If you wish to respond to a paper or other item already published in the BJA, please go to the abstract/full text version of that item and click on the link "E-Letters: Submit a response to the article".
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E-letters: Electronic letters published:
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Re: Re: The Reduction of Pain During Intravenous Cannulation
- Benjamin O Titford (29 February 2008)
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Re: The Reduction of Pain During Intravenous Cannulation
- Allan M Cyna (22 January 2008)
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The Reduction of Pain During Intravenous Cannulation
- Steven M. Neustein (10 January 2008)
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Change is immortal
- Rajinikanth Sundararajan, Yogini Kalamkar, Plymouth Hospitals NHS Trust, UK (10 January 2008)
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A neutral or positive warning is OK! Negative suggestions are not!
- Allan M Cyna (8 December 2007)
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Warning is bad: An oxymoron to normal practice?
- Santhanam Suresh (3 December 2007)
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Thank you Dr. Dutt-Gupta
- Kent P Weinmeister (6 November 2007)
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Benjamin O Titford, FTSTA Anaesthetics
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I was very interested to read a paper demonstrating the negative impact of language on patients' experience. I wonder in a similar vein, whether our use of the word 'painkiller', with its very unpleasant component-words reduces the effectiveness of analgesia, paticularly in children. Conflict of Interest:None declared |
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Allan M Cyna, Senior Consultant Anaesthetist Women's and Children's Hospital, Adelaide, SA 5006, Australia
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In response to Dr Sundararajan’s query regarding the timing of the intervention, we stated that the “opaque, sealed envelopes were opened by the anaesthetist performing the procedure (J.D.-G.) approximately 1 min before i.v. cannulation.” We can confirm that the intervention was administered at this time point. Dr Sundararajan also states that “Patients fear surgery significantly more than anaesthesia”, however to our knowledge there is no clear evidence for this. The reference quoted supporting this statement did not report a comparison of anaesthesia fears with those of surgery and in any event found that “the time in-hospital awaiting surgery” provoked the most concern for patients. In response to the final point raised, we did not specifically note whether patients looked away during the cannula insertion, however this should be documented in future studies. We agree with Dr Neustein that “The suggestion of more pain may lead to the perception of more pain.” Dr Neustein also asks for data supporting the statement in our paper that “this is contrary to generalized belief?” For an answer one has to look no further than the other correspondence to our paper from Dr Sundararajan that “Beyond doubt, the authors must have raised the eyebrows of many experienced anaesthetists for contradicting their age old practice.” or Dr Weinmeister who comments that residents have learned their negative language “from their peers and mentors”. At least one published observational study [1] referenced in our original manuscript and a more recent observational study by our team in Adelaide reports the frequent use of negative language in clinical practice.[2] Dr Neustein appears to have inadvertently misrepresented the statement made to the patients in our study that “the tourniquet causes the arm to become heavy, numb, and tingly” which in his opinion is “neither appealing, nor true in most instances.” In fact the actual statement made to patients: ‘I am going to apply the tourniquet on the arm. As I do this many people (not most) find (not causes) the arm becomes heavy, numb and tingly and allows the drip to be placed more comfortably.’ This statement suggests indirectly that if (or when) the patient experiences a tingly, heavy numb arm they too will experience the drip placement more comfortably! We agree with Dr Neustein that other statements need investigating. However it is the belief of the operator that the procedure will be performed comfortably (or not), rather than the actual words used, that is most likely to contribute to the subconscious patient response. We agree that the use of local anesthesia can be beneficial in reducing pain when placing a large guage intravenous cannula. The explanation that “the local anaesthetic will numb the skin to allow the drip to be placed more comfortably than otherwise” is likely to be a more useful statement than the one we commonly hear: “this is going to sting!” References: [1] Lang EV, Hatsiopoulou O, Koch T, et al. Can words hurt? Patient–provider interactions during invasive procedures. Pain (2005) 114:303–9 [2] Carlyle AV, Ching PC, Cyna AM. Communication during induction of paediatric anaesthesia: an observational study. An Int Care, 2008;36:(2) In Press. Conflict of Interest:None declared |
