Pain Management for Vascular Access Procedures Policy

1. Policy Statement

It is the policy of this organization that pain associated with venipuncture and vascular access device insertion shall be systematically assessed using age-appropriate and developmentally suitable tools, and that evidence-based pharmacologic and nonpharmacologic interventions shall be implemented for all patients across the lifespan, with particular attention to neonates, infants, children, and adults with needle phobia or cognitive impairment, to minimize procedural pain, reduce cumulative distress, and support first-attempt insertion success.

2. Purpose

This policy exists to:

• Establish the standard that all patients undergoing venipuncture or vascular access device insertion are entitled to appropriate pain management
• Define age- and developmentally appropriate pain assessment tools across the lifespan
• Identify and require mitigation of institutional and clinician-level barriers to pain management implementation
• Specify evidence-based nonpharmacologic and pharmacologic interventions for neonates, infants, pediatric patients, and adults
• Promote first-attempt success strategies that reduce cumulative procedural pain
• Ensure patient and caregiver education regarding realistic expectations and available pain reduction strategies

3. Scope

This policy applies to:

• All clinical personnel performing venipuncture, peripheral intravenous catheter insertion, central venous access device insertion, and other vascular access procedures
• All care settings where vascular access procedures are performed, including acute inpatient, ambulatory, emergency, perioperative, intensive care, and home care settings
• All patient populations, from premature neonates through elderly adults
• Caregivers and parents present during vascular access procedures

4. Policy Requirements

4.1 Patient and Caregiver Education

4.1.1 Patients and caregivers shall receive clear information about realistic expectations regarding potential pain or discomfort associated with vascular access procedures prior to the procedure.

4.1.2 Patients and caregivers shall be actively engaged in shared decision-making to identify and implement pain reduction strategies.

4.1.3 Clinicians shall employ interventions that increase first-attempt success with vascular access device insertion. Research demonstrates that patient experience with vascular access management directly influences satisfaction with overall hospitalization, and that structured vascular access team approaches are associated with improved pain perception compared to placement by bedside nurses alone.¹

4.2 Barriers to Pain Management

4.2.1 Clinicians shall identify and address institutional and individual barriers that influence the use of pain management strategies, including:

• Underestimation of procedural pain
• Excessive focus on technical task completion over patient experience
• Time constraints and workload pressures
• Lack of standing orders or clinical protocols for pain management
• Cost considerations

4.2.2 Organizations shall implement standing orders, clinical protocols, and sufficient supply availability to remove barriers to timely pain management for vascular access procedures.

4.3 Developmental Considerations and Long-Term Impact

4.3.1 Clinicians shall understand the neurobiological impact of procedural pain across developmental stages when selecting and implementing pain management strategies.²

4.3.2 Preterm and Neonatal Populations. Preterm infants possess sensitive, developing nervous systems. Research has identified long-term changes in response to pain and stress during preterm hospitalizations, including reduced white matter microstructure, altered subcortical gray matter development, and dorsal horn central desensitization. Pain management for all procedures in this population is a clinical imperative.

4.3.3 Early and Middle Childhood. Repeated needle-related procedures during early to middle childhood significantly increase the risk of long-term consequences, including procedural anxiety and subsequent hospital avoidance behaviors.³ Pain management shall be routinely implemented to reduce these risks.

4.3.4 Adolescent Populations. Adolescents experience comparable levels of pain and distress during peripheral intravenous catheter insertion as younger children, yet consistently receive fewer pain relief interventions. Clinicians shall provide equivalent pain assessment and management for adolescent patients.

4.4 Pain Assessment by Developmental Stage

4.4.1 Clinicians shall use validated, age-appropriate pain assessment tools for all patients undergoing vascular access procedures.

4.4.2 Infants

4.4.2.1 Pain assessment in infants shall evaluate crying patterns, facial expressions, and body posture or limb movements using validated tools, including:

• Neonatal Infant Pain Scale (NIPS)
• Premature Infant Pain Profile (PIPP)
• Neonatal Pain Agitation and Sedation Scale (NPASS)
• Face, Legs, Activity, Cry, Consolability (FLACC) scale
• Modified Behavioral Pain Scale (MBPS)
• Newborn Comfort Behavior Scale (NCBS)

4.4.3 Toddlers

4.4.3.1 Pain assessment in toddlers shall rely on behavioral observation, including facial expressions, bodily movement, and crying characteristics. The FLACC scale shall be used for this age group.

4.4.4 Preschool and School-Age Children

4.4.4.1 Children in this developmental stage shall be encouraged to self-report pain. The FACES® pain rating scale is validated for pediatric self-report. The FLACC scale may be used in conjunction with self-report for preschool-age children. School-age children may use numerical pain scales effectively.

4.4.5 Children with Intellectual Disabilities

4.4.5.1 Children with intellectual disabilities may have limited ability to communicate pain verbally and frequently experience greater pain and anxiety during needle-related procedures compared to children without disabilities. The FLACC scale shall be used for this population.

