1 University of Exeter UK, 2 Royal Devon and Exeter Foundation Trust UK, 3 Research Design Service South West UK

Contact: m.bond@exeter.ac.uk

First Do No Harm: Pain Relief for the Peripheral Venous
Cannulation of Adults, a Systematic Review
Bond M
1
, Haasova M
1
, Coelho H
1
, Cooper C
1
, Milner Q
2
, Shawyer V
2
, Hyde C
1
, Powell R
3
, Crathorne L
1


No pain Worst pain
10 cm

3.6 SD 2.9
Background: Peripheral venous cannulation (PVC) is an everyday,
painful, hospital procedure. However, it is only common practice to
provide children with pain relief.
Method: Systematic review using NHS CRD principles
Population adults who have had a routine PVC
Intervention any local anaesthetic used in routine PVC
Comparator - routine PVC without local anaesthetic or with other
anaesthetic
Design all controlled trials and observational studies with control groups
and economic evaluations
Primary outcome self-reported pain
Objective: To discover the relative effectiveness of local anaesthetics
for reducing the pain of routine PVC in adults, whether the ease of
cannulation was affected by their use and whether it is cost-effective.
Results: The searches returned 16,368 titles and abstracts. After dual
independent review 34 papers were included. The study quality varied,
often details of randomisation were missing but statistical methods were
appropriate and estimates of mean differences with precision were
generally reported
Results: All agents (lidocaine, EMLA, amethocaine, diclophenac, ethyl
chloride) significantly reduced the pain of PVC vs. no treatment
Results: Random effects meta-analysis comparing lidocaine and
EMLA.
Results: Buffering lidocaine with sodium bicarbonate reduces the pain of
this injection.
Mean 95% CI reduction 0.98 (-1.45 to -0.5), 10 cm VAS
Conclusions:
Adults find routine PVC painful
This pain can be successfully addressed without making the procedure
more difficult
Buffered lidocaine is the most effective agent in reducing routine PVC pain
Adults should receive the same consideration for PVC pain relief as
children
Results: Pooled control group results of 6 RCTs found that adults rated
the mean (SD) unattenuated pain of PVC at 3.6 (2.9) on a 0 - 10 visual
analogue scale (VAS), N = 261
Funding: Royal Devon & Exeter Foundation Trust UK
PROSPERO No. CRD42012002093
WMD= weighted non-standardised mean difference (mm). Negative WMD favours lidocaine and positive WMD favours EMLA.
Results: The pain of an unbuffered lidocaine injection was 13.5 points less
painful than PVC pain on a 100 mm VAS
Mean (range) 10.0 (3.5 to 19.0) vs. 23.5 (12.0 to 47.75)
Results: Is pain relief too time consuming?
a. Two studies looked at time taken to cannulate and both found no
significant difference between intervention and control groups (control =
no local anaesthesia)

b. One study demonstrated lidocaine is effective at reducing the pain from
PVC when left for only 30 seconds
Results: Does using local anaesthetic make PVC more
difficult?
a. Two studies looked at the number of attempts needed to cannulate and
both found no significant difference between local anaesthetic agents and
the control group

b. Four studies looked at ease of cannulation and all found no significant
difference between different local anaesthetic agents and the control
group

Comment: adequate pain relief may mean a more relaxed, calmer patient,
especially if multiple attempts are needed or the patient suffers from a
needle phobia
Results: RCTs comparing EMLA with Ametop did not reach statistical
significance but mean differences show an additional benefit from Ametop
Conflict of interest: none
Results: Adverse effects, if present, were mild and transient
Results: Cost-effectiveness
Lysakowski et al. (2003) One extra patient with a PVC pain score 1 cost $18
(1% lidocaine) or $11 (2% lidocaine), on a 0 10 numerical verbal scale
VS. PLACEBO OR CONTROL N Effect size (95% CI)
lidocaine 670 pooled (9 RCTs) 17.34 (26.60, 8.08)
EMLA 280 pooled (3 RCTs) 34.11 (59.63, 8.59)
Ametop 42 O'Connor p=0.01
diclophenac 92 Agarwal et al. 2006, 2007 p=0.001, p<0.05
ethyl chloride 160 pooled (2 RCTs) 17.15 (23.19, 11.11)
Study year
(location)
N intervention dose delivery outcome
measure
median
(IQR [range])
mean
(SD [SEM])
mean difference
(95%CI)[SE]
YeoH&Lee
2012
39 EMLA
5%
1ml cream VAS 30 27.9 (9.8) NS
(Malaysia) 41 Amethocaine
4%
1ml cream 100mm 20 19.1 (14.1)
Molodecka et al
1994
30 EMLA
30min
2.5 g cream VAS 19.0 (10.4) [1-81] NS
(UK) 29 Amethocaine 5%
30 min
1 g cream 100mm 18.0 (14.0) [0-82] NS
30 EMLA
60min
2.5 g cream 13.5 (10.5) [1-81] NS
29 Amethocaine 5%
60 min
1 g cream 8.5 (9.6) [0-34] NS
NS not significant