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Steven M. Neustein, MD, Anesthesiology The Mount Sinai Medical Center
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I read with interest the article entitled “Effect of communication on pain during intravenous cannulation: a randomized controlled trial”, by Dr. J Dutt-Gupta et al (1). The authors successfully demonstrated that the warning of a “sting” prior to placement of intravenous (IV) cannula may not be helpful. The authors state in the discussion that their results suggest that “the procedure is less painful and better tolerated when no warning of a sting is given and is quite contrary to what is generally believed.” This was an interesting study, but I disagree with the authors’ assertion quoted above that this is contrary to what is generally believed. What data is there to support the statement that this is contrary to generalized belief? It is common knowledge that there is a placebo effect or power of suggestion, which is why studies are done in a double blinded placebo controlled manner if possible. The suggestion of more pain may lead to the perception of more pain. Additionally, the statement made to the patients that “the tourniquet causes the arm to become heavy, numb, and tingly” in my opinion, is neither appealing, nor true in most instances. There was a higher, but not significant increase, in withdrawal response in Group S. The results of this study might be taken one step further, to simply tell patients prior to IV placement,” I am going to place the IV, and it is important to not move.” This statement would not carry any negative information. Additionally, the use of local anesthesia is beneficial in reducing pain when placing larger IVs, which should be explained to patients if being used. Reference: 1. Dutt-Gupta J, Bown T, Cyna AM. Effect of communication on pain during intravenous cannulation: a randomized controlled trial. British Journal of Anaesthesia (2007) 99: 871-875. Steven M. Neustein, M.D., Mount Sinai Medical Center, One Gustave L. Levy Place, Box 1010, Dept. of Anesthesiology, New York, NY 10029-6574, Telephone (212) 241-7467, Fax: 212-426-2009 Email: steve.neustein@mountsinai.org Conflict of Interest:None declared |
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Rajinikanth Sundararajan, Specialist Registrar in Anaesthetics Plymouth Hospitals NHS Trust, UK, Yogini Kalamkar, Plymouth Hospitals NHS Trust, UK
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It was interesting to read J. Dutt-Gupta and colleague’s comprehensive study, emphasising the effect of negative remarks on pain during venous cannulation, but we would like to share our observations on this study [1]. Beyond doubt, the authors must have raised the eyebrows of many experienced anaesthetists for contradicting their age old practice. We agree that pessimistic verbalisation may not be well received by the patients in their stressed and hypnotic frame of mind and could possibly make a difference to their outcome. We regularly perform a ‘Cough Trick’ during venipuncture as stated by Taras I. Usichencko and colleagues, as “Distraction” a well known cognitive method of pain reduction through the direction of attenuation to a nonnoxious stimulus [2, 3]. Author’s discovery of an easily performed and inexpensive method for reducing pain during venous cannulation, may perhaps be substantiated with the inclusion of following information. Pain being a complex symptom due to its subjective nature, a cross over study might have added more impact to the results. Hypoglycaemia accompanies various pain conditions, could even exaggerate the pain [4]. We believe diverse nature of the starvation periods among patients might have influenced their pain threshold. Blood sugar measurement during the procedure might have solved this issue. Circadian oscillations of pain sensitivity are well explained in the literature, procedure could have been dutifully conducted at a fixed time [5]. Authors failed to mention the timing of the intervention in the article. Patients fear surgery significantly more than anaesthesia [6]. We assume selecting patients undergoing same surgical procedure might have been wiser. Finally, we also wonder whether interventions were carried out when patients looking at the course of action or away from it. References: 