|
| |
| |
 One of the most important aspects of performing a procedure is minimizing the pain and anxiety (distress) that the patient experiences. More broadly, the physician’s goal should be to successfully manage the patient’s experience through the procedure to ensure minimal distress, maximal comfort, patient cooperation, and perception of good care.
|
|
| Image | Pain | Family |
The prospect of an invasive medical procedure can produce intense fear, insecurity, and anxiety in a patient. The first step to managing these negative feelings is establishing good communication to ensure the patient’s needs are being met. Patient’s concerns and needs vary widely according to age, previous experience, coping mechanisms, social support, and belief systems. Understanding these factors is key to managing the patient’s experience. Before any procedure starts, the patient must feel comfortable that their concerns have been addressed and that they will be able to communicate freely with the physician throughout the procedure. |
|
- 85% of patients surveyed said they would not feel comfortable having a resident to their lumbar puncture if it was the resident’s first time. 69% said they would be uncomfortable if it were the resident’s tenth time. (Santen SA)
- Pay attention to the image you project: are you calm and confident, or nervous and green? Does the patient get the impression that this might be your first time?
|
|
- Some patients are uncomfortable hearing the word “pain”, and prefer other, less frightening words be used to describe the process of the procedure
- Some patients need to be told each time something will be done, as in “you’re going to feel some cold cleaning solution now.”
- For other patients, particularly younger pediatric patients, this only creates more distress. These patients might do better with distraction techniques.
|
|
- Healthcare providers have mixed feelings. In one study, Only 65% of physicians felt parents should be present during lumbar puncture on a pediatric patient; less than 40% felt family should be present during a major invasive resuscitation. (Beckman)
- Family members feel strongly that they should be present, and that their presence benefits the patient, the family, and sometimes the provider. (Bourdeaux)
- A number of randomized, controlled trials have suggested that Parents and Patients experience less distress if parents are present during invasive procedures (venipuncture) and that the parents’ presence is unlikely to affect the practitioner. (Wolfman, Wolfman)
|
|
 Minimizing the pain and anxiety surrounding a procedure with medications is just one part of controlling the patient’s experience. A number of non-pharmacological techniques can be used as to minimize distress and enhance cooperation, particularly in pediatric patient (Kennedy, Krauss). In young infants, techniques such as swaddling, holding, or allowing sucking can be effective. In older children, distraction with play activities, reading, or imagery are can be used. While these techniques have been employed and studied primarily in the pediatric population, certain adult patients may also be responsive to this approach.
|
|
|
| Topical | Injected |
|
 Particularly useful in patients who may not cooperate with injection of local anesthetics (due to age, combativeness, or needle-related phobias), there are a number of anesthetic preparations for topical use. LET (4.0% lidocaine, 0.1% epinephrine, and 0.5% tetracaine), TAC (0.5% tetracaine, 0.05% adrenaline, and 4-11% cocaine), and EMLA (Lidocaine/Prilocaine mixture) are all suitable for placement in wounds or over intact skin (e.g. prior to IV insertion), and provide anesthesia within 30 minutes to 1 hour. Significant vasoconstriction precludes their use on digits.
|
|
 Intrdermal or subcutaneous injection of local anesthetics provides quick, effective anesthesia. The pain of injection can be minimized by injecting at a slow rate through a finer gauge needle (#27 or finer), buffering the anesthetic with sodium bicarbonate, and warming the solution to body temperature. (Kennedy / Luhmann 1999; Scarfone) The addition of epinephrine to the solution limits the chance of systemic toxicity and prolongs the duration of action of the local anesthetic. Epinephrine-containing solutions cannot be used on digits or on the nose, due to the potential for inducing tissue ischemia.
|
|
|
When wounds are innervated by one or two superficial nerves, effective anesthesia may be obtained with a regional block. Wounds on the digits and face are particularly amenable to regional anesthesia. Advantages include minimal distortion of wound edges, fewer injections, and the ability to repair multiple wounds within the distribution of the blocked nerve.
|
|
|
| It has been well documented that physicians tend to under-treat pain in the emergency department, particularly when the patient is a child. (Rupp; Krauss / Zurakowsi) But the availability of short-acting sedative agents and advances in patient monitoring have made it easier to provide a deep level of sedation, along with adequate analgesia (and often amnesia) that facilitates the performance of exquisitely painful procedures (such as reduction of dislocations) and procedures in uncooperative patients. The term ‘Procedural Sedation and Analgesia’ (PSAA) has replaced the older ‘conscious sedation’ because of the recognition that sedation is actually a continuum with great variation in level of consciousness, and often the patient is completely unconscious for a brief time. The agents used for PSAA all have potential for significant respiratory and/or cardiovascular compromise, and should only be used by physicians trained in their safe application and prepared to manage the potential complications, particularly airway compromise. PSAA should be considered a procedure that, like any other, must be studied, prepared for, and practiced until competency has been achieved. |
Back | Next
|
|
|
