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Local warming to reduce pain on peripheral intravenous cannula insertion: A

randomised controlled study

Article  in  Journal of Advanced Perioperative Care · February 2006


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Margita Svensson Ulrica Nilsson

Örebro University Karolinska Institutet


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Svensson et al Local warming to reduce pain

Local warming to reduce pain on peripheral

intravenous cannula insertion: a randomised
controlled study
Margita Svensson RNA, BScN
Department of Anaesthesiology and Intensive Care, Örebro University Hospital, Örebro, Sweden

Siv Rosén RNA, BScN

Department of Anaesthesiology and Intensive Care, Örebro University Hospital, Örebro, Sweden

Ulrica Nilsson RNA, MScN, PhD

Senior Lecturer, Department of Health Sciences, Örebro University, and Department of Anaesthesiology and Intensive Care, Örebro University
Hospital, Örebro, Sweden

All correspondence to be addressed to: Ulrica Nilsson, Department of Anaesthesiology and Intensive Care, Örebro University Hospital, SE-701 85
Örebro, Sweden. E-mail: ulrica.nilsson@orebroll.se

Accepted for publication: 17 January 2005

Keywords Abstract
Local warming (LW) Insertion of intravenous cannulas (IVCs) is one of the most commonly used invasive
procedures in healthcare and can be perceived as very painful by the patient.The aim of this
Peripheral intravenous
study was to evaluate whether venous dilatation produced by local warming (LW) reduces
cannula (IVC)
pain on peripheral IVC insertion.The study with a sample size of 125 patients was undertaken
Pain in a day care unit. Patients were randomised to an experimental group (n = 61) or a control
group (n = 64).The experimental group received LW during 60 seconds before cannula
insertion.The control group received no treatment.The intravenous catheter used was optiva,
Visual analogue scale an 18 gauge over-the-needle catheter. Pain was measured with a 10cm visual analogue scale
(VAS) (VAS) with a possible pain score of 0–10.The results showed no statistical significance
between the groups in mean pain, with 1.74 measured in the LW group versus 2.01 scored in
the control group.The percentage of patients who had a VAS > – 3 was 15.6% in the LW group
versus 22.9% in the control group. However, this difference was not statistically significant. In
conclusion, LW before peripheral IVC insertion appears not to have any pain-reducing effect.
Altogether 20% of all the participants experienced the insertion as a painful procedure.

Introduction about 4.5 million IVC insertions are performed each

year and the procedure is a routine preoperative task
Intravenous parenteral therapy is an important for the nurse anaesthetist.
procedure in modern medicine. Thousands of patients
throughout the world receive intravenous cannulas It is no secret that the IVC procedure is painful and that
(IVCs) used to administer drugs, solutions or blood for some patients it is almost intolerable. The procedure
substitute and for life-saving treatment (Lundgren & Ek possibly represents the most anxiety-provoking event
1996, Davis 1998). remembered by the patient (Mbamalu & Banerjee 1999,
Moreau & Zonderman 2000, Lenhardt et al 2002). A
Insertion of IVCs is a common task for nurses in all hospital-induced stressor, a IVC can even disrupt
kinds of care in Sweden. Knowledge of how to plan the homeostasis, healing and recovery by increasing the
insertion, and insert and handle the peripheral body stress response (Moreau & Zonderman 2000).
intravenous line has been basic to nursing education Because of these potential effects, it is important for
since the 1950s and is included in the final year’s nurses to use techniques for IVC insertion pain
practical training (Lundgren & Ek 1996). In Sweden reduction (Davis 1998). A number of methods for

