arterial puncture is well established and includes use of a local anesthetic. However, the actual practice of using a local anesthetic is not universal. Intradermal injection of lidocaine before arterial puncture decreases the incidence and severity of localized pain.1,7 Clinicians’ perceptions of the use of a local anesthetic before arterial punctures, however, can affect whether the clinicians use intradermal lidocaine.
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Concerns Related to the Use of Local Anesthesia |
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In a telephone survey on use of local anesthesia for arterial punctures, Lightowler and Elliot9 found that 84% of the junior hospital physicians surveyed never administered a local anesthetic before doing arterial punctures; 47% of the physicians thought that injecting a patient with a local anesthetic would be just as painful as the arterial puncture itself.
Sado and Deakin8 surveyed 178 physicians to assess the prevalence of anesthetic use for arterial punctures to obtain samples for ABG analysis. The investigators found an interesting difference between anesthesia providers and non–anesthesia providers. Approximately 60% of anesthesia providers used local anesthetic for arterial punctures, whereas less than 3% of non–anesthesia providers did.
Does Local Anesthesia Reduce the Pain From Arterial Puncture?
Giner et al1 conducted a double-blind study with 270 subjects to compare perceptions of pain during an arterial puncture with and without local anesthesia and to compare that pain with the pain associated with a venous puncture. Results from the study1 indicated that subcutaneous infiltration of a local anesthetic (mepivacaine hydrochloride without epinephrine) before arterial puncture reduced pain by more than 50%, so much so that the arterial puncture was even less painful than venous cannulation.
Lightowler and Elliot9 evaluated pain levels associated with arterial puncture with and without lidocaine infiltration and noted that the use of a local anesthetic reduced patients’ reported pain levels. On a 4-point pain scale, arterial puncture was less painful with lidocaine infiltration; scores were 1.5 with lidocaine versus 2.2 with placebo (P < .001) and 1.5 with lidocaine versus 2.1 with nothing (P < .001).
A solid foundation of published work10–15 is available on using a local anesthetic to reduce the pain associated with intravenous cannulation. Fewer studies, though with no less compelling results, have addressed using a local anesthetic to reduce the pain associated with arterial punctures.1,9 The arterial wall has many more pain receptors than do venous walls and is therefore more sensitive to pain. However, the greatest benefit of using an anesthetic is the reduction of pain throughout the epidermis, dermis, and subcutaneous tissue.
| Obtaining samples for arterial blood gas analysis is ranked higher than endotracheal suctioning as an unpleasant experience in the intensive care unit.
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Does Injection of an Anesthetic Decrease the Success Rate of Obtaining an Arterial Blood Sample?
Giner et al1 addressed the concerns related to the misconception that the use of an intradermal injection of a local anesthetic would actually decrease the success rate for obtaining an arterial blood sample. They found that increased levels of pain associated with not using local anesthesia actually decreased success rates for obtaining arterial blood samples because patients could not remain immobile during the procedure. Giner et al1 recommended administering local anesthesia before obtaining an arterial blood sample because their results showed that mepivacaine not only reduced pain, but did not hinder locating the artery to be punctured. In the study by Lightowler and Elliot,9 0.5 mL of 2% lidocaine was injected with a 29-gauge needle. The rate of successful arterial punctures was higher in the lidocaine group than in the group that received no local anesthetic. Similar results were also found with respect to venous cannulation.11,12
| The arterial wall has many more pain receptors than do venous walls.
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Does It Matter What Size of Needle or What Local Anesthetic Is Used?
Use of smaller gauge needles for arterial puncture does produce less damage of the arterial wall.16 In most clinical situations, 22-gauge arterial puncture needles are sufficient in size to allow self-filling of the syringe17 and may reduce the incidence of arterial vasospasm.2 No study has been done to compare pain levels associated with use of different sized needles for the actual puncture, though Palmon et al18 studied the effects of different needle gauges (25 and 30 gauge) on the discomfort related to the actual injection of lidocaine. They found no significant difference in the report of pain with the different gauge needles. The current AACN Procedure Manual for Critical Care2 recommends the use of a 25-gauge needle for injection of lidocaine. Anecdotally, many clinicians use even smaller gauge needles (with tuberculin and insulin syringes) for the injection of a local anesthetic.
