Lidocaine prior to IV start?

Specialties CRNA

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I am in a front-loaded program and will be starting full-time clinicals in August (thank goodness), but this semester we have had several "observation days." During my last obs day I was with one of my professors who asked me to go ahead and start a peripheral IV on our patient. Well, imagine my surprise when I got reamed a new one for not numbing the patient with lidocaine beforehand. Now, I have been an ER nurse for two years and have started a million IV's and I have never numbed a patient (with the exception of children) before starting an IV. My professor said to me, "We are in the profession of preventing pain, why would you not numb the patient first?" Is numbing the IV site beforehand common practice everywhere or is my professor just being overly anal-retentive? Any comments would be appreciated! Thanks!!!

Until recently, only the perioperative areas in my facility were able to use Lido for IV starts (an MD order was required). Our Day Surgery undertook a research study on the effectiveness of subQ lido vs 0.9% bacteriostatic normal saline for "numbing" for IV starts. The data supported the use of Bacteriostatic saline and the practice has now been expanded to the entire facility. It's written as a protocol so that all RNs can use it and no MD order is required. If you are interested in their data it was published in JOPAN (see below).

A comparison of bacteriostatic Normal Saline and Lidocaine used as interdermal anesthesia for the placement of intravenous lines

Kwan M, Windle PE, Warwick H, Sibayan A, Espiritu C, Vergara J

Journal of PeriAnesthesia Nursing

August 2004 (Vol. 19, Issue 4, Page 267)

This technique was used by the hospital IV start team many years ago. Glad to hear it has been proven to work.

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I think it is more appropriate to stand your ground and make a stink, instead of telling a half-truth which could come back to bite you. That said, you can do whatever you want and use terms however you like as a PATIENT - as a nurse you do hopefully use "allergy" in the accurate sense.

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There seems to be much confusion about the role of local anesthetic to ease the pain of an IV stick. The fact of the matter is, it doesn't matter what you use to create an intradermal skin wheal, it the stretching of the skin that causes anesthesia. You'll find that Lactated Ringers, Normal Saline, and Lidocaine all do the same quick job. If you have a laceration repaired in the ER, you might notice that it takes a few minutes for the local to numb the area sufficiently to begin suturing. Yet, when a skin wheal is injected properly with a lot of skin tautness, you have instant analgesia to insert an IV, spinal, or epidural needle. Another example from OB: when the perineum is stretched during crowning, an episiotomy can be performed with no "anesthesia" because the stretching creates loss of sensation. Yet, minutes later after the stretching is over, local must be injected in order to suture the episiotomy closed. As a final point for discussion, consider the insertion of an epidural. A good skin wheal allows you to almost immediately insert a big, honking, dull pointed needle. Yet, some like to make a deep injection of local as well, into tissue planes that cannot be stretched such as sub-q fat. Why bother? Even if you try and inject the ligament, do they really think they can hit that same spot with the epidural needle? Especially if you don't wait long enough for the local act? I just always found that curious.

In conclusion, I think everyone deserves a skin wheal to start an 18 gauge or larger IV catheter. I think everyone deserves a skin wheal for an SAB or an epidural block. If a patient claims an allergy to lidocaine, I merely draw some fluid out of their IV that is about to be started and use that...it works just as well.

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I have been an RN for more than 20 yrs and this debate has not changed. Early in my career, we used lido subq on every IV start unless the pt had an allergy to it. After several yrs, someone decided lido is a med (duh!) and then required a physician's order. Many hospitals currently have a policy for prepping the IV site either with EMLA cream or lido subq. Check your facility's policy. I personally like to use it as it decreases anxiety/discomfort for patients but if administered too close to the vein may cause the it to "collapse" thus requiring another stick.

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I agree 100+% with your instructor. I rarely start an IV without local. A few hints-- I use a 30 gauge needle and buffer the local with sodium bicarb. My patients think I am great and routinely tell me they never felt a thing. All of the RNs in my facility MUST use local if they want to continue working for us.

I am in a boutique practice where the patient having a good, as well as safe ecperience is essential. Obviously, if there is an emergency situation or I restart an IV after induction, I don't use local.

In an elective setting, I haven't seen or heard of one good reason for not using local. In my opinion, it is just laziness. Before you start flining the flack, give me one good reason why not to do it.

A true story--a member of the Board of Nursing in my state had surgery at my facility years ago. An RN tried and failed to start an IV without local. She called a CRNA who, of course used local and started the IV. About a month later the Board of Registered Nursing published a position statement that it was within the scope of practice of an RN to use local prior to starting an IV. The BRN person had strong feelings about the technique.

Yoga

ive had both and personally it depends on who is doing the iv - anyone who is bad at ovs i have learned the lido dont do crap to help the pain of em rooting in there so it dont matter. ive also had ones who start it without the lido and i didnt even know they had it in they were so good. as for using it myself if im statrting an iv ts stat and there isnt time to dig out and administer lido. so i have to say its up tothe individual. hgs tracie

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I started working in Pre-op and PACU over 12 years ago. At that time I had minimal IV starting experience. An anesthiologist started helping me learn new and better techniques, one of which was giving a local before starting an IV.

At first it made it harder for me to hit the vein on the first stick,but with practice and time it didn't make a difference. That seems to be one of the biggest complaints I've heard from other nurses, that they have more trouble seeing and feeling the vein under the local.

Another difference is that NS9% can be used and be just as effective as using lidocaine, it's what I used for years and so did the anesthesoligist, other than for art lines or for centeral lines.

Over the years many patients began requesting me to start their IV's because I was the only nurse that used a local. I received a lot of feedback from patients as to how much better their experience was with less fear of the IV stick. I agree that there are cases that using a local is not always a good idea, usually when you have patients with very fragile veins, and especially veins that are just below the surface of the skin as you run the risk of nicking the vein trying to inject the local.