1. J. Dutt-Gupta, T. Bown and A. M. Cyna. Effect of communication on pain during intravenous cannulation: a randomized controlled trial. Br J Anaesthesia 2007; 99: 871-5 2. Taras I. Usichenko, Dragan pavlovic, Sebastaian Foellner, and Michael Wendt. Reducing Venipuncture pain by a cough trick: A randomized crossover volunteer study. Anaesth Analg 2004; 98: 342-5 3. Fernandex E, A classification system of cognitive coping strategies for strategies for pain. Pain 1986; 26: 141-51 4. Buskila D. Fibromyalgia, Chronic fatigue syndrome, and myofascial pain syndrome. Curr Opin Rheumatol 2000; 12: 113-23 5. Procacci P, Corte MD, Zoppi M, Maresca M. Rhythmic changes of the cutaneous pain threshold in man: a general review. Chronobiologia 1974; 1: 77-96 6. Kindler CH, Harms C, Amsler F, Ihde-Scholl T, Scheidegger D. The visual analog scale allows effective measurement of preoperative anxiety and detection of patients' anesthetic concerns. Anaesth Analg 2000; 90: 706-12 Conflict of Interest:None declared |
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Allan M Cyna, Senior Consultant Anaesthetist Women's and Children's Hospital, Adelaide, SA 5006, Australia
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We thank Dr Santhanam for his comment on our article. It is well recognised by the hypnotherapeutic community that children and adults when stressed are in a hypnotic frame of conscious awareness most of the time and therefore highly receptive and responsive to suggestions - be these negative or positive. In the stressful hospital environment, this responsiveness can be utilised therapeutically. We agree that the power of suggestion regarding pain in the postoperative period may well contribute to both its duration and severity experienced after procedures. As Dr Santhanam notes, the same technique used in our study could be adapted to the taking of blood samples though this has yet to be tested formally. Although our trial has investigated two different types of warnings prior to the procedure it appears from at least one other study that even a negative suggestion is better than no warning at all, at least in children.[1] We agree that an understanding of this use of language is likely to be critical in eliciting subconscious responses that may well make a difference to patient outcomes. References 1.Spafford PA, von Baeyer CL, Hicks CL. Expected and reported pain in children undergoing ear piercing: a randomized trial of preparation by parents. Behaviour Research and Therapy 40 (2002) 253–266 Conflict of Interest:None declared |
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Santhanam Suresh, Pediatric Anesthesiologist Children's Memorial Hospital, USA
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I read with great interest this study and muse myself about the number of times that I have observed the same thing with older children particularly adolescents. I wonder if the power of suggestion regarding pain in the postoperative period may contribute to an increased duration of pain after moderate procedures. This article alludes to the power of suggestion and is intriguing as we look at the entire dimension of the human being rather than the nociceptive aspect of pain. I wonder if utilizing the same technique for blood draws in the hospital may decrease pain. There is no doubt that as our specialty improves and we become more sophisticated, yet the appeal to human senses is what may make the difference to outcomes. Conflict of Interest:None declared |
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Kent P Weinmeister, MD -Anesthesiologist, Asst. Prof. Mayo Clinic Arizona
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Dear Dr.Dutt-Gupta: Your article re communication during intravenous (IV) cannulation confirms my belief that a negative connotation communicated prior to a procedure effects a negative outcome. I have been telling residents for years not to yell "stick and a burn" prior to numbing the skin prior to any procedure, such as an IV start or nerve block. They have learned this verbal clue from their peers and mentors, I presume, as they almost universally say it, at least here in the U.S. What I teach them to do, prior to anesthetizing the skin, for example for an epidural steroid injection, is to thump the area to be needled gently, and tell the patient they may feel a little pressure in that area. This is, in effect, using gate theory to attenuate the small fibers firing and the stinging effect of the needle. A veterinarian would never inject a cow in the rump area without tapping the area first - they have learned that this prevents getting kicked! Thank you for obtaining data to confirm my teaching. Conflict of Interest:None declared |
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