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Purpose of Review: Iron overload disorders such as hemochromatosis involve unregulated absorption of dietary iron, leading to excessive iron accumulation in multiple organs. Phlebotomy is the standard of care for removal of excess iron, but dietary modification is not standardized in practice. The purpose of this article is to help standardize hemochromatosis diet counseling based on commonly asked patient questions., Recent Findings: The clinical benefit regarding dietary modification in iron overload patients is limited due to lack of large clinical trials, but preliminary results are promising. Recent studies suggest diet modification could reduce iron burden in hemochromatosis patients resulting in less annual phlebotomy as supported through small patient studies, concepts of physiology, and animal studies., Summary: This article is a guide for physicians to counsel hemochromatosis patients based on commonly asked questions such as foods to avoid, foods to consume, use of alcohol, and use of supplements. The goal of this guide is to help standardize hemochromatosis diet counseling to reduce phlebotomy amount in patients. Standardization of diet counseling could help facilitate future patient studies to analyze the clinical significance., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Newborns in NICUs experience many painful procedures. The aim of the study was to evaluate the effect of whole body massage therapy on pain scores during venipuncture and to compare with oral 10% dextrose and Kangaroo care., Study Design: Newborns with gestational age ≥34 weeks were randomly enrolled to one of three groups: dextrose, massage and Kangaroo care and a blinded investigator scored the pain using NIPS before and during the procedure., Results: There were 25, 26 and 23 newborns in dextrose, massage and Kangaroo care groups, respectively. Pain scores were similar before and during venipuncture in groups (p > 0.05). 36.5% of newborns (27/74) had severe pain scores. Number of newborns with no pain (score 0-2), moderate pain (score 3-4) and severe pain (score 5-7) were similar in each group., Conclusion: Massage, Kangaroo and oral 10% dextrose had similar effects on pain scores during venipuncture., (© 2022. The Author(s), under exclusive licence to Springer Nature America, Inc.)

Background: Today, due to the side effects of drugs, there is a greater desire to use non-pharmacological interventions to relieve pain caused by painful procedures. Using non-pharmacological interventions in combination is more effective than using them alone in relieving the pain of infants. Reducing sensory and environmental stimuli such as visual and auditory stimuli is one of the non-pharmacological methods to relieve pain. The aim of this study was to investigate the effect of using eye shield and ear muffs on pain intensity during venous blood sampling of premature infants., Methods: In this clinical trial study, 148 premature neonates admitted to the Neonatal Intensive Care Unit of Rouhani and Children Hospitals in Babol were randomly assigned to four groups of 37. Fifteen minutes before intravenous blood sampling until 15 min later, in the first group, eye shield; in the second group, ear muffs, and in the third group, eye shield plus ear muffs were used. In the fourth group (control), blood sampling was performed routinely. NIPS pain scale and demographic questionnaire were used to collect the data., Results: The results showed that during the venous blood sampling was a significant difference between the mean pain intensity of neonatal in the eye shield plus ear muffs group (3.14 ± 0.71), the ear muffs group (4.43 ± 1.21), the eye shield group (5.41 ± 1.04).) and the control group (5.94 ± 0.84) (P = 0.001). Moreover, after the venous blood sampling, there was a significant difference between the mean neonatal pain intensity in the eye shield plus ear muffs group (1.19 ± 0.39), the ear muffs group (1.43 ± 0.50), the eye shield group (1.33 ± 0.37) and the control group (1.89 ± 0.90) (P = 0.001)., Conclusions: In this study, the pain severity during and after venous blood sampling in the ear muffs plus eye shield was lower than in other groups. Therefore, a combination of ear muffs and eye shield is recommended as a better pain reliever when performing venous blood sampling in premature infants., (© 2023. The Author(s).)

