Distraction using virtual reality for children during intravenous injections in an emergency department: A randomised trial.

AIM AND OBJECTIVES: To determine whether the virtual reality as a distracting intervention could reduce pain and fear in school-age children receiving intravenous injections at an emergency department. BACKGROUND: An intravenous injection is the most common invasive procedure that paediatric patients encounter in emergency department. School-age children seldom show their fear or discomfort during the procedure which may be ignored. DESIGN: A randomised controlled trial was conducted from December 2017-May 2018 and performed according to the CONSORT guidelines. METHODS: One hundred and thirty-six children aged 7-12 years were randomly allocated to receive either a routine intravenous injection procedure or one with an immersive virtual reality experience. Children were asked to rate their pain and fear along with their caregivers and nurses on the Wong-Baker FACES Pain Rating Scale and Children's Fear Scale, respectively. The time required for successful intravenous insertion was also assessed in the emergency department. Clinical trial registration was done (ClinicalTrials.gov.: NCT04081935). RESULTS: Pain and fear scores were significantly lower in the virtual reality group, as were the children's ratings as perceived by their caregivers and nurses. The children's ratings of pain and fear were positively correlated with the caregivers' ratings and the nurses' ratings as well. The time required for successful intravenous insertion was significantly lower in the virtual reality group. CONCLUSION: Visual reality intervention can effectively reduce the pain and fear during intravenous procedure in school-age children in emergency department. RELEVANCE TO CLINICAL PRACTICE: The results of this study indicate the feasible clinical value of virtual reality interventions during the administration of intravenous injections in school-age children in emergency departments.

The mask or the needle? Which induction should we go for?

PURPOSE OF REVIEW: This review summarizes the current evidence available to guide anaesthetists along the decision-making process between inhalational and intravenous anaesthesia when caring for paediatric patients. RECENT FINDINGS: A recent large randomized controlled trial in children with risk factors demonstrated a significant benefit of intravenous induction over inhalational induction with regards to respiratory adverse events. This difference is particularly pronounced in those with respiratory symptoms. SUMMARY: For children scheduled for elective surgery, intravenous induction has significant advantages with regards to reduced respiratory adverse events and for less postoperative behavioural disturbances, it may be associated with more anxiety at the time of induction. The anaesthetist in charge of the patient needs to weigh up the balance between the clinical risk of respiratory adverse events, the 'veins on offer', the level of anxiety and previous experiences of the child and his/her parents.

Effect of high-dose paracetamol on needle procedures in children with cancer--an RCT.

AIM: The aim was to investigate whether children experience less pain, fear and/or distress when they receive high-dose paracetamol compared with placebo, using a needle insertion in a subcutaneously implanted intravenous port as a model. METHODS: Fifty-one children ranging from 1 to 18 years of age being treated in a paediatric oncology setting were included consecutively when undergoing routine needle insertion into a subcutaneously implanted intravenous port. All children were subjected to one needle insertion following topical anaesthetic (EMLA) application in this double-blind, placebo-controlled RCT, comparing orally administered paracetamol (n = 24) 40 mg/kg body weight (max 2000 mg) with placebo (n = 27). The patients' pain, fear and distress were reported by parents, nurses and children (≥7 years of age) using 0- to 100-mm visual analogue scales (VAS). In addition, pain observation, procedure time and cortisol reduction were assessed. RESULTS: No differences between the paracetamol and the placebo group were found with respect to demographic characteristics. According to VAS reports, paracetamol did not reduce pain, fear and distress compared with placebo. Pain observation, cortisol reduction and procedure time did not differ between the study groups. CONCLUSION: Paracetamol provides no additive effect in reducing pain, fear and distress when combined with topical anaesthesia in children undergoing port needle insertion.

[Reducing fear in preschool children receiving intravenous injections].

BACKGROUND & PROBLEM: Our pediatric medical ward administers an average of 80 intravenous injections to preschool children. We found that 91.1% exhibit behavior indicative of fear and anxiety. Over three-quarters (77.8%) of this number suffer severe fear and actively resist receiving injections. Such behavior places a greater than normal burden on human and material resources and often gives family members negative impressions that lower their trust in the healthcare service while raising nurse-patient tensions. Using observation and interviews, we found primary factors in injection fear to be: Past negative experiences, lack of adequate prior communication, measures taken to preemptively control child resistance, and default cognitive behavioral strategies from nursing staff. PURPOSES: This project worked to develop a strategy to reduce cases of severe injection fear in preschool children from 77.8% to 38.9% and achieve a capacity improvement target for members of 50%. RESOLUTIONS: Our team identified several potential strategy solutions from research papers and books between August 1st, 2009 and April 30th, 2010. Our proposed method included therapeutic games, self-selection of injection position, and cognitive behavioral strategies to divert attention. Other measures were also specified as standard operating procedures for administering pediatric intravenous injections. RESULT: We applied the strategy on 45 preschool children and identified a post-injection "severe fear" level of 37.8%. CONCLUSIONS: This project was designed to reduce fear in children to make them more accepting of vaccinations and to enhance children's positive treatment experience in order to raise nursing care quality.