I hope this helps some of you newbies and even us more experienced nurses.

Isn't what we are, what we do, and what we represent all about doing what we can to make our patients more comfortable and any experiences they have the least painful and fearful as possible. For me it is and always will be.

BEST OF LUCK TO ALL OF YOU!

RN-NANA#1

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It always depended entirely on the patient for me. Most patients did fine without the lido, and it would just have been another stick to them. I have never had lido myself. IV starts HURT, but it's not that bad and it's over pretty quickly and I'm a hard stick.

There were needle phobic patients and pain phobic patitents and those are the ones I'd distract while I poked in a little lidocaine. Using lidocaine was NOT protocol for IV starts, though.

Check the policy and procedure manual for that hospital. The lido happy nurse might have been blowing some serious smoke in your direction.

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Hi I am a Certified Infusion Therapist. I have been an IV nurse for 28 years. Lidocaine is used by the people who do not know how to stick. Whether, it is an 18 or a 24 the pain is the same if done properly. Proper preparation with reassurance, confidence, and proper vein dilation really helps with the pain issue. It is a needle, it is going to hurt but it will hurt more if you make an issue out of it. I have had both and I found that the lidocaine was worse because it causes vasoconstriction and you end up with 2 or more sticks. As far as children are concerned, most children are fine, it is the parents who need the Emla. Once again it cases vasconstriction and it sometimes ends up to be more than one stick. Cathy

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Hi I am a Certified Infusion Therapist. I have been an IV nurse for 28 years. Lidocaine is used by the people who do not know how to stick. Whether, it is an 18 or a 24 the pain is the same if done properly. Proper preparation with reassurance, confidence, and proper vein dilation really helps with the pain issue. It is a needle, it is going to hurt but it will hurt more if you make an issue out of it. I have had both and I found that the lidocaine was worse because it causes vasoconstriction and you end up with 2 or more sticks. As far as children are concerned, most children are fine, it is the parents who need the Emla. Once again it cases vasconstriction and it sometimes ends up to be more than one stick. Cathy

Please show us your reference for lidocaine (without epinephrine--which is what should be used) causes vasoconstriction. If you are going to post on the CRNA board, you better be able to defend your knowledge of pharmacology.

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Hi!

This is an interesting topic, with a few sideshows to boot, but why not? We all have our opinions on the subject, so I guess I can 'insert' mine just as painlessly as the rest of you all...lol...

I have been a nurse for a long long time....since we had to wear white dresses and caps as a matter of fact! And when doctors were considered to be gods. This topic comes up in nursing every few years, and the arguements are always the same. I have done IV inserts with lido, without lido, with NS, with EMLA. I have worked in ER, PACU, M/S, Dialysis, Ortho, Transplant, Plastics, Urology....everywhere you can think of except OB and Peds. I am very good at IV insertion, rarely miss....and I have come to the conclusion that lido actually inhibited my IV insertion. I have found, over the years, that technique and PRACTICE (how do you get to Carnegie Hall?) are the best ways to preventing pain. One observation I have made with all the new nurses I have seen, is they tend to put too tight a tourniquet on, which in my opinion can cause just as much pain as a small needle stick. And it can also cause the overblown balloon effect....touch a needle to that overpumped, overstressed vein and they POP...necessitating another needle stick to the patient. In fact, at this point in my career, I rarely ever use a tourniquet anymore. If I do, it is not very tight. And trust me, I am very, VERY good at IV starts. Out of the last 50 or so, I think only one has needed a second try. Another thing, I am a travel RN, have been so for the past 10 years, been all over the country, and I don't usually see lidocaine being used as a matter of course on M/S floors. When I did ask, I usually get that "Huh?" look, so I guess I just don't bother anymore. I can start an IV either way. But I do think that prepping the site, and more importantly, prepping your patient, goes a long way to successful IV starts, whether or not lido is used.

Laura RN

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Lidocaine is used by the people who do not know how to stick.

I wish I could hear you tell our entire Anesthesia department this.

The majority of my patients are suprised when I tell them that the IV is in and running and that is directly due to them not feeling it.

I'll use that as proof enough.

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There seems to be much confusion about the role of local anesthetic to ease the pain of an IV stick. The fact of the matter is, it doesn't matter what you use to create an intradermal skin wheal, it the stretching of the skin that causes anesthesia. You'll find that Lactated Ringers, Normal Saline, and Lidocaine all do the same quick job. If you have a laceration repaired in the ER, you might notice that it takes a few minutes for the local to numb the area sufficiently to begin suturing. Yet, when a skin wheal is injected properly with a lot of skin tautness, you have instant analgesia to insert an IV, spinal, or epidural needle. Another example from OB: when the perineum is stretched during crowning, an episiotomy can be performed with no "anesthesia" because the stretching creates loss of sensation. Yet, minutes later after the stretching is over, local must be injected in order to suture the episiotomy closed. As a final point for discussion, consider the insertion of an epidural. A good skin wheal allows you to almost immediately insert a big, honking, dull pointed needle. Yet, some like to make a deep injection of local as well, into tissue planes that cannot be stretched such as sub-q fat. Why bother? Even if you try and inject the ligament, do they really think they can hit that same spot with the epidural needle? Especially if you don't wait long enough for the local act? I just always found that curious.

In conclusion, I think everyone deserves a skin wheal to start an 18 gauge or larger IV catheter. I think everyone deserves a skin wheal for an SAB or an epidural block. If a patient claims an allergy to lidocaine, I merely draw some fluid out of their IV that is about to be started and use that...it works just as well.

Great Post.

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