Introduction: Shortly after birth, neonates are exposed to several painful medical procedures, such as newborn metabolic screening, vaccination and venipuncture, without proper management of pain. Unpleasant experiences during the neonatal period are proven to be associated with negative long-term consequences. Non-pharmacological interventions have been studied, although rarely administered and seldom documented. The aim of this systematic review was to assess non-pharmacological approaches to neonatal pain during diagnostic and treatment procedures., Evidence Acquisition: Extensive literature research to access randomized controlled trials on non-pharmacological pain management in neonates was performed in MEDLINE (through PubMed), Scopus and Web of Science from October 2011 to September 2021. First analysis included all article titles and abstracts screening to identify relevant studies, and second analysis included a full-text screening of previously selected studies. Eligibility was assessed independently by two authors, and disagreements were resolved by discussion and consensus. In the end, 19 published studies were included, representing a total of 1930 newborns. Main outcome, neonatal pain, was assessed by different neonatal pain evaluation scales., Evidence Synthesis: Non-pharmacological interventions including sucrose/glucose solutions, non-nutritive sucking, breastfeeding, olfactive stimulus, auditory stimulus and sensory stimulus (skin-to-skin care, kangaroo/maternal holding, heat, therapeutic massage, swaddling/facilitated tucking and acupressure) showed decreased behavioral and physiologic pain responses., Conclusions: Evidence suggests non-pharmacological approaches are safe, effective and can be easily applied in daily practice. There is the need for continued research on non-pharmacological interventions on neonatal pain to help healthcare providers build a tailored pain treatment plan for neonates submitted to procedural pain.

Objectives: To determine the effect of flippits versus virtual reality on pain, fear and satisfaction among children during phlebotomy., Method: The quasi-experientialstudy was conducted at the Paediatric Medical Department of Kafrelsheikh University Hospital, Egypt, from November 2021 to April 2022, and comprised children of either gender aged 6-12 years. The subjects were randomised into flippits group A, virtual reality group B and control group C in which only traditional care was provided. Data was collected using a structured interview, Wong-Baker Faces Pain Rating Scale, Children's Fear Scale, and Blood Specimen Collection Satisfaction Evaluation Scale. Data was analysed using SPSS 20., Results: Of the 120 children, 40(33.3%) were in each of the three groups. There were 21(52.5%) boys and 19(47.5%) girlsin group A with mean age 8.2±1.6 years, 22(55%) boys and 18(45%) girlsin group B with mean age 7.8±1.7 years, and 27(67.5%) boys and 13(32.5%) girls in group C with mean age 7.9±1.9 years (p>0.05). Mean pain and fear scores were significantly lower and mean satisfaction score was higher in groups A and B than group C (p<0.05). There was no significant difference in the mean pain scores of group A and group B (p>0.05)., Conclusions: Flippits and virtual reality interventions had a positive effect on pain, fear and satisfaction levelsin children during phlebotomy.

Background: Venipuncture is a common and quiet unpleasant experience for pediatric patients. The pain associated with venous cannulation disturbs the children. Different methods have been used to minimize the pain. The present study evaluated the efficacy of holding and pressing the tip of the nose on the venipuncture pain in pediatric patients., Methods: A prospective randomize controlled study carried out using the Visual Analogue Scale (YAS) for assessment cannulation pain and the Yale Preoperative Anxiety Scale (YPAS) for the assessment of anxiety before cannulation. Sixty patients aged 6 to 12 years, who needed venipuncture for general anesthesia, were divided into two groups of 30 each: a control group and a study group. Nasal tip was held and pressed during venipuncture by the parents in the study group. No intervention was done in the control group., Results: The YPAS scores were not different between the two groups before venous cannulation (P=0.136). Comparing the two groups. There was no difference regarding the change in HR and BP during venous cannulation. There was significantly lower cannulation pain in the study in comparison with the control group (P=0.010)., Conclusions: Holding and pressing the tip of the nose during venipuncture reduce the severity of venipuncture pain in pediatric patients. This could be secondary to distraction along with the physiological effect of the Valsalva maneuver on pain. Therefore, we recommend that holding and pressing the tip of the nose is a safe and effective method for reducing the severity of pain from venipuncture in pediatric patients.

