Evidence Based Practice for Pain Management during Peripheral Intravenous Cannulation among Paediatric Population in ICU

This essay evaluates best evidence based practice for successful pain management during PIVC among the paediatric population under the clinical settings of ICU. The essay will mainly initiate with a brief review of the importance of evidence-based practice followed by a critical analysis of the chosen evidence-based practice for the successful pain management among the paediatric population in ICU.

Running head: EVIDENCE BASED PRACTICE
Evidence Based Practice
Name of the Student
Name of the University
Author Note

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EVIDENCE BASED PRACTICE
Introduction
Administration of fluids and drugs through intravenous (IV) cannulae is an important
aspect of care in the intensive care unit (ICU) of the hospital. One of the common procedures
of IV cannulation is peripheral intravenous cannulation (PIVC) (Heinrichs et al., 2013).
However, Hogan et al. (2014) highlighted that PIVC is difficult to perform and at time
painful for the patients. Establishing intravenous access among the paediatric population is
often challenging for healthcare professionals. The main challenge arises in the domain of
localizing the required blood vessel by palpation and proper identification of the adjacent
anatomical landmarks. This finding the right vein for PIV, increases the total number of
attempts towards successful PIVC and this, increases pain along with overall delay in
delivering therapy (Heinrichs et al., 2013). The following essay aims to evaluate best
evidence based practice for successful pain management during PIVC among the paediatric
population under the clinical settings of ICU. The essay will mainly initiate with a brief
review of the importance of evidence-based practice followed by a critical analysis of the
chosen evidence-based practice for the successful pain management among the paediatric
population in ICU.
Discussion
Pain management in ICU in paediatric population
According to Dang and Dearholt (2017), evidence based practice (EBP) is a
conscientious use of current available evidence in making proper decision about the patient
care. Dang and Dearholt (2017) highlighted that EBP is a problem solving approach towards
effective clinical practice which guides the nurses towards improved patient outcome. De
Graaff et al. (2013) conducted a randomised control trail in order increase the patient

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outcome in the domain of PIVC among the paediatric population. They mainly analysed the
effectiveness of near infrared light towards finding the peripheral nerve in order to stream
line the process of PIVC in children. Their study mostly recruited 1913 children between the
age group of 0 to 18 years. The results highlighted that infra-red device, the vein viewer
though is helpful in increasing the visualization of veins in ICU, the success rate if snot
significant and thus unable to effectively reduce pain in PIVC. The interview conducted by
Twycross and Finley (2013) parents in the domain of pain during PIVC cannulation by
Twycross and Finley (2013) highlighted that moderate to severe pain is associated with
PIVC. The parents are of the opinion that the short-term and long-term consequences of the
un-relieved pain increases the level of distress among their children and thereby hampering
the overall care process in ICU.
Presence of parents in effective management of pain
Kim et al. (2015) highlighted that children undergoing surgery are mainly prone to
separation anxiety before the process of anaesthesia and at the time of PIVC process. The
reason behind this, they are dependent on their parents. Furthermore, the placement of the
needle, mask and other ICU equipments in the absence of their parents further increases the
sense of distress, anxiety and level of pain among the children. Evidence-based practice
highlights that distraction is common non-pharmacological interventions which is successful
in reducing children’s distress behaviour during PIVC. Distraction decreases the emotional
distress and intensity of reported pain in children. Many health care setting use materialistic
procedures to distract the children. However, the presence of parents in the clinical setting
during the procedure proved to be one of the successful procedures to manage the pain of
infants in ICU departments (Palermo, Valrie and Karlson, 2014). In order emphasise on the
importance of distraction in effective pain management of the children in ICU during PIVC,
Kim et al. (2015) conducted a randomised control trial. Kim et al. (2015) mainly used video

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distraction and parental presence for the management of the pre-operative anxiety at the time
of IV cannulation and post-operative pain and behavioural disturbances in children. They
conducted their study over 117 children between the age group of 2 to 7 years. Their results
highlighted that video distraction along with the presence of parents or a combination of both
acts as an effective psychological intervention for reduction of pain among the children in
ICU during PIVC and post surgery. They found that the overall change in the anxiety level is
significant in the experimental group in comparison to the placebo group. Video distraction
and parental presence appears to cast anxiolytic mechanisms under the ICU settings. Video
distraction helps the child to become oblivious to the surrounding unfamiliar settings and
helps to absorbs them in a familiar imaginary world. On the other hand, the presence of
parents helps to decreases the sense of distress which is associated with the sudden separation
from the parents. Uman et al. (2013) conducted another study over 3394 children between the
age group of 2 to 19 years. The presence of parents at the time of the PIVC acts as an
effective distraction technique for the children. The presence of parents helps to reduce the
sense of distress and this in turn helps to reduce the overall sensation of pain. In the context
of presence of parents, Eccleston et al. (2013) highlighted that presence of parents acts as one
of the effective psychological therapies for the effective management of pain among the
children who are in the ICU. Eccleston et al. (2013) further highlighted that psychological
therapies are effective in reducing anxiety under post-operative treatment in ICU. In order to
investigate the effect of distraction of attention by a toy and parental presence in painful
invasive technique for children, Matziou et al. (2013) conducted a randomised control trail.
They mainly recruited 130 children within the age group of 7 to 10. These children were
randomly assigned to three different groups that is presence of parents, presence of toy and
one placebo group. The verbal rating scale of pain and assessment of the vital signs were
used as the marker of pain. The analysis of the study highlighted that the children who had