Randomized interventions for needle procedures in children with cancer.

The aim of this study was to examine whether children experience less fear, distress and pain connected to a routine needle insertion in an intravenous port when subjected to an intervention: blowing soap bubbles or having a heated pillow vs. standard care. Twenty-eight children, 2-7 years, cared for at a paediatric oncology unit, undergoing a routine needle insertion in an intravenous port were included consecutively. All children were subjected to two needle insertions; at the first they received standard care, and at the second standard care + a randomized intervention. Parents and nurses assessed children's fear, distress and pain on 0-100 mm visual analogue scales. According to parents' report, children experienced less fear when subjected to intervention vs. standard care reported by parents (P < 0.001). Children also experienced less fear (P < 0.05) and distress (P < 0.05) when subjected to standard care + blowing soap bubbles vs. standard care (n = 14), and less fear when subjected to standard care + heated pillow vs. standard care (P < 0.05). Nurses' reports did not show any differences for standard care + intervention vs. standard care. Blowing soap bubbles or having a heated pillow is more effective than standard care in reducing children's fear and distress in needle procedures, according to parents' report.

A good "doctor" is hard to find: Assessing uncredentialed expertise in assisted injection.

This article examines how laypeople assess uncredentialed expertise in a high-risk practice: assisted injection, in which one person injects another with illicit drugs. In metropolitan areas in the US, about 2.3% of the population injects illicit drugs. Injection assistance is common and recipients of injection assistance are at high-risk for injury, overdose, and infection. Yet little is known about how injection recipients attempt to reduce these risks by assessing their injection provider's expertise. Drawing on ethnographic observations and interviews from 2015 to 2018 with 59 people who inject drugs in San Francisco, California, this article examines how people who need injection assistance assess injection provider expertise. It finds that people use an informal hierarchized decision-tree approach of three measures of trust to assess expertise: strong personal ties, referrals, or professional rhetoric. Using measures of trust to assess expertise minimizes some forms of risk by increasing the chance that injection providers are motivated to help them. However, this strategy offers little protection against technically unskilled providers. Moreover, it may increase health risks because people employ few self-protective strategies in trust-based relationships. This research offers new insights for theorization on expertise and trust in social contexts where high-risk skills are in demand. This approach also has implications for public health research and interventions for reducing risks related to lay medical practices, particularly those in assisted injection.

Effect of communication on pain during intravenous cannulation: a randomized controlled trial.

BACKGROUND: Clinicians frequently warn patients of discomfort before potentially painful procedures, despite the lack of evidence that such communications are helpful. We aimed to compare two communications (one with, and the other without, a warning of a 'sting') immediately before i.v. cannulation in order to measure differences in perceived pain by patients during the procedure. METHODS: Randomly assigned patients awaiting elective surgery received a communication immediately before i.v. cannulation consisting of either 'I am going to apply the tourniquet and insert the needle in a few moments. It's a sharp scratch and it may sting a little' (Group S) or 'I am going to apply the tourniquet on the arm. As I do this many people find the arm becomes heavy, numb and tingly. This allows the drip to be placed more comfortably' (Group NS). Cannulation pain was measured by a 0-10 verbal numerical rating score (VNRS) and five-point Likert scale. RESULTS: Of 101 participants, 49 were allocated to Group S and 52 to Group NS. Median VNRS pain scores with inter-quartile ranges (IQR) were 1 and 2, respectively, for both groups. Median Likert scores were 3 in Group S and 2 in Group NS with an IQR of 1 for both groups (P = 0.13). Six participants vocalized pain in Group S and none in Group NS (P = 0.01). Three participants withdrew their arm spontaneously in Group S and none in Group NS (P = 0.11). CONCLUSIONS: Warning patients of a 'sting' before i.v. cannulation may not be helpful.

Effectiveness of Cognitive-behavioral Program on Pain and Fear in School-aged Children Undergoing Intravenous Placement.

PURPOSE: This study aimed to evaluate the effects of cognitive-behavioral program on pain and medical fear in hospitalized school-aged children receiving intravenous (IV) placement. METHODS: This study used an quasi-experimental design. Thirty-five participants were assigned to the experimental group and 33 to the control group in the acute internal medicine ward of a children's hospital. The cognitive-behavioral program entailed having the patients read an educational photo book about IV placement before the procedure and having them watch their favorite music video during the procedure. The outcome measures were numeric rating scales for pain intensity and fear during the procedure. RESULTS: After applying the cognitive-behavioral program, the mean scores on pain and fear decreased in the experimental group. However, the difference in pain intensity between these two groups was nonsignificant. The intensity of fear in the experimental group was significantly lower than that in the control group. CONCLUSION: In this study, the cognitive-behavioral program used with school-aged hospitalized children promoted less fear during IV placement. The results of this study can serve as a reference for empirical nursing care and as care guidance for clinical IV injections involving children.

Compensatory and mimetic conditioned responses to effects of heroin in addicted persons.