Background: Phlebotomy can be an uncomfortable and even painful experience that increases in likelihood in patients who require frequent blood draws, such as those with cancer. The 25-gauge BD Vacutainer® UltraTouch™ Push Button Blood Collection Set has a smaller outer bore needle size and unique bevel configuration, which in theory should reduce pain associated with phlebotomy. Smaller needles typically cause less pain, however, they have a higher incidence of compromising the specimen integrity. Innovative engineering allows this particular needle to maintain a larger inner bore size similar to a standard 23-gauge needle. This study compares pain and specimen integrity between this novel device and a standard 23-gauge needle., Methods: Two cohorts of 190 patients each had phlebotomy performed with either needle. Pain experienced was assessed by patient surveys, rating pain from 0 (low) to 10 (high). Sample integrity was assessed by determining the hemolysis index (Abbott Architect c8000)., Results: No statistically significant difference in median pain scores was observed between the 2 cohorts, P-value: 0.068. The 23-gauge cohort more frequently reported 3+ pain than the 25-gauge cohort, 14/190 vs 5/190. Pain scoring 1 and 2 was more frequent in the 25-gauge cohort, 84/190 vs 54/190. Pain scores of 0 were more frequent in the 23-gauge cohort, 122/190 vs 101/190. This stratification is statistically significant, P-value: 0.003. The 25-gauge needle showed no increase in hemolysis rates, P-value: 0.5., Conclusions: Sample integrity was identical between both needles. The 25-gauge needle resulted in less 3+ pain, while pain scoring 1 and 2 was more frequent in the 25-gauge cohort., (© American Association for Clinical Chemistry 2023. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Vasovagal syncope (VVS) or reflex is usually caused by physical and mental stress-related factors, like pain, anxiety, and fear, and it is one of the most frequent complications during dental treatment. Two patients, both with histories of dental phobia and of VVS during vaccination, venipuncture, and dental treatment with local anesthetics, were scheduled for dental treatment under intravenous (IV) sedation. However, both experienced episodes of VVS that occurred during venipuncture using a 24-gauge indwelling needle. We determined that pain was the main trigger of VVS for these patients and attempted to reduce venipuncture-associated pain using 60% lidocaine tape applied 3 hours before venipuncture at their next dental visits, respectively. Use of the lidocaine tape was successful and permitted comfortable placement of the IV catheter without any onset of VVS., (© 2023 by the American Dental Society of Anesthesiology.)

Objectives: Medical needle procedures are a common source of pain, distress, and fear for children, which can worsen over time and lead to needle noncompliance and avoidance, if unaddressed. Children's pain experience is multiply determined by external (e.g., parent behaviors) and internal (e.g., cognitive and affective) factors. Some parent behaviors (e.g., reassurance, giving control to child, empathy, apologies, criticism) have related to poor child pain experiences. No research has examined how children's internal emotion regulation, commonly measured via heart rate variability (HRV), may buffer, or strengthen this association. This study is the first to examine child HRV in relation to pain experiences, and as a moderator between a constellation of parent behaviors (reassurance, giving control, empathy) and child pain, fear, and distress., Methods: Sixty-one children aged 7-12 years undergoing venipuncture and a parent participated. Child HRV was measured before the procedure. After venipuncture, children rated their pain and fear. Parent and child behaviors during venipuncture were coded using the "distress promoting" and "distress" composites of the Child-Adult Medical Procedure Interaction Scale-Revised., Results: Children with lower HRV displayed greater distress. Child HRV moderated the positive association between parent behaviors (reassurance, giving control, empathy) and child distress such that the association was strongest among children with low HRV., Conclusions: Findings suggest children with lower HRV, indicative of lower emotion regulation capacity, may be at risk of experiencing higher levels of distress and may be more vulnerable to distress when facing parent reassurance, giving control, and empathy verbalizations during venipuncture., (© The Author(s) 2022. Published by Oxford University Press on behalf of the Society of Pediatric Psychology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: The aim was to evaluate the effectiveness and safety of the vapocoolants for vascular puncture in children and adults., Method: The search was carried out in PubMed, Web of Science, Embase and The Cochrane Library, from inception to March 2022. Randomized controlled trials comparing vapocoolants to control conditions for participants received intravenous cannulation or arterial puncture were included. Two reviewers independently performed selection of studies, data extraction, and assessment of risk of bias. The analysis was performed using fixed or random-effects model with mean differences or standardized mean difference and risk ratios., Results: A total of 25 studies involving 3143 participants were included. Compared with control conditions, vapocoolants may not decrease the pain of patients with arterial puncture (SMD = -0.36, 95% CI = -0.92 to -0.19, P = 0.20), but may more effectively relieve pain for adults received vein puncture (SMD = -0.65, 95% CI = -0.85 to -0.45, P < 0.00001). The application of vapocoolant increased the procedural difficulty of medical personnel (RR = 2.49, 95% CI = 1.62 to 3.84, P<0.000 1) and participants were more willing to use the spray in the future (RR = 1.88, 95% CI = 1.34 to 2.64, P = 0.0002). There was no significant difference for the first attempt success rate of the procedure and the occurrence of adverse events., Conclusions: Vapocoolant spray may relieve pain in adults received vein puncture and cannot cause severe side effects, but is ineffective in children. It also had no effect on patients with arterial puncture. In addition, the application of spray increases procedural difficulties for medical professionals, but does not decrease first attempt success rate, and many patients would like to use the spray again for pain relief in the future. Thus, more rigorous and large-scale studies are needed to determine its effectiveness in vascular access., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Wang et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Venipuncture is a routine nursing procedure in the pediatric ward for blood collection and transfusion. However, this procedure can cause severe pain and distress if not adequately managed., Methods: Children aged 3-16 years old were randomized into three groups: EMLA group, distraction group, and combined group. The primary outcome was children's self-reported pain scored using the Wong-Baker FACES® Pain Rating Scale. The parents-reported and observer-reported pain were scored using the Revised Face, Legs, Activity, Cry and Consolability Scale, and children's salivary cortisol levels, heart rate, percutaneous oxygen saturation, venipuncture duration and retaining time of IV cannulas were the secondary outcomes., Results: A total of 299 children (167 male, 55.8%, median age 8.5) were enrolled: EMLA group (n = 103), distraction group(n = 96) and combined group(n = 100). There was no statistical difference in self-reported pain (P = 0.051), parent-reported pain (P = 0.072), and observer-reported pain (P = 0.906) among the three groups. All three interventions can decrease children's pain during IV cannulations. Additionally, the distraction group's salivary cortisol levels were lower than the combined group(P = 0.013). Furthermore, no significant difference was observed in the heart rate(P = 0.844), percutaneous oxygen saturation (P = 0.438), venipuncture duration (p = 0.440) and retaining time of IV cannulas (p = 0.843) among the three groups., Conclusions: All three groups responded with slight pain during the peripheral venipuncture procedure. Therefore, medical workers in pediatric settings can use the interventions appropriate for their medical resources and availability while involving parents and children's preferences whenever possible., Trial Registration: This trial was registered on https://register., Clinicaltrials: gov/ (Gov.ID NCT04275336)., (© 2023. The Author(s).)