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their parents at the time of invasive procedure showed reduction in the respiratory rate, blood
pressure and pulse in comparison to the children who parents were absent. The level of pain
scale and the level of distress were also found less among the children whose parents were
present. Overall, the study highlighted that parental presence can be considered as an
important means of decreasing children’s pain and stress level at the time of invasive
procedures (Matziou et al., 2013). Thus evidence-based practice in nursing research
emphasise the presence of parents for the effective management of pain among the children
in ICU.
Difficulty in implementation of the evidence-based practice
In relation to presence of parents at the time of PIVC, Boudreault-Bouchard het al.
(2013) stated that presence of parents might increase the overall sense of distress among the
children. The condition is mostly prevalent when the parents start to receive panic attacks at
the time of PIVC. Boudreault-Bouchard het al. (2013) is of the opinion that parental distress
hampers the mental health and well-being of the children and thereby increasing their sense
of distress. Boudreault-Bouchard het al. (2013) stated that positive parental practices are
associated with the decreased level of anxiety and distress among the parents. Moreover,
Salama et al. (2013) stated that crowing at ICU might increase the sense of noscomical
infection.
Overcoming barriers
Salama et al. (2013) are of the opinion that proper compliance of the hand hygiene
and use of personal protective equipments like nasal mask, aprons and sterile gloves helps in
the compliance on hospital-acquired infections under ICU settings. Thus the parental
presence at ICU at the time of PIVC must be done only after detailed parental education. This
parental education must be structured in the domain of maintenance of basic hygiene, use of

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aprons and lab coats while entering into the ICU. The parental education must also be done in
the domain of importance of PIVC for their children towards effective treatment and how
reduction in the sense of anxiety will be helpful in delivering the proper therapy. This
parental education will help the parents to overcome their panic attacks and thereby
successfully guiding their wards in effective management of pain from the non-psychological
perspective (Noble et al., 2015).
Alternative evidence-based practice
The pediatric venous access increases unnecessary anxiety and pain in children, which
prove to be reduced in the presence of parents in ICU. However, it is essential to consider
that parental presence in ICU during the procedure is always not a feasible option. The reason
behind this is, the majority of the parents are both working and difficulty is also observed in
the case of orphan patients. In such cases, effective management of pain can be done under
the application of external cold and vibration. In relation to this, Canbulat, Ayhan and Inal
(2015) randomized control trials study. They recruited 176 children with in the age group of 7
to 12 years who were randomly allocated into two different groups. External cold and
vibration were given to the one group (experimental group) via buzzy until the end and IC
procedure performed and another group was placebo group who received no external cold
and vibration approach. The result suggested that pre-procedural anxiety of the two groups
did not differ significantly. However, during the procedure, the anxiety level decreased
substantially for the patient of the experimental group. Şahiner, İnal and Akbay (2015)
conducted another identical randomized controlled trial study where two groups were
allocated in the same manner. The result suggested that the combined stimulation of skin
along with the application of external cold plus vibration could be used to reduce pain and
vibration. Thus evidenced-based practice highlights that the presence of parents in association

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to the external application of cold and vibration and be use as an effective means of managing
pain among the pediatric population in ICU during PIVC.
Conclusion
Thus from the above discussion, it can be concluded that presence of parents at the
time of PIVC can be regarded as an effective evidence-based practice for effective reduction
of pain among the children in the ICU. The critical analysis of the evidence-based practice
highlighted that pain management is crucial under the pediatric ICU settings for the effective
procurement of the care delivery. In order to deliver care infrared video imaging is used for
the effective localization of the veins. However, this approach failed to provide effective
insight towards successful execution of PIVC and effective management of pain. Towards
management of pain, the presence of parents acts as a stalwart psychological intervention.
The presence of parents helps to reduce the sense of distress among the children and thereby
helping to reduce the overall sensation of pain. In order to increase the effectiveness of pain
management, other strategies that can be used in association to the presence of parents
include toys, and video clips. However, the proper parent education must be provided prior
they entry into the ICU in the domain of ICU hygiene and panic attacks. Moreover, in cases
where parents are unable to assist children in ICU, application of external cold and vibration
can be used as an effective evidence-based practice for pain management.

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