Help with Painful Procedures

So far we have looked at various methods to relieve a child's pain. This section applies these ideas to specific procedures your child may have and gives more information about the different procedures.

  • Fingerpricks
  • Venipunctures
  • Spinal Tap or Lumbar Puncture
  • Bone Marrow Aspiration and Bone Marrow Biopsy
  • Central Venous Access

FINGERPRICKS

Fingerpricks are used to obtain a small amount of blood for tests. A small blade or lancet is used to make a tiny cut or puncture in the skin. The finger is then squeezed gently to make blood come out.

Specific methods of pain control for fingerpricks are:

Explanation:The reason for the procedure should be explained.

Play: For younger children, anxiety may be reduced by doing a pretend fingerprick on a doll. Other types of play may be useful for older children.

Distraction: Distraction geared to the child's age and interests may work very well.

Relaxation: If the child can relax, the fingerprick will be easier and less painful.

Problem solving: With the help of a parent or health professional, older children and adolescents can work out the best strategy for their own situation.

VENIPUNCTURES

Venipunctures involve placing a small needle into a vein, usually in the hand or arm. These are done to get a small amount of blood for tests, to give medication, or to give liquid to prevent dehydration. A venipuncture needle may be left in the vein for only a few moments, or it may be left in for several days (in which case, a soft plastic intravenous catheter is usually used).

To do a venipuncture, the doctor or nurse first looks closely at the child's hand or arm to find the best vein. A tight band (tourniquet) may be placed around the child's arm to make the veins easier to see. Once the best vein is found, the skin over it is cleaned with an alcohol swab. The needle is then put through the skin into the vein. If the needle is to stay in the vein for awhile, it will be taped in place. A small board may also be taped to the child's arm or hand to decrease movement of the needle. Without pain-control techniques, venipunctures are painful for most children.

Explanation, play, distraction, relaxation, and problem-solving can be used as described above. In addition, EMLA® cream can make most venipunctures pain-free and is used routinely in some cancer clinics.

SPINAL TAP OR LUMBAR PUNCTURE (LP)

The brain and spinal cord are washed by a liquid called "spinal fluid." Sometimes a sample of this fluid is needed to find out the child's diagnosis or treatment progress. At other times, spinal taps are done to put chemotherapy medicine right into the spinal fluid.

The doctor will have your child lie on his/her side, with knees bent up and chin touching the chest. The child's back is cleaned with a special antiseptic soap. A small needle is put into one of the spaces between the child's vertebrae (the small bones down the centre of the back) and into the spinal fluid.

Spinal fluid usually comes out drop by drop, and is collected in small bottles that are sent to the lab for testing. Medicine may then be slowly injected through the same needle. The needle is removed and a bandaid is placed over the area.

Explanation, play, distraction, relaxation, and problem-solving can be used as described above. In fact, many children can manage spinal taps well with just these techniques and EMLA®. Injected local anaesthetic is often used and can be quite effective, but may sting during the injection unless EMLA® is used as well.

Children who are very anxious may find conscious or deep sedation is the best way to manage spinal taps.

BONE MARROW ASPIRATION AND BONE MARROW BIOPSY

Bone marrow is a soft gel in the middle of bones where white blood cells, red blood cells, and platelets are made. A sample of bone marrow may be needed to see if it is making the right types and amounts of blood cells. Usually marrow is taken from the hip bone with a special bone marrow needle. The child lies on his or her side and is properly positioned by the nurse. The doctor puts on gloves and cleans the area with an antiseptic soap. The needle is placed into the bone and a syringe is used to take marrow out. Sometimes a small piece of bone is also taken (bone marrow biopsy). The procedure is painful unless appropriate pain-control steps are taken.

Specific methods of pain control for bone marrow procedures are:

Explanation: The reason for the bone marrow aspiration and how the procedure will be done should be explained.

Play: For younger children, anxiety may be reduced by doing a bone marrow aspiration on a doll. Adolescents may wish to write a story or poem, or draw a picture about the procedure.

Relaxation: Children and adolescents who have practised relaxation, and can do it well, may find it very effective in relieving anxiety.

Problem solving: Older children and adolescents can problem solve with a parent or health professional to find the best strategies for their own situation.

Local anaesthetic: An injected local anaesthetic should be used to numb the deeper tissues. EMLA® should also be used to prevent pain from the needle and the burning feeling as the local anaesthetic goes in.

Conscious or deep sedation: Since bone marrow procedures can be frightening and painful, children should be offered conscious or deep sedation. Some older children may decide to stay awake during bone marrows. In these cases, relaxation, distraction, EMLA®, and local anaesthetic may be sufficient.

CENTRAL VENOUS ACCESS

When children need frequent intravenous medicines, blood products, and blood tests, it becomes harder to find a usable vein. Fortunately, there are new ways to easily access a child's veins. These are known as "central venous access lines" or "central lines". A central line is a permanent intravenous tube or catheter which can stay in place as long as it is needed. There are two main types of central lines. One type is entirely under the skin (an "interna" line) and the other has tubing outside the skin (an "external" line). Both have a long thin tube that reaches the large vein that goes to the heart.

Internal lines (such as the Port-a-Cath®) cannot be seen once they are under the skin. The internal line is placed in the upper part of the child's chest by a surgeon in the operating room while the child is under general anaesthesia. In order to use the internal line, a needle is put through the child's skin into a reservoir (see diagram). To prevent infection during the use of the internal line, the skin over it will be washed with an antiseptic soap. The nurse or doctor will wear surgical gloves and often use a face mask. The needle may be kept in for only a few moments, or for several days. If the needle is to stay in, a special dressing will be used to cover the needle. Once the needle is in place, it is not painful.

If the needle going through the skin causes pain, EMLA® and the other methods described for venipunctures should be used.

External central lines have tubing outside the skin (usually on the child's chest). To use this type of line, a needle is placed through the end of the tubing. This is not painful.