Background: Recent guidelines recommend avoiding venipuncture to prevent lymphedema for breast cancer patients. This study investigated whether single or multiple sterile venipuncture procedures develop a systemic inflammation or infection and increase lymphedema in the rabbit ear lymphedema model. Methods and Results: Eighteen New Zealand white female rabbits were included. The right ear lymphedema model was created by surgical procedure; then, rabbits were divided into three randomized groups. Single and multiple venipuncture procedures were applied at least the 60th day after surgery for Group I and II, respectively. Group III was a control group. C-reactive protein (CRP) and procalcitonin (PCT) levels were analyzed to determine inflammation and infection. Ear thickness measurements were applied using a vernier caliper to assess the differences in lymphedema between the ears. All rabbits were euthanized on the 90th day after surgery. Histopathological analysis was performed to evaluate lymphedema by measuring tissue thicknesses. Ear thickness measurements showed that ear lymphedema was developed and maintained with surgical operation in all groups ( p  < 0.05). There was no difference in the ear thickness measurements between and within-groups results ( p  > 0.05). CRP and PCT levels were below the lower detection levels in all groups. According to the differences of histopathological ear distances, there were significant differences within-groups for all groups ( p  < 0.05), and no differences were identified between groups ( p  > 0.05). Conclusion: This experimental study demonstrated that single or multiple sterile venipuncture procedures did not trigger infection or inflammation and did not exacerbate ear lymphedema in the rabbit ear lymphedema model.