Study 1: The aim of this study was to analyze in persons detoxified of heroin, compensatory conditioned responses (CCRs) that are opposite to the unconditioned physiological, and subjective effects that are induced by this substance. The procedure consisted in presenting slides with images of neutral stimuli (NSs) and conditioned stimuli (CSs) of heroin to both non-addicted and detoxified addicted persons. The evaluated responses were heart rate (HR) and desire for heroin (DH). Study 2: The aim was to facilitate the emission of mimetic conditioned responses (MCRs) to the unconditioned physiological, and subjective effects of heroin in detoxified heroin addicts. Three different stimulus series were manipulated: SA, during which the participant remained alone; SB, administration of a needle prick given by the researcher; SC, performance of the "pump" ritual without drug by the participants. The responses measured were HR and DH. The results of both studies are considered, respectively, to be indicators of compensatory and mimetic conditioned responses.

Diabetes Fear of Injecting and Self-Testing Questionnaire: a psychometric evaluation.

OBJECTIVE: To study the psychometric properties of the Diabetes Fear of Injecting and Self-Testing Questionnaire (D-FISQ). RESEARCH DESIGN AND METHODS: Two groups of patients were studied. Sample A consisted of 252 insulin-treated diabetes patients. Sample B incorporated 24 insulin-treated patients with high scores (> or = 95th percentile) on the D-FISQ. Test-retest correlations were assessed in both samples. Discriminant and convergent validity of the D-FISQ were assessed with questionnaires concerning fear of hypoglycemia, trait anxiety, and fear of bodily injury, illness, or death. To evaluate criterion-related validity, sample B participated in a behavioral avoidance test (BAT), in which the current level of avoidance of either self-injecting or self-testing was determined. Exploratory factor analysis (EFA) was performed to study whether 2 factors (fear of self-injecting [FSI] and fear of self-testing [FST]) could be detected. RESULTS: Test-retest correlations ranged from 0.50 to 0.68 (P < 0.001). Correlations between D-FISQ and fear of hypoglycemia, trait anxiety, and fear of bodily injury, illness, or death ranged from 0.28 to 0.45 (P < 0.001). Patients who refused to do a BAT for self-injecting or self-testing had higher scores on FSI (P = 0.095) and FST (P = 0.01). EFA yielded 2 separate factors, FSI and FST. CONCLUSIONS: Results from this study support reliability and validity of the D-FISQ, a self-report instrument that can be used for both clinical and research purposes.

Behavioral management of children's distress during chemotherapy.

Three children, aged 11-14, undergoing cancer chemotherapy were coached in cue-controlled muscle relaxation, controlled breathing, pleasant imagery and positive self-talk during chemotherapy venopunctures. Using a multiple baseline across subjects design, 46-68% reductions from baseline levels of observed behavioral distress during venopunctures were found during intervention. Medical personnel and self-report ratings of the children's distress during venopunctures also decreased during intervention. Parental ratings of children's distress, however, did not change. Methodological issues in inpatient treatment of cancer patients and the self-report assessment of children's distress are discussed.

Disgust, anxiety, and vasovagal syncope sensations: a comparison of injection-fearful and nonfearful blood donors.

Although research has implicated disgust in the fainting response observed in blood-injection-injury (BII) phobia, this finding has not been consistently observed in the literature. The present study further examines the relationship between disgust and fainting symptoms among injection-fearful (n=108) and nonfearful (n=338) blood donors. Volunteers from community blood drives provided pre-donation levels of anxiety and disgust towards giving blood and completed a standardized measure of vasovagal reactions (fainting) to blood donation after giving blood. As predicted, injection-fearful participants reported significantly more pre-donation anxiety and disgust compared to nonfearful participants. Injection-fearful donors also reported experiencing more fainting symptoms during blood donation and found the donation experience more unpleasant than did nonfearful participants. Although pre-donation disgust and anxiety levels each uniquely predicted fainting symptoms among nonfearful donors, only pre-donation anxiety uniquely predicted fainting symptoms among injection-fearful donors. Implications of these findings for conceptualizing the disgust-faint relationship in BII phobia are discussed.

Helping preschool leukemia patients and their parents cope during injections.

Taught 4 preschool leukemia patients (ages 3-5) to engage in specific coping behaviors before and during painful intramuscular and intravenous injections. Parents were taught to coach their children in the use of the coping behaviors. Intervention was delivered in a multiple baseline across-subjects design. Parent and child behavior was coded using the Child-Adult Medical Procedure Interaction Scale-Revised (CAMPIS-R, Blount, Powers, & Sturges) and Observation Scale of Behavioral Distress (OSBD, Elliott, Jay, Woody). Parents and nurses rated child behavior as well. Results indicated that parents learned coping-promoting behaviors, children learned specific coping behaviors, and children displayed less behavioral distress. Maintenance of behavior change was addressed. Contributions of this study to the current literature on children's coping with invasive medical procedures and implications for future research and clinical practice are discussed.

Patients' perceptions of pain with spinal, intramuscular, and venous injections.

Most of 46 patients believed that spinal injection would be more painful than intramuscular or intravenous injections. The reverse proved true: spinal injections were perceived to be less painful than the other two procedures. Intramuscular injections should be avoided. Local anaesthesia should be given for lumbar punctures and intravenous cannulation.