© AfPP 2006 Journal of Advanced Perioperative Care Vol 2 No 3 February 75

Svensson et al Local warming to reduce pain

reducing the pain of this procedure have been al 1993) and is well known both in the literature and in
developed to optimise the patient’s comfort and clinical practice. The 10 cm VAS line, printed on paper,
satisfaction. They include local anaesthetics (LAs) was handed to the patient immediately after the IVC was
(Selby & Bowles 1995, Patterson et al 2000, Brown 2004), secured. The patient was left alone when marking the
ethyl (Selby & Bowles 1995), ice (Richman et al 1999), score for experience of IVC insertion pain.
the cough trick (Usichenko et al 2004), the Tellington
touch (Wendler 2003) and nitrous oxide (N2O) Intervention
(Gerhardt et al 2001). However, pain control achieved
by injection of LAs can be painful in itself. All IVC insertions were standardised and performed by
the first two authors (MS and SR) in order to reduce
Many patients awaiting elective surgery experience variation. To standardise the cannula insertion
preoperative anxiety (Kindler et al 2000) and the procedure the two nurses performed the first ten IVC
reported incidence in adults ranges from 11% to 80%, insertions together. The two had been working as
depending on the assessment method (Maranets & nurses since 1979 and 1983 and as nurse anaesthetists
Kain 1999). There are also patients who are afraid of since 1985 and 1987, respectively, which means both
needles or have had bad experiences of IVC (Lenhardt have good knowledge of and are well trained in IVC
et al 2002). Fear and anxiety activate the sympathic insertion. Data collection was performed in such a way
nervous system, thereby provoking peripheral as not to affect the normal work at the day care unit.
vasoconstriction, and this can complicate intravenous
cannulation (Mbamalu & Banerjee 1999, Lenhardt et al The intravenous catheter used was an 18 gauge over-
2002). A non-pharmacological technique that has been the-needle optiva catheter. The procedure was
reported to optimise the IVC insertion by venous performed with the patient recumbent on his or her
dilatation is local warming (LW) (Mbamalu & Banerjee bed. Cannulation was performed in a vein on the
1999, Lenhardt et al 2002). This is a non-painful dorsum of the left or right hand. Before cannulation 60
technique that has no side effects (Lenhardt et al 2002). seconds of pressure with a manometer cuff at 60 mmHg
The aim of the current study was to evaluate whether was administered. The patients in the LW group
venous dilatation produced by LW reduces pain on received LW during these 60 seconds. The control
peripheral venous cannulation in preoperative patients. group patents received no warming but only 60
seconds of pressure. The area was then cleaned with
Klorhexidine® 5mg/mL and a vein on the hand was
Method clearly visualised. Cannulation was performed. To
confirm a successful IVC insertion an injection of 5 mL
Research design normal saline solution was used.

The study was a prospective consecutive randomised Ethical consideration

control trial conducted preoperatively in a day care unit
at a university hospital. A sample of 134 American The study was approved by the regional research ethics
Society of Anesthesiologists (ASA) physical status I–II, committee. The patients were asked about participation
>16-year-old, Swedish-speaking elective surgery patients by the two first authors preoperatively in the day care
were invited to participate in the study. The patients had unit. Information was given verbally and in writing,
not been taking any analgesic or anxiolytic medication and was repeated. The participants were guaranteed
preoperatively. The participants were randomly assigned confidentiality and were informed that participation
to two groups. Group one received LW and group two, was voluntary and that they could withdraw from the
the control group, received no treatment. The study at any time without any consequences for their
randomisation codes were sealed in closed envelopes. treatment and care.

Equipment Excluded patients

For LW before IVC insertion, a warming pillow was Nine of the participants were withdrawn, six in the LW
used. Recommended time to obtain venous dilatation group and three in the control group (Figure 1). The
was 60 seconds. Before use the warming pillow was reason for this was cannulation failure in eight patients
heated in a microwave oven at 700W for 60 seconds, while one patient was converted from ASA II to ASA III
giving a temperature of 39–40ºC. status. A total of 125 patients, 61 in the LW group and
64 in the control group, were included in the results of
Measures the present study.

The patients were asked to report pain intensity on the 10 Statistics

cm VAS, with zero meaning no pain and ten meaning
maximum possible pain. The VAS is a validated and We used a sample size calculation based on a one-way
reliable instrument (Scott & Huskinsson 1976, Mantha et analysis of VAS, with a significance level of 5%, a

76 Journal of Advanced Perioperative Care Vol 2 No 3 February 2006 © AfPP 2006

Svensson et al Local warming to reduce pain

134 patients:
Elective surgery, ASA stage I–II,
– yrs old


Local warming (LW) group Control group

n = 67 n = 67

Withdrawn: six patients Withdrawn: three patients

n = 61 n = 64

60 seconds pressure 60 seconds pressure

60mmHG + LW 60mmHG

Area cleaned Area cleaned

Klorhexidine® (70%) Klorhexidine® (70%)

IV cannulation IV cannulation
and fixation and fixation

Record pain Record pain

(VAS 0–10) (VAS 0–10)

Figure 1 Local warming versus control treatment study profile

power of 80% and a common standard deviation (SD), however, this difference was not statistically significant
which gave a sample size of 134 participants. (Table 2).

The results from the pain measurement on the VAS

scale (ordinal data) were analysed with the non-
parametric Mann-Whitney U-test, and described as Our aim was to investigate in a randomised controlled
frequencies, arithmetic means and ranges. A p-value of trial, whether venous dilatation produced by LW
<0.05 was considered statistically significant. reduces pain on peripheral venous cannulation to justify
its application in clinical practice. The methodological
approach was influenced by the nomothetic sciences. We
Results hoped to find results that would be possible to generalise
There were no significant differences in baseline to a larger group of patients and allow assumptions
characteristics between the groups and the number of about causal relations (Nilstun 1995). Before we started
cannulations performed by the two nurses in the the study a cross-over design was discussed, in which
groups (Table 1). There were no statistically significant patients would be their own controls and have two
differences in scores for insertion pain between the two intravenous catheters. However, we decided that using
groups. Mean pain score during intravenous such a design would be unethical.
cannulation was 1.74 in the LW group and 2.01 in the
control group (Table 2). A true experimental design must be characterised by
three essential elements: randomisation, manipulation
Both in the literature and in routine care a VAS score of and control (Jadad 1998). This is the ‘golden standard’
0–3 represents adequate analgesia (Mantha et al 1993). of ranking evidence from research (Jadad 1998,
In the present study 16.4% (10/61) in the LW group and Goodman 2000), but only if the trial is well designed
23.4% (15/64) in the control group rated a VAS >3; – and meticulously carried out (Goodman 2000). The