Importance: Venipuncture is one of the most painful and distressing procedures experienced by pediatric patients. Emerging evidence suggests that providing procedural information and distraction using immersive virtual reality (IVR) may reduce pain and anxiety among children undergoing needle-related procedures., Objectives: To examine the effects of IVR on reducing the pain, anxiety, and stress experienced by pediatric patients undergoing venipuncture., Design, Setting, and Participants: This 2-group randomized clinical trial recruited pediatric patients aged 4 to 12 years undergoing venipuncture from a public hospital in Hong Kong between January 2019 and January 2020. Data were analyzed from March to May 2022., Interventions: Participants were randomly allocated to an intervention (an age-appropriate IVR intervention offering distraction and procedural information) or a control (standard care only) group., Main Outcomes and Measures: The primary outcome was child-reported pain. Secondary outcomes included child-reported anxiety, heart rate, salivary cortisol, length of procedure, and satisfaction of health care professionals with the procedure (rated on a 40 point scale, with higher scores indicating greater satisfaction). Outcomes were assessed 10 minutes before, during, immediately after, and 30 minutes after the procedure., Results: A total of 149 pediatric patients were recruited, with 86 female patients (57.7%) and 66 patients (44.3%) diagnosed with fever. Compared with the 74 participants in the control group (mean [SD] age, 7.21 [2.49] years), the 75 participants in the IVR group (mean [SD] age, 7.21 [2.43] years) reported significantly less pain (β = -0.78; 95% CI, -1.21 to -0.35; P < .001) and anxiety (β = -0.41; 95% CI, -0.76 to -0.05; P = .03) immediately after the intervention. Health care professional satisfaction in the IVR group (mean [SD] score, 34.5 [4.5]) was significantly higher than that in the control group (mean [SD] score, 32.9 [4.0]; P = .03). Moreover, the length of venipuncture procedure in the IVR group (mean [SD] duration, 4.43 [3.47] minutes) was significantly shorter than that in the control group (mean [SD] duration, 6.56 [7.39] minutes; P = .03)., Conclusions and Relevance: In this randomized clinical trial, integrating procedural information and distraction in an IVR intervention for pediatric patients undergoing venipuncture significantly improved pain and anxiety in the IVR group compared with the control group. The results shed light on the global trends of research on IVR and its clinical development as an intervention for other painful and stressful medical procedures., Trial Registration: Chinese Clinical Trial Registry identifier: ChiCTR1800018817.

Introduction: Blood loss and red blood cell (RBC) transfusion in liver surgery are areas of concern for surgeons, anesthesiologists, and patients alike. While various methods are employed to reduce surgical blood loss, the evidence base surrounding each intervention is limited. Hypovolemic phlebotomy, the removal of whole blood from the patient without volume replacement during liver transection, has been strongly associated with decreased bleeding and RBC transfusion in observational studies. This trial aims to investigate whether hypovolemic phlebotomy is superior to usual care in reducing RBC transfusions in liver resection., Methods: This study is a double-blind multicenter randomized controlled trial. Adult patients undergoing major hepatic resections for any indication will be randomly allocated in a 1:1 ratio to either hypovolemic phlebotomy and usual care or usual care alone. Exclusion criteria will be minor resections, preoperative hemoglobin <100g/L, renal insufficiency, and other contraindication to hypovolemic phlebotomy. The primary outcome will be the proportion of patients receiving at least one allogeneic RBC transfusion unit within 30 days of the onset of surgery. Secondary outcomes will include transfusion of other allogeneic blood products, blood loss, morbidity, mortality, and intraoperative physiologic parameters. The surgical team will be blinded to the intervention. Randomization will occur on the morning of surgery. The sample size will comprise 440 patients. Enrolment will occur at four Canadian academic liver surgery centers over a 4-year period. Ethics approval will be obtained at participating sites before enrolment., Discussion: The results of this randomized control trial will provide high-quality evidence regarding the use of hypovolemic phlebotomy in major liver resection and its effects on RBC transfusion. If proven to be effective, this intervention could become standard of care in liver operations internationally and become incorporated within perioperative patient blood management programs., Trial Registration: ClinicalTrials.gov NCT03651154 . Registered on August 29 2018., (© 2023. The Author(s).)

