Appraisal of Systematic Review


Appraisalof Systematic Review

Venipunctureand venous cannulation remain two of the most common yet mostchallenge procedures in pediatric and adult medical care. Manyproviders who do not treat infants, for example, are oftenuncomfortable performing these procedures because of theinsurmountable amount of pain involved. Consequently, children,parents, and even some healthcare professionals may be anxious wheninserting an intravenous catheter becomes necessary (Higgins &ampGreen, 2011). Venipuncture as the name implies consists of puncturinga vein and it continues to be the primary method for obtaining bloodsamples for children and adults. On the other hand, IV cannulation orperipheral venous access provides a means of maintaining or replacingbody stores of fluid or blood volumes, restoring acid-base balance,and administering medications. Both adults and children who requirevenipuncture or intravenous access procedures pose a dilemma for aclinician who wishes to make this a painless procedure. Recentadvances have demonstrated that many percutaneous procedures can beperformed painlessly. For instance, ample evidence exists to showthat lidocaine-prilocaine cream is an excellent trans-dermalanesthetic for procedures such as venipuncture, intravenousplacement, and injections (Todd, Funk, &amp Bonacci 1996). Skinrefrigerants or Vapocoolants have been associated with pain reductionfor IV cannulation and venipuncture. Some studies have documentedevidence to suggest that vapocoolants are effective in both childrenand adults during these procedures, while other studies questiontheir effectiveness. In this analysis, the following determinationwill be made: in adult and children are Vapocoolants compared toplacebo effective in reducing pain before venipuncture and IVcannulation.

Toanswer this question, a systematic review conducted by Hogan, et al.(2014) to assess the impact of vapocoolants in reducing pain fromvenous cannulation and venipuncture in children will be used. Thearticle review 1195 articles from Medline, EMBASE, CINAHL, and CCTR.Databases. The purpose of the review was to establish whetherVapocoolants can be recommended for pain reduction during venalcannulation or venipuncture for both adults and children.


Thisstudy involved a review of 1195 of which 692 were from Medline, 293from EMBASE, 105 from CINAHL, and 105 from CCTR. Of these, 196 wereconsidered to be duplicates and therefore only 999 abstracts werereviewed. When excluded by way of the title of abstract, 963 did notqualify for full review and only 36 papers are fully reviewed. Thefinal meta-analyses study utilized 12 articles.


Thereview evaluated studies that examined the impact of vapocoolants onpaint reduction for adults relative to placebo. It was established intwo of the reviewed article, which involved 289 participants thatthere was statistically significant reduction of pain whenVapocoolants are use compared to placebo. A similar observation wasmade on six articles, which involved 482 adults. In these studies, astatistical difference was found in pain after Vapocoolantpre-treatment. Some studies reported pain after the administration ofvapocoolants during cannulation and venipuncture. These studies weremeta-analyzed and found to report adverse effects in cases wherevapocoolants was used.

Consequently,it was established from the meta-analyses that vapocoolants inchildren and adults undergoing I.V cannulation or venipuncture wereineffective when compared to placebo but effective when noalternative treatment was used. In children, vapocoolants wereobserved to be ineffective compared to placebo or no treatment.Statistically, the magnitude of benefits associated with vapocoolantsin adults was established as -10 mm. These results were consistentwith the clinically determined minimal pain 9-13 mm. However, theresearchers concluded that the reported good news might have been asa result of the placebo effect.

Finally,vapocoolants were observed to be more painful to apply for adultscompared to placebo sprays however, there was no data available forthe same observation for children.

Whilethe review results confirmed authoritatively the ineffectiveness forVapocoolants in IV cannulation and venipuncture, in both adults andchildren, numerous limitations could not be avoided. For instance,the findings in this review included the presence of heterogeneityand potential biases emanating from the studies reviewed.Consequently, there were inconsistent results from the review,particularly when the meta-analysis was performed on studies ofvapocoolants vs. placebo and single studies for nitrous oxide. Whilethe single study showed a reduction in pain, the meta-analysis didnot show any reduction in pain. Nevertheless, the inclusion ofrandomized or quasi-randomized controlled trials was a major strengthof the study.

Levelof Evidence

Thelevel of evidence in medical research refers to the ranking systemused in evidence-based practice to weigh the strengths and weaknessesof a research study or a clinical trial. There are five main levelsof evidence to consider when assessing the quality of a researchstudy. Level 1, Level II, Level III, Level IV and Level V. For sstudy to qualify as level I, it has to be high quality randomizedtrials or prospective studies testing previously developed diagnosticprocedures on various patients. It should demonstrate sensibility incosting the alternatives and assess the studies obtained withmultiway sensitivity analyses. A systematic review of level I RCTsand Level I studies also qualifies as a Level I study.

LevelII research are less quality Random Controlled Trials, retrospectivestudies, comparative studies, untreated controlled studies from RCTsor less quality prospective studies. Consequently, the systematicreview of level II studies or Level I studies with incoherent resultsqualifies as a level II review. Level III studies includecase-control studies, retrospective comparative studies, andsystematic review of level III studies. Level IV studies arecharacterized by poor reference standards, lack of sensitivityanalyses, case-control studies, and case series. Finally, level Vstudies are purely expert opinion on particular subjects.

Qualitywise, Level I research has high-quality standards and is moresuperior, rigorous, and reliable than Level II research. As such,Level I research has stronger evidence. The current review qualifiesas a Level I research. This is because the review assesses theevidence presented in studies that meet the rigorous standards ofLevel I. As stated above, reviews that scrutinize studies that meetLevel I criterion qualify as Level I studies.

Authors`Definitive Conclusion about the use of Vapocoolants

Theauthors concluded that Vapocoolants are ineffective in children andadults when compared to placebo but effective in adults when there isno other form of treatment. In their view, Vapocoolants should not berecommended for routine use in children or adults.

EBPOpinion on the proposed Plan to use Vapocoolants on children andadults

Basedon the evidence presented in the literature, Vapocoolants should notbe used on either children or adults during IV cannulation orvenipuncture. Furthermore, there is no significant evidence tosuggest that they are more effectiveness than the existing nursingpractices.


Higgins,JPT, &amp Green, S. (2011). CochraneHandbook for Systematic Reviews of Interventions Version 5.1.0 TheCochrane Collaboration.

Hogan,et al. (2014). A systematic review of vapocoolants for reducing painfrom venipuncture and venous cannulation in children and adults. TheJournal of Emergency Medicine,47(6), pp. 736โ€“749

Todd,K.H., Funk, K.G., Funk, J.P., &amp Bonacci, R. (1996). Clinicalsignificance of reported changes in pain severity. AnnEmerg Med27, pp. 485โ€“9.