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Recognizing and easing procedural pain

By: Yvonne D’Arcy, MS, CRNP, CNS
Most healthcare practitioners think of pain as something that goes with the territory when patients undergo procedures, such as venipuncture, I.V. line placement, and suctioning. But that’s not how patients see—and feel—it.
Patients report that procedures, including femoral line removal, surgical drain removal, tracheal suctioning, and even turning in bed, are painful and that analgesics effectively reduce procedural pain. Yet, providing medication before and during procedures is the exception, not the rule.
Even when a practitioner does administer an analgesic, the patient may experience pain because the dose or the technique is inadequate. For example, some practitioners use a local anesthetic to decrease pain during I.V. line insertions and simple procedures, such as suturing. But often, the provider doesn’t allow enough time for the anesthetic to relieve the pain, and the patient doesn’t experience the anesthetic benefit until after the procedure.
When patients rate pain
In one study, 1,171 patients rated emergency department (ED) procedures from most painful to least painful as follows:
1. nasogastric intubation
2. fracture reduction
3. abscess drainage
4. digital block
5. urinary catheter insertion.
Procedures such as I.V. line insertion, lumbar puncture, and suturing were ranked as less painful than the top five—but still painful. Practitioners also ranked the procedures from most painful to least painful. Interestingly, the practitioners’ rankings did not correlate with the patients’ rankings.

How to ease the pain
In another study, lidocaine gel and either lidocaine spray or normal saline were administered to ED patients undergoing nasogastric intubation. In the lidocaine spray group, the pain scores were significantly lower than those of the normal saline group.
Oncology patients report that the pain of bone marrow aspiration is severe. In two studies, lorazepam effectively reduced the patients’ memories of this procedure. The patients who didn’t receive the sedative reported more pain and experienced the pain as more intense.
For most patients, an I.V. insertion can be painful. A topical anesthetic cream such as EMLA (lidocaine and prilocaine) or Iontocaine (lidocaine and epinephrine) can provide pain relief for pediatric and adult patients. Use EMLA cautiously in neonates less than 1 month old and in infants less than 12 months old who are receiving methemoglobin-inducing agents, such as sulfonamides and acetaminophen, because of the risk of methemoglobinemia.
Infiltrating an I.V. site with lidocaine or another local anesthetic helps numb the area and makes placing an I.V. line less traumatic.
Using a Synera patch (lidocaine and tetracaine) makes the procedure even easier for the patient and doesn’t require a needlestick. This patch has an integrated oxygen-activated heating component that increases delivery of the two anesthetics.
For femoral catheter insertion, infiltration or injection of lidocaine through the catheter port provided excellent pain relief in two studies. Patients reported mild levels of pain during insertion and removal.

Assessing pediatric pain
Most patients can tell you about their pain. But some can’t because of their age. And that puts them at risk for receiving inadequate pain relief. Remember, children as young as age 3 can have painful memories of procedures.
To assess pain in young children, use a tool such as the FLACC (faces, legs, activity, cry, consolability) scale. For neonates, you can use the CRIES scale and for older children, you can use the standard 0 to 10 pain scale or FACES.

Relieving pediatric pain
Children can benefit from age-appropriate doses of analgesics and carefully administered local anesthetics. For pain relief during circumcision, the American Society of Anesthesiologists recommends penile blockade, a regional anesthesia technique. Other recommendations include EMLA before circumcision and subcutaneous ring block, which provides better pain relief than penile nerve block.
A noninvasive analgesic, such as a sugar-solution pacifier, can also relieve pain during a procedure such as circumcision. This technique activates the analgesic mu receptors that trigger the release of endogenous opioids. Though the technique is effective, you should not use it as the sole means of pain relief in infants undergoing procedures.
You can use simple relaxation techniques, as well. Use distraction by steering the conversation away from the procedure. Instead, focus on discussing family, friends, or favorite activities. For an older child, try relating the patient’s response to the procedure to the actions of a favorite superhero.

Assessing pain in intubated patients
Like children, adults undergoing certain procedures—intubation, for example—can’t tell you about their pain. Because intubated patients are usually given a sedative, many clinicians assume they can’t experience pain. Unfortunately, that’s not true. Despite the sedation, the body mechanisms still recognize painful stimuli for what it is. In one study, 55% of patients remembered their intensive care experience, could identify individual nurses by their voices, and were able to describe events during the time they were intubated and sedated.
To assess pain in critically ill intubated patients, you can use the Payen behavioral pain scale (BPS) or the Pain Observation Tool. Either one can provide an indication of pain, even though the patient is sedated with a drug such as propofol.
In the Thunder Project II, a study sponsored by the American Association of Critical-Care Nurses, several procedures commonly performed on critical-care patients were explored. Reports from 6,201 patients found that all the procedures were painful to some degree. Children rated tracheal suctioning as 2.8 to 3.0 on a 1-to-5 pain intensity scale. Adolescents reported wound-dressing changes, turning, tracheal suctioning, and wound drain removal as 5 to 7 on a 0-to-10 pain intensity scale. And adults scored turning in bed as 2.65 to 4.93 on a scale of 1 to 10. Sadly, only 20% of the patients received opioids for analgesia before their procedures. And, of course, many of these procedures are performed every day on critically ill patients with little or no thought given to the pain.
Clearly, intubated critically ill patients experience pain. In a group of 5,957 patients undergoing a procedure, clinicians noted behaviors that indicate pain—moaning, grimacing, rigidity, wincing, eye closing, and fist clenching. A 2001 study using a BPS found that critically ill intubated patients, even those who were heavily sedated, demonstrated pain behaviors. In 2006, these findings were replicated: Using a turn in bed as a pain stimulus, researchers found that critically ill intubated patients demonstrated measurable pain behaviors at all levels of sedation.
The keys to managing pain in these vulnerable patients are understanding that they are experiencing pain and recognizing that you can assess their pain.

Advocate procedural pain relief
When you understand the scope and adverse effects of procedural pain, you can advocate adequate pain relief for patients undergoing procedures of all kinds. Remember, we have a responsibility to assess and relieve the pain of all our patients. That includes patients undergoing “routine” procedures.

Selected references
Brown J. Using lidocaine for peripheral IV insertions: patient’s preferences and pain experiences. Medsurg Nurs. 2003;12(12):95-100.
Payen JF, Bru O, Bosson JL, et al. Assessing pain in critically ill sedated patients by using a behavioral scale. Crit Care Med. 2001;29(12):1-11.
Puntillo KA. Dimensions of procedural pain and its analgesic management in critically ill surgical patients. Am J Crit Care. 1994;3:116-122.
Puntillo KA, White C, Morris A, et al. Patients’ perceptions and responses to procedural pain: results from the Thunder Project II. Am J Crit Care. 2001;10(4):238-251.
Puntillo KA, Morris A, Thompson C, Stanik-Hutt J, White C, Wild L. Pain behaviors observed during six common procedures: results from the Thunder Project II. Crit Care Med. 2004;32(2):421-427.
For a complete list of selected references, visit

Yvonne D’Arcy, MS, CRNP, CNS, is a Pain Management and Palliative Care Nurse Practitioner at Suburban Hospital in Bethesda, Maryland.

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