Prior injection of local anaesthetic and the pain and success of intravenous cannulation
Date First Published:
March 1, 2000
Last Updated:
May 9, 2001
Report by:
Ross Murphy, Specialist Registrar (Manchester Royal Infirmary)
Search checked by:
Simon Carley, Manchester Royal Infirmary
Three-Part Question:
In [a patient requiring intravenous cannulation] will [a prior injection of local anaesthetic] reduce [the pain of cannulation without effecting the chance of successful cannulation]?
Clinical Scenario:
A 45 year old female attends the emergency department with cellulitis. You decide to admit her for intravenous antibiotics. She becomes agitated, distressed and tearful when you explain this to her. On questioning she reveals that she is afraid of the pain of intravenous cannulation. You wonder whether a prior injection of local anaesthetic would lessen the pain of cannulation without affecting your chances of success.
Search Strategy:
Medline 1966-07/00 using the OVID interface.
Search Details:
[Venflon.mp OR cannula.mp or exp catheterization, peripheral OR exp infusions, intravenous OR exp injections, intravenous] AND [local anaesthetics.mp OR exp anaesthetics,local OR exp bupivicaine OR exp lidocaine OR exp procaine OR exp tetracaine] AND [pain.mp OR exp pain]. Limit to human AND English language AND abstracts.
Outcome:
251 papers were found of which 241 were irrelevant or of insufficient quality for inclusion. The remaining 10 papers are shown in the table.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Appropriate use of local anaesthetic for venous cannulation. Harrison N, Langham BT, Bogod DG. 1991, UK | 60 patients for surgery. Cannulation with 18G or 20G or 22G venflon on one arm v injection with 1% sub-cut lignocaine with a 25G needle on other arm. | Clinical trial. Randomized. Blinded. | Pain using visual analogue scales. | Cannulation significantly more painful than lignocaine injection in all groups. | Some patients were pre-medicated |
| Local anaesthetic: does it really reduce the pain of insertion of all sizes of venous cannula? Langham BT, Harrison DA. 1992, UK | 60 patients for surgery. Double cannulation with 18G, 20G or 22G venflons preceded by an injection of 1% sub-cut lignocaine with 25G needle on one arm v nothing on the other. | Clinical trial. Randomized. Blinded. | Pain using visual analogue scales. | Cannulation without lignocaine significantly more painful than cannulation with lignocaine | Some patients were pre-medicated |
| Establishing intravenous access: a study of local anesthetic efficacy. Nuttall GA, Barnett MR, Smith RL 2d, et al. 1993, USA | 280 patients for surgery. Cannulation with 18G venflon preceded by nothing v injection with 25G needle of 0.9% benzyl alcohol or 3% 2-chloroprocaine or 1% lignocaine or 1% lignocaine with preservative or 1% alkalinized lignocaine with preservative or normal saline. | Clinical trial. Randomized. Double-blinded. Controlled. | Pain using visual analogue scales. | Cannulation without anaesthetic significantly more painful than cannulation withanaesthetic.Alkalinized lignocaine had the lowest mean pain score for cannulation. | |
| Analgesia for venous cannulation: a comparison of EMLA (5 minutes after application), lignocaine, ethyl chloride and nothing. Selby IR, Bowles BJ. 1995, UK | 160 patients for surgery. Cannulation with 20G venflon preceded by nothing v cannulation preceded by EMLA or ethyl chloride spray or 1% sub-cut lignocaine injected with 25G needle. | Clinical trial. Randomised. | Pain on anaesthetic application, cannulation and a minute afterwards using visual analogue scales. | Cannulation without lignocaine significantly more painful than lignocaine injection. | Not blinded Did not compare pain of whole procedure |
| Number of failed cannulations | No significant difference in number of failed cannulations. | ||||
| Rationalising venepuncture pain: comparison of lignocaine injection, Butterfly (21 gauge and 23 gauge)and Venflon (20 gauge). Van den Berg AA, Prabhu NV. 1995, USA | 278 patients for surgery. Cannulation with 21G butterfly or 23G butterfly or 20G venflon v injection with 1% sub-cut lignocaine with 25G needle prior to cannulation with a venflon of any size. | Clinical trial. Randomized. Blinded. | Pain. Subjectively using observation and objectively using visual analogue scales. | Cannulation with 20G venflon and 21G butterfly significantly more painful than cannulation with 23G butterfly and anaesthetic injection prior to cannulation. | Single-blinded |
| Buffered lidocaine: analgesia for intravenous line placement in children. Klein EJ, Shugerman RP, Leigh-Taylor K, et al. 1995, USA | 59 children requiring cannulation in emergency dept. Cannulation with 18-24G venflons preceded by nothing v cannulation preceded by injection with 27G needle of sub-cut buffered lignocaine. | Clinical trial. Randomized. | Pain of entire procedure using visual analogue scales. | Cannulation without lignocaine significantly more painful than cannulation with lignocaine regardless of venflon size. | Not blinded Small sample size with wide confidence intervals |