© AfPP 2006 Journal of Advanced Perioperative Care Vol 2 No 3 February 2006 77

Svensson et al Local warming to reduce pain

Local warming Control Local Control p-value

(LW) treatment warming (LW) treatment
n=61 n=64 n=61 n=64
Age: Mean VAS
years (range) 49 (17–79) 49 (17–81) score, cm 1.74 2.01 n.s.
(range) (0.1–4.8) (0.3–7.2)
male/female 31/30 40/24 VAS >3,
– n (%) 10 15 n.s.
(16.4%) (23.4%)
ASA stage:
I/II, n 47/14 48/16 Abbreviations n.s. = non-significant; VAS = visual analogue scale.

Table 2 Pain score during intravenous cannulation with

Performing nurse: or without local warming
MS/SR 29/32 22/42

Table 1 Patient group characteristics In the present study the patients were asked to report
pain intensity on a VAS measuring no pain (zero) to
maximum possible pain (ten). The VAS was chosen
present study was a randomised control trial study because it is a validated and reliable instrument (Scott
based on a sample size calculation, however; we could & Huskinsson 1976, Mantha et al 1993) and has been
not demonstrate that the intervention was successful. used in other interventional studies of pain on IVC
Nevertheless, the technique is easily performed and is insertion (Gerhardt et al 2001, Fetzer 2002, Usichenko et
inexpensive while other methods of pain reduction for al 2004). Questions we need to ask are whether the
IVC insertion require special equipment (N2O) and discrepancy between no pain and maximum possible
specialised staff (Gerhardt et al 2001) and may produce pain is too large? Can maximum possible pain be valid
pain in themselves – as is the case with subcutaneous in IVC insertion pain? Or should the highest possible
injection of LAs (Patterson et al 2000, Brown 2004). VAS score denote severe pain? Finally, is the VAS scale
Some methods, such as dermal analgesia with a eutectic valid for measuring IVC insertion pain at all? Further
mixture of Lidocaine and Prilocaine preparations studies evaluating pain on IVC insertion with different
produce additional costs (Selby & Bowles 1995, Fetzer pain instruments are needed.
2002). Moreover, Lidocaine and Prilocaine provide
sufficient local anaesthesia only after 60 minutes of Although we could not demonstrate that venous
application, with shorter application times making it dilatation produced by LW in preoperative patients had
ineffective (Fetzer 2002). any pain-reducing effect, we will recommend it because it
improves peripheral venous access (Mbamalu & Banerjee
Mean pain scores in the present study were 1.74 in the 1999, Lenhardt et al 2002) and this facilitates the insertion
LW group and 2.01 in the control group. Median pain (Lenhardt et al 2002). Although IVC is the most common
scores in Gerhardt et al’s study (2001) on healthy male procedure performed on perianaesthesia patients and
subjects with N2O intervention were 1.5 in the N2O group healthcare providers view the procedure as a quick,
and 3.1 in the control group. In Usichenko et al’s (2004) routine and simple skill, it is laden with anxiety and often
study using the cough trick the scores were 3.1 in the dreaded by the patient. A painful IVC can result in
treated versus 4.6 in the control group. It appears that the patient fear of needles and dissatisfaction. Nurses have a
control patients in the present study rated less pain than responsibility to work actively towards providing
did the control patients in both Gerhardt et al (2001) and consistent and appropriate pain relief and as patients’
Usichenko et al (2004). The reason for this could be advocates they have continuing responsibility to provide
cultural differences in expression of pain, as well as the their patients with the most humane care possible.
type and size of the intravenous catheter and the
competence of the IVC performers. The optiva
intravenous catheter has been shown to cause
significantly lower pain than the venflon catheter (Lucker This study was supported by grants from the
& Stahleber-Dilg 2003) and in the present study optiva Foundation for Medical Research at Örebro University
catheters were used. Davis (1998) points out that good Hospital.
technique, skill and vein selection will reduce the amount
of pain experience by the patient. Nurse anaesthetists in
Sweden insert several IVCs per day, which facilitates
skilfulness in the use of the technique. The nurses in the Brown D 2004 Local anaesthesia for vein cannulation: a
present study have been working as nurse anaesthetists comparison of two solutions Journal of Infusion Nursing
for seventeen and nineteen years, respectively. 27 (2) 85–88

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© AfPP 2006 Journal of Advanced Perioperative Care Vol 2 No 3 February 2006 79

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