Introduction

Peripheral venous catheterization (PVC) is one of the most common procedures in the emergency department (ED), and approximately 1.2 billion intravenous (IV) cannulation procedures are performed annually worldwide [1]. PVC is an invasive procedure that involves inserting a sterile catheter through the patient’s skin into the peripheral vein. The peripheral venous catheter is crucial for fluid electrolyte therapy, blood and blood product transfusion, IV drug administration and nutritional support [2]. In addition, PVC has various complications such as phlebitis, dislodgement, occlusion, and pain [3]. One of the most important factors affecting complications in peripheral vein catheterization is the experience of the healthcare provider [4]. Rapid IV catheterization is important for effective resuscitation in patients with trauma, shock, and burns admitted to the ED. Conditions such as vascular problems due to IV drug use, age (elderly, child), peripheral edema, hypothermia, and dehydration can cause obstacles in the IV catheter procedure [5,6]. In such patients, emergency team members may not be able to localize the vein and insert the catheter blindly. IV cannulation is a painful procedure that affects cognitive abilities by increasing pain and fear of pain (FOP), and this blind intervention may increase the number of attempts and increase the patient’s pain [7,8].  Pain is a condition that negatively affects a person’s physical, psychosocial, and social life. Therefore, controlling the patient’s pain, increasing the patient’s comfort, and minimizing the complications related to pain are important in reducing the length of stay in the ED [9]. FOP was evaluated as a condition affected by pain and can be defined as a verbal, behavioral, and physiological response to the possibility of current or potential pain [10]. In recent years, the use of technologies to improve efficiency and reduce pain in painful procedures such as PVC has become more important. In this regard, infrared vein finder (IVF) devices have been used, especially in patients in whom peripheral catheterization is difficult [11]. This study was conducted to reveal the effect of the IVF on pain and FOP in patients who underwent PVC in the ED.

Materials and Methods

Patients and Study Design

This prospective randomized observational study was conducted between June 2 and September 30, 2019 in the ED of University of Health Sciences Türkiye, İstanbul Şişli Hamidiye Etfal Training and Research Hospital, which is a tertiary hospital and has approximately 150,000 admissions to the ED annually. The study was approved by the Local Ethics Committee of University of Health Sciences Türkiye, İstanbul Şişli Hamidiye Etfal Training and Research Hospital (approval number: 2402, date: 14.05.2019). The inclusion criteria were; older than 18 years, patients with PVC indication in the ED, conscious, patients with at least one previous PVC experience, and no communication barrier. Exclusion criteria were; younger than 18 years old, infection, burn, vascular disorder, and neurological sequelae in the extremity planned for catheterization. Two groups were formed the IVF group and the control group according to simple randomization. The researchrandomizer.com website was used for randomization. Power analysis (G*Power 3.1.9.2) was used to determine the size of the sample. The a value was 0.05, the power of the study was 80%, and the effect size was between low and -medium (0.40) [12]. According to the power analysis, it was planned to include 100 patients in the IVF group and 100 patients in the control group. A total of 312 patients were evaluated for eligibility, and 112 patients were excluded because they did not meet the inclusion criteria or refused to participate in the study. A total of 200 patients participating in the study were analyzed.

Control Group

Peripheral catheterization was performed using the conventional method in patients in the control group. The following steps were applied according to the conventional method; the patient was informed about the procedure and informed consent was obtained. The fear of pain questionnaire-3 (FPQ-3) [13] and the numeric pain rating scale (NRS) [14] were explained to the patients, and the FOP 3 scale was administered. Antecubital skin antisepsis was provided. A tourniquet was applied 10-15 cm above the area where the procedure will be performed, and an appropriate peripheral venous catheter was placed. NRS was administered the patients after the procedure.

IVF Group

The following steps were performed; before intervention, the patient was informed about the procedure and informed consent was obtained. The use and function of the IVF are explained. The FPQ-3 and the NRS were explained to the patients, and the FOP 3 scale was administered. Then, routine peripheral venous catheter insertion was performed using the AccuVein AV400 IVF. NRS was administered the patients after the procedure. In both groups, PVC was administered by a nurse with 7 years of emergency room experience.

FPQ-3

The FPQ is a 30-item self-report measure of pain-related fear designed to tap fear related to severe pain (e.g. “breaking your leg”), minor pain (e.g. “getting a paper-cut on your finger”), and medical pain (e.g. “receiving an injection in your hip/buttocks”). Items are scored on a 5-point Likert scale ranging from 1 (not at all) to 5 (extreme) [13].

NRS

The NRS is one of the most preferred and easily applied scales in pain assessment. Absence of pain is scored 0 (zero), and extreme pain is scored 10 (ten). In this way, the patient is asked to express the appropriate pain score [15].

Statistical Analysis

Statistical analysis was performed using the SPSS 21 package program. Mean, standard deviation, median, minimum, and maximum values were used for descriptive statistics for continuous variables, and numbers and percentages were used for categorical variables. Compliance with normal distribution was checked using the Kolmogorov-Smirnov test. T-test (Student’s t-test) was used in independent groups with normal distribution and Mann-Whitney U test was used in cases not showing normal distribution. Differences in three or more groups were used for ANOVA in the variables that provided the normality assumption and the Kruskal-Wallis test in the variables that did not provide the normality assumption. Correlation analysis was performed while examining the relationship between continuous variables. Statistically, p<0.05 was considered significant.

Results

The flow chart of the study is shown in Figure 1 and the demographic characteristics of the patients participating in the study are given in the table below (Table 1).

Information about the PVC, patients’ previous experience about PVC, inserted catheter sizes, discomfort with the idea of PVC, FOP during catheterization, and number of attempts are summarized in Table 2.