| Number of attempts preceding successful cannulation. | No significant difference in number of attempts. | ||||
| Subcutaneous lidocaine does not affect the success rate of intravenous access in children less than 24 months of age. Sacchetti AD, Carraccio C. 1996, USA | 110 children under 2 years requiring cannulation in Emergency Dept.. Cannulation with 24G venflon preceded by nothing v cannulation preceded by injection with 27-29G needle of sub-cut lignocaine. | Clinical trial | Number of attempts preceding successful cannulation. | No significant difference between groups. | 2 groups entered into study over 2 different periods Not blinded Not randomized. |
| Subcutaneous buffered lidocaine for intravenous cannulation: is there a role in emergency medicine? Burgher SW, McGuirk TD. 1998 UK | 103 patients requiring cannulation in Emergency Dept.. Cannulation with 18G venflon preceded by nothing v cannulation preceded by injection with 27g needle of sub-cut buffered lignocaine or sub-cut 0.9% benzyl alcohol and normal saline. | Clinical trial. Randomized. Blinded. | Pain of anaesthetic injection and cannulation using visual analogue scales. | Cannulation without lignocaine significantly more painful than lignocaine injection and significantly more painful than cannulation with lignocaine. | Patients entered into study when investigators available and department not too busy Did not compare pain of whole procedure |
| Number of attempts prior to successful cannulation and number of successful cannulations on the first attempt. | No significant difference in number of attempts or success rate. | ||||
| Saline with benzyl alcohol as intradermal anesthesia for intravenous line placement in children. Fein JA, Boardman CR, Stevenson S et al. 1998, USA | 99 children requiring cannulation in Emergency Dept. Cannulation with 18-24G venflons preceded by nothing v cannulation preceded by injection with 27G needle of sub-cut lignocaine or benzyl alcohol and normal saline. | Clinical trial. Randomized. | Pain using visual analogue scales. | Cannulation without lignocaine significantly more painful than cannulation with lignocaine regardless of venflon size | Patients entered into study when investigators available |
| Does local anaesthetic affect the success rate of intravenous cannulation? Holdgate A, Wong G. 1999, Australia | 166 patients requiring cannulation in Emergency Dept. Cannulation preceded by nothing v cannulation preceded by injection with 25G needle of sub-cut 1% lignocaine. | Clinical trial. Randomized | Successful cannulation at first attempt. | No significant difference between groups. | Not blinded Venflon size not considered |
Author Commentary:
The above studies do indicate that a prior injection of local anaesthetic lessens the pain of intravenous cannulation without affecting the chances of successful cannulation. However, none of the trials were fully blinded and most were not properly single blinded. One used a placebo control and only one reported side effects. While the results were statistically significant it is not known if they were clinically significant and few of the trials commented on the increased length of time it takes to administer anaesthetic or the cost to the health service. Although different anaesthetics were used in different studies most concentrated on 1% lignocaine. Previous studies have shown that the pain of injection of local anaesthetic is less when it is warmed and buffered with bicarbonate and in order to achieve best results this is how lignocaine should be administered prior to attempted cannulation.
Bottom Line:
A prior injection of local anaesthetic does reduce the pain of intravenous cannulation without affecting the success.
References:
- Harrison N, Langham BT, Bogod DG.. Appropriate use of local anaesthetic for venous cannulation.
- Langham BT, Harrison DA.. Local anaesthetic: does it really reduce the pain of insertion of all sizes of venous cannula?
- Nuttall GA, Barnett MR, Smith RL 2d, et al.. Establishing intravenous access: a study of local anesthetic efficacy.
- Selby IR, Bowles BJ.. Analgesia for venous cannulation: a comparison of EMLA (5 minutes after application), lignocaine, ethyl chloride and nothing.
- Van den Berg AA, Prabhu NV.. Rationalising venepuncture pain: comparison of lignocaine injection, Butterfly (21 gauge and 23 gauge)and Venflon (20 gauge).
- Klein EJ, Shugerman RP, Leigh-Taylor K, et al.. Buffered lidocaine: analgesia for intravenous line placement in children.
- Sacchetti AD, Carraccio C.. Subcutaneous lidocaine does not affect the success rate of intravenous access in children less than 24 months of age.
- Burgher SW, McGuirk TD.. Subcutaneous buffered lidocaine for intravenous cannulation: is there a role in emergency medicine?
- Fein JA, Boardman CR, Stevenson S et al.. Saline with benzyl alcohol as intradermal anesthesia for intravenous line placement in children.
- Holdgate A, Wong G.. Does local anaesthetic affect the success rate of intravenous cannulation?