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Effectiveness of External Cold and Vibration for Procedural Pain Relief During
Peripheral Intravenous Cannulation in Pediatric Patients
Article in Pain management nursing: official journal of the American Society of Pain Management Nurses · June 2014
DOI: 10.1016/j.pmn.2014.03.003 · Source: PubMed
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Sevil Inal
Istanbul University
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- ABSTRACT:
The aim of this study was to investigate the effect of external cold and
vibration stimulation via Buzzy on the pain and anxiety level of chil-
dren during peripheral intravenous (IV) cannulation. This study was a
prospective, randomized controlled trial. The sample consisted of 176
children ages 7 to 12 years who were randomly assigned to two
groups: a control group that received no peripheral IV cannulation
intervention and an experimental group that received external cold
and vibration via Buzzy. The same nurse conducted the peripheral IV
From the *Nursing Department, cannulation in all the children, and the same researcher applied the
Karamano glu Mehmet Bey external cold and vibration to all the children. The external cold and
University, Karaman, Turkey; †Selcuk
the vibration were applied 1 minute before the peripheral IV cannu-
University, Institute of Health Science,
Surgical Nursing, Konya, Turkey; lation procedure and continued until the end of the procedure. Pre-
‡
Istanbul University, Health Science procedural anxiety was assessed using the Children’s Fear Scale, along
Faculty, Midwifery Department, with reports by the children, their parents, and an observer. Proce-
Istanbul, Turkey.
dural anxiety was assessed with the Children’s Fear Scale and the
Address correspondence to Nejla parents’ and the observer’s reports. Procedural pain was assessed us-
Canbulat, PhD, Department of ing the Wong Baker Faces Scale and the visual analog scale self-reports
Nursing, Karamanoglu Mehmet Bey
University, Karaman 70100, Turkey.
of the children. Preprocedural anxiety did not differ significantly.
E-mail: ncanbulat@gmail.com Comparison of the two groups showed significantly lower pain and
anxiety levels in the experimental group than in the control group
Received October 6, 2012;
during the peripheral IV cannulation. Buzzy can be considered to
Revised March 12, 2014;
Accepted March 17, 2014. provide an effective combination of coldness and vibration. This
method can be used during pediatric peripheral IV cannulation by
The authors report there are no pediatric nurses.
conflicts of interest.
Ó 2015 by the American Society for Pain Management Nursing
1524-9042/$36.00
Ó 2015 by the American Society for INTRODUCTION
Pain Management Nursing
http://dx.doi.org/10.1016/ The simple insertion of a needle has been shown to be one of the most frightening
j.pmn.2014.03.003 and distressing medical procedures for hospitalized children (Baxter et al., 2011;
depending on whether the child was left- or right- responses of the children, their parents, and the ob-
handed. In left-handed children, the peripheral IV can- servers were scored blindly.
nulation was inserted in the dorsum of the right hand. The children’s pain levels immediately after the pe-
In right-handed children, it was inserted in the dorsum ripheral IV cannulation procedure were also assessed
of the left hand. External cold and vibration stimulation via self-reports using the Wong Baker Faces Scale
were applied with Buzzy. Buzzy is a reusable 8 5 (WBFC) and the visual analog scale (VAS)
2.5-cm plastic bee containing a battery and vibrating (Hockenberry & Wilson, 2009; Wewers & Lowe,
motor. Buzzy was designed especially for pain control 1990). The WBFC is a scale ranging from 0 to 10,
in children and adults. An ice pack is placed under the consisting of six cartoon faces that range from a
device. The combination of coldness and vibration neutral expression (0 ¼ very happy/no pain) to a
with Buzzy is considered more effective than the use screaming face (10 ¼ hurts more than you can
of cold or vibration. In Turkey, routine nonpharmaco- imagine) (Hockenberry & Wilson, 2009). The VAS is
logic methods are not used to reduce the pain and anx- a measurement instrument that tries to measure a char-
iety associated with peripheral IV cannulation. acteristic or attitude that is believed to range across a
continuum of values and cannot easily be measured
Sample directly. For example, the amount of pain that a patient
The inclusion criteria were patients aged 7 to 12 years feels ranges across a continuum from none to an
who required peripheral IV cannulation. Potential par- extreme amount of pain. The VAS is usually a horizontal
ticipants were excluded if there was a break or abra- line, 100 mm in length, anchored by word descriptors
sion on the skin where the device would be placed. at each end. The child marks on the line the point
Additional exclusion criteria were nerve damage in that he or she feels represents his or her perception
the affected extremity, critical or chronic illness or of the current state. The VAS score is determined by
poor health, neurodevelopmental delays, verbal diffi- measuring in millimeters from the left-hand end of the
culties, use of an analgesic within the last 6 hours, or line to the point that the child marks (Wewers &
a history of syncope due to blood specimen collection Lowe 1990).
or immunization. None of the children had any prior The same nurse conducted the peripheral IV can-
experience of peripheral IV cannulation. nulation procedure in all cases. The same researcher
applied the external cold and vibration stimulation
Ethical Considerations via Buzzy (Fig. 2).