 The total and subgroup FOP 3 scale scores of the patients were calculated. The mean total score of the patients were; 78.8±21.5 8 (minimum: 41.0-maximum: 148.0) in the IVF group and 85.8±22.0 (minimum: 44.0-maximum: 150.0) in the control group (p=0.025). The scale subgroup “minor pain” score was compared for all variables. When the groups were compared, this score was found to be different (p=0.021) and was higher in the control group. Although the “severe pain” score was lower in the IVF group, it was not statistically different (p=0.088) (Table 3).

The mean NRS score of the patients in the IVF group was 2.56±1.25 (minimum: 1.00, maximum: 6.00), and the mean score of the patients in the control group was 2.94±1.58 (minimum: 1.00, maximum: 7.00). Considering the NRS scores of the IVF and control groups, the IVF group score was lower but statistically similar to the control group (p=0.121) (Table 4).

The correlation between the patients’ FPQ-3 scores and NRS scores were analyzed. There was a moderate positive correlation between the NRS score and the “severe pain” (r=0.407, p<0.001), “minor pain” (r=0.534, p<0.001) and “medical pain” scores (r=0.390, p<0.001) in the intervention group (Table 5).

According to the regression analysis; one-point increase in FPQ-3 total score increased NRS 0.03 points in the IVF group (R²=0.282, p<0.001) and 0.05 points in the control group (R²=0.464, p<0.001). Considering the subgroups of FPQ-3, it was found that a one-point increase in “severe pain” score increased NRS by 0.06 points in the IVF group (R²=0.167, p<0.001) and 0.09 points in the control group (R²=0.270, p<0.001). One-point increase in “minor pain” score increased NRS 0.09 in IVF group (R²=0.297, p<0.001) and 0.11 points in control group (R²=0.309, p<0.001). Also, one-point increase in “medical pain” score increased NRS 0.06 in IVF group (R²=0.184, p<0.001) and 0.11 points in control group (R²=0.388, p<0.001) (Table 6).

Discussion

Peripheral venous catheter intervention in the ED causes moderate pain and anxiety. There are several methods such as the use of local anesthetics, ultrasonography, and local ethyl chloride to reduce pain and anxiety and increase the success of the intervention [2,5,8]. Although most of the patients in our study had previous PVC experience, they were still afraid of this procedure. The demographic characteristics of the groups were similar in terms of age and gender. In a randomized controlled study conducted by Aulagnier et al. [16] in which the use of IVF devices in the emergency room was investigated, the average age of the participants was higher than that in this study, and the demographic characteristics were similar in the intervention and control groups.

Considering the effect of the IVF on the number of PVC attempts, the number of vascular accesses in the first attempt in the IVF group was 92 (92%); in the control group, the success of the first attempt was 97 (97%), and there was no statistically significant difference between them (p=0.121). In the study conducted by Aulagnier et al. [16], no significant difference was found between the intervention and control groups in terms of the number of interventions. Curtis et al. [17] showed that there was no significant difference in the number of interventions between ultrasonography, IVF, and the standard approach in the pediatric population. In the study of De Graaff et al. [18] with 1,913 pediatric patients, it was found that the IVF device had no effect on the number of interventions and PVC success. On the other hand, Demir and Inal [19] and Inal and Demir [20] have shown that IVF increases the success of PVC intervention in their studies in the 3-18 and 0-3 age groups. As mentioned above, IVF devices appear to be more effective in the pediatric population than in adults.

The total FPQ-3 scores and the minor pain scores were found to be lower in the IVF group. IVF devices are not effective enough to reduce the fear of severe pain but may help reduce the fear in those with a mild FOP. Therefore, although it is seen that IVF results in a decrease in the total pain scores, it is thought that it would not be appropriate to use them to reduce the fear and anxiety of the patients, especially in those who have severe FOP. A moderate positive correlation was found between the FPQ-3 subgroups (minor, severe, medical), total pain scores, and NRS scores. There was no strong correlation between the NRS and FPQ-3 scores.

There was no statistically significant difference between the control and IVF groups’ NRS scores. Aulagnier et al. [16] also showed that IVF has no effect on pain. In a study with 450 patients with hemophilia, IVF reduced pain in patients with difficult vascular access but had no effect on pain in patients without difficult vascular access [21]. On the other hand, it has been shown that the use of IVF in the pediatric population reduces pain, especially in patients younger than 3 years of age [20,22,23]. Therefore, IVF devices seem to be more effective in reducing pain in the pediatric population than in adults.

Conclusion

Although the use of IVF for venous catheterization reduces the FOP in adults, it does not reduce the fear of severe pain; it only reduces the fear of minor pain and does not affect the success of the procedure. More studies are needed in adults because most of the studies were conducted in the pediatric population.

Ethics

Ethics Committee Approval: The study was approved by the Local Ethics Committee of University of Health Sciences Türkiye, İstanbul Şişli Hamidiye Etfal Training and Research Hospital (approval number: 2402, date: 14.05.2019).

Informed Consent: Required informed consent was obtained from the study participants.

Authorship Contributions

Surgical and Medical Practices: C.U.A., Y.E.A., Consenp: C.U.A., İ.Ç., Design: C.U.A., İ.Ç., Y.E.A., Data Collection or Processing: C.U.A., İ.Ç., Y.E.A., Analysis or Interpretation: C.U.A., İ.Ç., Y.E.A., Literature Search: C.U.A., İ.Ç., Y.E.A., Writing: C.U.A., İ.Ç., Y.E.A.

Conflict of Interest: No conflicts of interest were declared by the authors.

Financial Disclosure: The authors declared that this study received no financial support.