title: First do no harm: pain relief for the peripheral venous cannulation of adults, a systematic review and network meta-analysis.
abstract: Peripheral venous cannulation is an everyday practice in hospitals, which many adults find painful. However, anaesthesia for cannulation is usually only offered to children. Inadequate pain relief is not only unpleasant for patients but may cause anxiety about further treatment and deter patients from seeking medical care in the future. The aim of this study is to discover the most effective local anaesthetic for adult peripheral venous cannulation and to find out how the pain of local anaesthetic application compares with that of unattenuated cannulation.
  
  
  
  These aims are addressed through a systematic review, network meta-analysis and random-effects meta-analysis. Searching covered 12 databases including MEDLINE and EMBASE from 1990 to August 2015. The main included study design was RCTs. The primary outcome measure is self-reported pain, measured on a 100 mm visual analogue scale.
  
  
  
  The systematic review found 37 includable studies, 27 of which were suitable for network meta-analysis and two for random-effects meta-analysis. The results of the network meta-analysis indicate that none of the 17 anaesthetic considered had a very high probability of being the most effective when compared to each other; 2 % lidocaine had the highest probability (44 %). When the anaesthetics were compared to no treatment, the network meta-analysis showed that again 2 % lidocaine was estimated to be the most effective (mean difference -25.42 (95 % CI -32.25, -18.57). Other members of the 'caine' family were also estimated to be more effective than no treatment as were Ametop®, EMLA®and Rapydan®patch. The meta-analysis compared the pain of anaesthetic application with the unattenuated pain of cannulation. This found that all applications of local anaesthetic were less painful than cannulation without local anaesthetic. In particular a 1 % lidocaine injection was estimated to be -12.97 (95 % CI -15.71, -10.24) points (100 mm VAS) less painful than unattenuated cannulation.
  
  
  
  The pain of peripheral venous cannulation in adults can be successfully treated. The pain of application of any local anaesthetic is less than that of unattenuated cannulation. Local anaesthetic prior to cannulation should become normal practice and a marker of high quality care.
  
  
  
  The protocol for the larger study was registered with PROSPERO no. CRD42012002093 .
authors.affiliation: University of Exeter Medical School, University of Exeter, Veysey Building, Salmon Pool Lane, Exeter, EX2 4SG, UK.
authors.forename: Mary
authors.initials: M
authors.lastname: Bond
authors.affiliation: University of Exeter Medical School, University of Exeter, Veysey Building, Salmon Pool Lane, Exeter, EX2 4SG, UK. L.Crathorne@exeter.ac.uk.
authors.forename: Louise
authors.identifier: 0000-0001-8018-517X
authors.initials: L
authors.lastname: Crathorne
authors.affiliation: University of Exeter Medical School, University of Exeter, Veysey Building, Salmon Pool Lane, Exeter, EX2 4SG, UK.
authors.forename: Jaime
authors.initials: J
authors.lastname: Peters
authors.affiliation: University of Exeter Medical School, University of Exeter, Veysey Building, Salmon Pool Lane, Exeter, EX2 4SG, UK.
authors.forename: Helen
authors.initials: H
authors.lastname: Coelho
authors.affiliation: University of Exeter Medical School, University of Exeter, Veysey Building, Salmon Pool Lane, Exeter, EX2 4SG, UK.
authors.forename: Marcela
authors.initials: M
authors.lastname: Haasova
authors.affiliation: University of Exeter Medical School, University of Exeter, Veysey Building, Salmon Pool Lane, Exeter, EX2 4SG, UK.
authors.forename: Chris
authors.initials: C
authors.lastname: Cooper
authors.affiliation: Department of Anaesthesia, Royal Devon and Exeter Foundation Trust, Exeter, UK.
authors.forename: Quentin
authors.initials: Q
authors.lastname: Milner
authors.affiliation: Vascular Access team, Royal Devon and Exeter Foundation Trust, Exeter, UK.
authors.forename: Vicki
authors.initials: V
authors.lastname: Shawyer
authors.affiliation: University of Exeter Medical School, University of Exeter, Veysey Building, Salmon Pool Lane, Exeter, EX2 4SG, UK.
authors.forename: Christopher
authors.initials: C
authors.lastname: Hyde
authors.affiliation: Research Design Service South West, Exeter, UK.
authors.forename: Roy
authors.initials: R
authors.lastname: Powell
mesh_terms: D000779:Anesthetics, Local / Q000009:adverse effects / Q000627:therapeutic use*; D002406:Catheterization, Peripheral / Q000379:methods* / Q000523:psychology*; D006801:Humans; D010146:Pain / Q000188:drug therapy*; D010147:Pain Measurement / Q000187:drug effects*
chemical_list: D000779:Anesthetics, Local
keywords: Adult; Local anaesthetic; Network meta-analysis; Pain; Peripheral venous catheterization; Systematic review