This study was approved by the Ethical Commission of The children (N ¼ 220) and their parents were
Selcuk University Selcuklu Medical. informed about the purpose and the content of the
Faculty, Konya (06. 26.2012/115). The aim and study and asked if they would volunteer to participate
the method of the study were explained to the children in the study. Of the 220 children, 176 children and
and their parents, and they were informed that if they their parents agreed to participate. All the parents
did not want to continue, they could withdraw from signed a research consent form. Background informa-
the study without stating a reason. tion about demographics, medical history, recent
Procedure
This study was conducted with one volunteer nurse
trained by the researcher. The nurse had 5 years of
experience in pediatric patient care and peripheral
IV cannulation. The nurse had no monetary interest.
The nurse was informed about the study at the begin-
ning. The preprocedural and procedural fear and
anxiety levels of the children were assessed via self-
parental and observer reports. The data were obtained
by interviewing the children, their parents, and the
observer. The Children’s Fear Scale (CFS) was used
for this purpose. The CFS is a well-established method
for evaluating pediatric fear and anxiety. It rates fear
and anxiety on a 5-point scale and consists of five
cartoon faces that range from a neutral expression (0
¼ no anxiety) to a frightened face (4 ¼ severe anxiety) FIGURE 2. - An example of the use of Buzzy (www.
(McMurtry, Noel, Chambers, & McGrath 2011). The buzzy4shots.com).
36 Canbulat, Ayhan, and Inal
analgesics, and body mass index (BMI) were collected years (8.43 1.61 years) and their parents volunteered
via self-report forms. Before randomization, the to participate in the study. There were no differences
researcher read a standard script to explain the pain between the two groups in terms of age, sex, BMI,
and anxiety measures. The parents and the observer and preprocedural anxiety according to the self, the
(the researcher) assessed the children’s anxiety levels. parents’, and the observer’s reports (p > .05) (Table 1).
The 176 children were randomized using a computer- When pain and anxiety levels were compared
generated table of random numbers into two equal with an independent sample t test, consistent with hy-
groups: an experimental group and a control group pothesis 1, the children in the external cold and vibra-
(n ¼ 88 for each group). The control group received tion stimulation group had significantly lower pain
no intervention. The experimental group received levels than the control group according to their self-
external cold and vibration stimulation via Buzzy. The reports (both WBFC and VAS scores; p < .001)
dorsum of the child’s hand area was cleaned and can- (Table 2). Consistent with hypothesis 2, the external
nulated with Buzzy. Buzzy was administered about 5 cold and vibration stimulation group had significantly
cm above the application area just before the proce- lower fear and anxiety levels than the control group,
dure, and the vibration was continued until the end according to the parents’ and the observer’s reports
of the procedure. (p < .001) (Table 3).
Data Analysis
Data were analyzed with SPSS version 15.00 (SPSS, DISCUSSION
Inc., Chicago, IL, USA). A p value < .05 was considered Pain experienced during medical procedures that are
significant. Parametric data, such as the pain and anxi- routinely performed in hospitals, such as phlebotomy,
ety levels of the children, were compared with the Stu- immunization, and IV cannulation, can cause stress,
dent’s t test. Nonparametric data, such as sex and fear, and anxiety in children (Cassidy et al., 2001;
mother’s and father’s education, were compared with Razzaq, 2006). These procedures also may cause
frequency and c2 comparisons. anxiety and fear in the family members of these
children (Cohen, 2008; Shavit & Hershman, 2004).
Although procedural pain and anxiety levels may be
RESULTS
influenced by the type of procedure applied (Rawe
The study was conducted between July and September et al., 2009), they also are associated with a number
2012. One hundred seventy-six children aged 7 to 12 of individual factors, including the child’s and parents’
TABLE 1.
Comparison of Groups in Terms of Variables that May Affect Procedural Pain and Anxiety Levels
c2
Characteristic Buzzy (n ¼ 88) Control (n ¼ 88) p
Sex
Female (%) n 11 (12.5) 13 (14.8) .82
Male (%) n 77 (87.5) 75 (85.2) .41
t
Characteristic Buzzy (n ¼ 88) Control (n ¼ 88) p
TABLE 3.
CONCLUSION
Comparison of Groups’ Procedural Anxiety
Levels During Peripheral IV Cannulation The application of external cold and vibration stimula-
tion were effective in relieving pain and anxiety in chil-
Procedural child Buzzy Control t dren during peripheral IV cannulation. Therefore, it
anxiety (n ¼ 88) (n ¼ 88) p
can be concluded that this method may be routinely
Parent reported 0.94 1.06 2.09 1.39 –6.135 used during peripheral IV cannulation in children.
(mean SD) 0.000 Nurses need to be aware of procedural anxiety and
Observer 0.92 1.03 2.14 1.34 –6.745 pain during peripheral IV cannulation. Interventions
reported (mean 0.000 should be implemented to decrease anxiety and pain
SD)
in children. Nurses can use external cold and vibration
IV ¼ intravenous. stimulation for pain and anxiety relief in children
38 Canbulat, Ayhan, and Inal
during peripheral IV cannulation. This study contrib- Second, the parents may have anticipated specific
utes to the literature on quick-acting and effective non- results because they were informed about our hypoth-
pharmacologic measures for pain reduction. esis. Thus, placebo effects were not controlled. This
could have biased our results by affecting the reports
of the parents and the observer reports. Third, the
Limitations nurse who participated in the study was not selected
There are three significant limitations in the current randomly. This could have influenced the usual care
investigation. First, this study was not double-blind. Re- process.
searchers had information on which child was in
which study group. To correct researcher bias, the Acknowledgments
pain and anxiety levels were not assessed by the The authors acknowledge the participating children and
researchers. their parents of this study.
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