Alkalinization (buffering) of lidocaine may decrease discomfort during percutaneous infiltration because of the pH of lidocaine. Hence, consideration has been given to buffering lidocaine with sodium bicarbonate. In 2 studies,19,20 the addition of sodium bicarbonate decreased the discomfort associated with the injection of lidocaine. Burgher and McGuirk21 also studied the use of buffered lidocaine in intravenous cannulation in the emergency department. Although their study focused on intravenous cannulation and not arterial punctures, subcutaneous injection of buffered lidocaine significantly reduced pain while not adversely affecting the success rate of intravenous cannulation in adult patients in the emergency department. In contrast, Richtsmeier and Hatcher22 found no significant differences between use of buffered and nonbuffered lidocaine in children during hemodialysis cannulation via arterial and venous access sites.
The generalizability of results from studies of hemodialysis cannulation to arterial punctures is a concern. Additional factors, such as warming the lidocaine solution23 and altering the speed of injection,24 did not change the perception of pain when either buffered or nonbuffered solution was used.
| Pain, rather than use of a local anesthetic, decreases arterial sampling success.
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Won’t a Topical Anesthetic Work Just as Well?
Giner et al25 compared a eutectic mixture of local anesthetics (EMLA) cream, placebo cream, and mepivacaine for arterial punctures. They concluded that mepivacaine injected subcutaneously was more effective at reducing pain than was EMLA cream applied topically. Researchers25–32 also have investigated whether a topical anesthetic would decrease pain experienced by patients during venous cannulation. The results of the effectiveness of lidocaine ointment, amethocaine gels, and EMLA creams as an alternative to intradermal lidocaine were mixed. The effectiveness of applying topical anesthetics before performing an arterial puncture is limited in the acute care environment by the extended application time required (30–60 minutes) for a topical anesthetic to penetrate sufficiently to reduce discomfort. Results of ABG analysis are needed in a more timely manner than topical anesthetics will allow.
As a final note, the use of intradermal lidocaine is not cost prohibitive. Fry and Aholt33 compared the cost of buffered lidocaine and syringe with the cost of EMLA cream patches. The cost of a single application of EMLA cream is $7, whereas lidocaine and a syringe cost approximately 17 cents. Adding lidocaine and needed supplies to the basic ABG supply requirement would add less than 20 cents per procedure.
| Up to 60 minutes is required for a topical anesthetic to penetrate sufficiently to reduce discomfort.
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Conclusion |
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Although the lack of use of local anesthetic could be the same among nurses and other care providers, the barriers would not. Thus, it may be inappropriate to generalize the findings of barriers from other care providers to nurses. For example, physicians do not need an order to use lidocaine, whereas nurses may need a physician’s order to incorporate lidocaine into the procedure. We highly recommended that nurse managers coordinate with their medical directors a standing order whereby the use of lidocaine is a standard protocol for obtaining all blood samples for ABG analysis. Still, we can only speculate about why nurses are not using local anesthetics for arterial punctures.
If standards are not being met, what are the barriers? Managers should first determine the use of local anesthesia and then identify the barriers to use. A series of questions (Table 2) may be useful in identifying factors that may inhibit or enhance the use of intradermal lidocaine for arterial punctures, including perceptions of critical care nurses (in intensive care units and emergency departments) of use of local anesthesia, local procedures and policies, and practice standards and current practice related to management of pain during arterial puncture. This information could then be used to identify areas of potential education and training and interventions to eliminate barriers and increase uptake of this evidence-based practice.
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ACKNOWLEDGMENTS |
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REFERENCES |
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