4.4.5.2 Clinicians shall not assume lower pain intensity in patients with intellectual disabilities based solely on limited verbal communication.

4.4.6 Adults

4.4.6.1 Patient self-report shall be the primary and most valid indicator of pain in adult populations. Clinicians shall recognize that asking about pain in different ways may be necessary to obtain accurate assessment.

4.4.6.2 For adults with mild-to-moderate cognitive impairment, validated tools including the Pain in Advanced Dementia (PAINAD) scale and Doloplus 2 shall be used for pain assessment.

4.5 Pain Management for Neonates and Infants

4.5.1 Every painful procedure performed on neonates and infants shall receive appropriate pain management. Pain management shall not be omitted on the basis of presumed tolerance or clinical urgency alone.

4.5.2 Parental Involvement in Neonatal Pain Management

4.5.2.1 When parents are present during painful procedures, their involvement in pain management shall be actively encouraged and supported.

4.5.2.2 Education provided to parents shall address infant pain responses and clarify the parental role in pain management. Clinical teams shall consider timing of procedures and visitation policies to maximize opportunities for parental involvement.

4.5.3 Nonpharmacologic Interventions for Neonates and Infants

4.5.3.1 The following nonpharmacologic interventions shall be available and used for neonatal and infant procedural pain management:

• Oral sucrose or glucose administration
• Non-nutritive sucking using a pacifier
• Breastfeeding during procedures
• Olfactory and auditory stimulation
• Skin-to-skin care (Kangaroo Care)
• Therapeutic massage
• Swaddling
• Facilitated tucking
• Acupressure
• White noise, music, or lullabies

4.5.3.2 Research demonstrates that facilitated tucking, oral sucrose, and Kangaroo Care decrease both behavioral and physiologic pain responses when used alone or in combination in preterm infants.

4.5.3.3 Evidence supports 25% dextrose as non-inferior to 24% sucrose for heel lancing in preterm infants. Repeating sucrose doses during heel prick procedures in preterm infants does not provide additional pain reduction benefit and is not required. Concurrent use of swaddling and sucrose demonstrates additive benefit for pain intensity reduction during venous blood sampling.

4.5.4 Pharmacologic Considerations for Neonates and Infants

4.5.4.1 Lidocaine/prilocaine cream (EMLA) shall not be used in neonates. Evidence demonstrates this topical anesthetic is inferior to sucrose or breastfeeding for pain control, and significant safety concerns exist, including risk of methemoglobinemia and increased skin blanching.

4.6 Pain Management for Pediatric Patients

4.6.1 Parental Role and Participation

4.6.1.1 Parents shall be encouraged to take an active role in managing their child’s procedural pain. Research demonstrates that parental presence is beneficial for children’s pain response, particularly when parents successfully implement distraction techniques.

4.6.1.2 Parents shall be instructed not to restrain or forcibly “hold down” a child during procedures, as this approach may increase fear. Emphasis shall be placed on supportive “hugging” positioning and use of distraction techniques.

4.6.2 Distraction Techniques

4.6.2.1 Distraction techniques shall be used as a standard component of procedural pain management for school-aged children and children with cancer. Effective distraction modalities include:

• Television, DVDs, videos, computers, and tablets
• Smartphones and video games
• Virtual reality systems
• Humanoid robots
• Therapeutic clowning
• Breathing exercises
• Hypnosis
• Age-appropriate toys

4.6.2.2 For toddlers specifically, peekaboo games, blowing bubbles, and reading books shall be offered as age-appropriate distraction modalities.

4.6.3 Virtual Reality Applications

4.6.3.1 Virtual reality technology shall be considered for procedural pain management in pediatric populations including children ages 4–18 years, children with kidney disease undergoing venipuncture, patients receiving intrathecal pump refills, and pediatric oncology patients.

4.6.3.2 Virtual reality is generally well-tolerated; however, the risk of cybersickness shall be considered and monitored during use.

4.6.4 Music Intervention

4.6.4.1 Music intervention shall be considered as an analgesic strategy for infants and children. Classical music, children’s music, and pop music have demonstrated the greatest impact on pain alleviation. Delivery methods may include headsets, earphones, or environmental speakers.

4.6.5 Vibrating Cold Devices

4.6.5.1 Vibrating cold devices shall be available and used for procedural pain management in appropriate pediatric patients. These devices provide distraction, reduce anxiety, and decrease self-reported, parent-reported, and observer-reported pain through gate control mechanisms.

4.6.6 Additional Nonpharmacologic Approaches

4.6.6.1 Massage therapy may be used to alleviate distress associated with burns and cancer in pediatric populations.

4.6.6.2 Acupressure applied by a trained clinician shall be considered for reducing venipuncture pain in pediatric patients based on randomized controlled trial evidence.

4.6.6.3 Application of ice for several minutes prior to venipuncture shall be considered as a cost-effective and efficacious pain reduction method.

