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- Blood specimens
- Guidelines for skin and vessel punctures
- To reduce the pain associated with heel, finger, venous, or arterial punctures:
- Apply EMLA topically over the site if time permits (>60 minutes). LMX cream also may be used and requires a shorter application time (30 minutes). To remove the transparent dressing atraumatically, grasp opposite sides of the film and pull the sides away from each other to stretch and loosen the film. After the film begins to loosen, grasp the other two sides of the film and pull. Use a vapo-coolant spray or buffered lidocaine (injected intradermally near the vein with a 30-gauge needle) to numb the skin.
- Use nonpharmacologic methods of pain and anxiety control (e.g., ask the child to take a deep breath when the needle is inserted and again when the needle is withdrawn, to exhale a large breath or blow bubbles to “blow hurt away,” or to count slowly and then faster and louder if pain is felt).
- Keep all equipment out of sight until used.
- Enlist parents’ presence or assistance if they wish.
- Restrain child only as needed to perform the procedure safely; use therapeutic holding.
- Allow the skin preparation to dry completely before penetrating the skin.
- Use the smallest-gauge needle (e.g., 25 gauge) that permits free flow of blood; a 27-gauge needle can be used for obtaining 1 to 1.5 mL of blood and for prominent veins (needle length is only 1.25 cm [0.5 inch]).
- If possible, avoid putting an IV line in the dominant hand or the hand the child uses to suck the thumb.
- Use an automatic lancet device for precise puncture depth of the finger or heel; press the device lightly against the skin; avoid steadying the finger against a hard surface.
- Have a “two-try” only policy to reduce excessive insertion attempts—two operators each have two insertion attempts. If insertion is not successful after four punctures, consider alternative venous access, such as a PICC; have a policy for identifying children with difficult access and appropriate interventions (e.g., most experienced operator for the first attempt, use transilluminator or ultrasonography for insertion guidance).
- For Multiple Blood Samples
- Use an intermittent infusion device (saline lock) to collect additional samples from an existing IV line; consider PICC lines early, not as a last resort.
- Coordinate care to allow several tests to be performed on one blood sample using micromethods of testing.
- Anticipate tests (e.g., drug levels, chemistry, immunoglobulin levels), and ask the laboratory to save blood for additional testing.
- For Heel Lancing in Newborns
- Heel lancing has shown to be more painful than venipuncture
- Kangaroo care (placing the diapered newborn against the parent’s bare chest in skin-to-skin contact) 10 to 15 minutes before and during heel lance reduces pain. In two studies, mothers were slightly more effective than fathers in decreasing pain
- Breastfeeding during a neonatal heel lance is effective in reducing pain and has been found to be more effective than sucrose in some studies
- If breast milk is unavailable, administer sucrose and encourage the newborn to suck a pacifier. When commercially manufactured 24% sucrose solution is unavailable, add 1 tsp of table sugar to 4 tsp of sterile water. Use this solution to coat the pacifier or administer 2 mL to the tongue 2 minutes before the procedure
- Although safe for use in preterm infants when applied correctly, EMLA has been found to be no more effective than placebo in preventing pain during heel lancing
- To reduce the pain associated with heel, finger, venous, or arterial punctures:
- Guidelines for skin and vessel punctures
- Respiratory secretions specimens
- Blood specimens
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