4.6.7 Pharmacologic Interventions for Pediatric Patients

4.6.7.1 Topical anesthetics shall be used for pediatric venipuncture when preparation time permits. All topical anesthetics are effective for pain prevention during venipuncture in children per large randomized controlled trial evidence. Available options and their approximate onset times include:

• 10% lidocaine spray: 5-minute application time
• Lidocaine HCL 2% gel: onset at 5 minutes, duration 20–30 minutes
• Lidocaine/prilocaine cream (EMLA): 60-minute application
• Ethyl chloride spray: 5-second application
• Lidocaine cream: 30-minute application

4.6.7.2 Topical lidocaine/prilocaine is more effective than subcutaneous needleless lidocaine for PIVC insertion; however, needleless lidocaine shall be considered when treatment delays are contraindicated.

4.6.7.3 Vapocoolant spray shall be considered as an option associated with significant pain reduction compared to placebo.

4.7 Pain Management for Adult Patients

4.7.1 Needle Phobia Recognition

4.7.1.1 Clinicians shall recognize that some patients experience significant fear of needles (needle phobia) and that appropriate pain management strategies may reduce this fear response.³ Needle phobia shall be documented and addressed proactively.

4.7.2 Nonpharmacologic Interventions for Adults

4.7.2.1 The following nonpharmacologic interventions shall be available and offered for adult procedural pain management:

• Heat application: Heat packs applied before PIVC insertion reduce both pain and anxiety
• Cold therapy: Cold therapy before port needle removal is associated with reduction in pain and anxiety
• Aromatherapy: Inhalation aromatherapy has been associated with decreased pain during port needle access procedures
• Behavioral interventions: Distraction, relaxation techniques, breathing exercises, and hand massage
• Valsalva maneuver: The Valsalva maneuver can alleviate pain severity in appropriate non-cardiac patients; this technique shall be avoided in patients with retinopathy and intraocular lens implantation due to associated rise in intraocular pressure
• Combined cold and vibration: Simultaneous application of cold and vibration has demonstrated effectiveness for both pain and anxiety reduction during intravenous catheterization

4.7.3 Pharmacologic Interventions for Adults

4.7.3.1 Injectable anesthetics. Intradermal lidocaine shall be considered to provide local anesthesia prior to PIVC insertion. Two percent lidocaine demonstrates greatest efficacy. Bacteriostatic saline containing benzyl alcohol possesses analgesic properties but is less effective than lidocaine.

4.7.3.2 Lidocaine buffered with saline provides comparable pain relief during PICC insertion to lidocaine buffered with bicarbonate.

4.7.3.3 Topical anesthetics. Topical lidocaine/prilocaine (EMLA) is effective for adult venous cannulation pain. Intradermal injection of lidocaine using microneedle devices shall be considered for rapid local anesthesia when available.

4.7.3.4 Alternative topical agents. Topical diclofenac and topical ketamine have both demonstrated efficacy in pain reduction during peripheral intravenous catheter insertion and may be considered as alternatives.

4.7.3.5 Vapocoolant spray. Vapocoolant spray shall be considered to reduce pain during PIVC insertion and blood collection. Clinicians shall inform patients that mild discomfort may occur during application.

4.7.3.6 Pre-treatment lidocaine technique. Application of room-temperature lidocaine (1–2 mL) to the skin prior to a 1% lidocaine subcutaneous injection for bedside procedures shall be considered, with particular benefit demonstrated for PICC insertion.

5. Compliance

5.1 Key Performance Indicators

• Rate of age-appropriate pain assessment documentation prior to vascular access procedures (target: ≥95%)
• Rate of pain management intervention documentation for pediatric vascular access procedures (target: ≥95%)
• Rate of topical anesthetic use for elective pediatric venipuncture when preparation time permits (target: ≥80%)
• Patient-reported satisfaction with pain management during vascular access procedures (measured by patient experience surveys)
• Rate of parental involvement documentation for neonatal and infant vascular access procedures (target: ≥90%)
• Incidence of EMLA use in neonates (target: 0%)
• Rate of first-attempt PIVC insertion success (tracked by vascular access team)

5.2 Enforcement

Non-compliance with this policy shall be addressed through the organization’s standard performance improvement and professional accountability processes, including documentation audits, targeted education, peer feedback, and escalation to unit leadership as appropriate.

6. Exceptions

Exceptions to pain management requirements may occur in emergent clinical situations where immediate life-saving treatment is required and preparation time for pain management is not available. Any such exception shall be documented in the patient health record with clinical justification. Planned procedures shall not be exempted from pain management requirements on the basis of time constraints alone, and institutional workflow shall be designed to accommodate routine pain management for vascular access.

7. Related Documents

• Vascular Access Device Selection and Insertion Policy
• Vascular Access Device Insertion Policy
• Peripheral Intravenous Access: Difficult Intravenous Access (DIVA) Protocol
• Informed Consent for Vascular Access Policy
• Patient Education — Infusion Therapy Policy
• Neonatal Intensive Care Pain Management Protocol
• Pediatric Procedural Sedation Policy

8. Revision History

References