Stress is identified as a cause of transient hyperprolactinemia, whereas venipuncture is considered a source of stress for patient. The aim of this study was to investigate the association of venipuncture-induced stress with elevation of serum prolactin. This was a cross-sectional observational study conducted on a group of 150 outdoor patients visiting a tertiary care hospital. Serial sampling was performed by drawing venous blood at different time intervals (0, 30 and 60 min) by single venipuncture to measure serum prolactin to diagnose stress-induced hyperprolactinemia. The study was conducted in two phases, namely, Phase 1 and Phase 2, at different times. The Phase 1 results were divided into two groups: Group 1 (0 min) and Group 5 (pool prepared from samples collected at 0 + 30 + 60 min). Likewise, the results of Phase 2 were segregated into five groups; Group 1 (0 min), Group 2 (30 min), Group 3 (60 min), Group 4 (average of three groups), and Group 5 (pool from samples collected at 0 + 30 + 60 min). In both Phase 1 and Phase 2 of the study, there was a statistically significant (p = 0.0003 in Phase 1 and p = 0.02 in Phase 2) decrease in the mean prolactin (17.99 ± 24.76 ng/mL in Phase 1 and 19.61 ± 23.42 ng/mL in Phase 2) in the pooled samples (Group 5) in comparison to the mean prolactin (19.67 ± 27.69 ng/mL in Phase 1 and 21.06 ± 25.06 ng/mL in Phase 2) of the serum collected at 0 h (Group 1). There was no significant difference in the mean prolactin measured from the pooled samples and average prolactin calculated after individual testing from each sample collected at 0 h, 30 min and 60 min. Venipuncture-triggered fear and apprehension may result in transient hyperprolactinemia. In comparison to performing multiple testing on the samples collected at different time intervals and determining the mean, measurement of the analyte from the pooled serum is the better alternative as it can conserve both time and resources., (© 2023. The Author(s).)

Introduction: Hemolysis is more commonly seen in the emergency department and causes delays in diagnosis, hospitalization, discharge, and treatment of patients. The aim of this study was to determine the most appropriate phlebotomy method and device to reduce blood sample hemolysis in the emergency department., Methods: This prospective, comparative descriptive study involved patients who presented to the emergency department with any medical condition and required blood sampling. Patients were divided into 6 groups according to the method of phlebotomy and the device used for phlebotomy. Data were analyzed with logistic regression., Results: A total of 715 patients participated in the study. The blood sample hemolysis rate in the emergency department was 25.7%. When the hemolysis rates were compared with a steel straight needle or intravenous catheter, it was found that the use of steel straight needle significantly reduced hemolysis. Blood drawing through a 20 G intravenous catheter with Luer-Lock access device reduces the risk of hemolysis. Male sex and difficult blood collection also have been shown to increase the risk of hemolysis., Discussion: Blood should be drawn with a steel straight needle instead of an intravenous catheter. However, when that is not possible, we recommend the use of a 20 G intravenous catheter with Luer-Lock access device if a blood sample is to be drawn from intravenous line., (Copyright © 2022 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved.)

Purpose: It was aimed to evaluate the efficacy of Buzzy and cold spray in reducing pain, anxiety, and fear of children during venipuncture in the emergency department (ED)., Methods: This study is an experimental, parallel-group (intervention-control), randomized controlled, single-blind design. The study was conducted with 161 children aged 5-12 years in pediatric ED. Data were collected by the 'Personal Information Form', 'Wong Baker-Facial Expression Rating Scale', 'Child Anxiety Statement Scale', and 'Child Fear Inventory'. Data were analyzed with descriptive statistics, Mann Whitney U test, Kruskal Wallis H test, and Intraclass Correlation., Results: Descriptive features of the children were homogeneous. 'Wong Baker-Facial Expression Rating Scale', 'Child Anxiety Statement Scale', and 'Child Fear Scale' score averages of the children in the control group were higher than the children in the Buzzy group and the cold spray group (p < 0.001). The pain scores of the Buzzy group were higher than those in the cold spray group (p < 0.001). The anxiety and fear mean scores of the children in the Buzzy and cold spray groups were similar (p > 0.05)., Conclusion: It was determined that Buzzy and cold spray were more effective than standard care in reducing the level of pain, anxiety, and fear in children ages 5-12 years during venipuncture in the pediatric emergency. The cold spray was more effective in reducing pain than Buzzy., Practice Implications: Nurses can use Buzzy and cold sprays to manage the fear, anxiety, and pain associated with venipuncture., Competing Interests: Declaration of Competing Interest The authors declare no known conflict of interest., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Fear is a recognized predictor of vasovagal reactions (VVRs) in blood donors. However, less is known about the role of other emotions, including positive emotions, that donors might experience. The aim of this study was to identify the emotions experienced in center that predict onsite VVRs, and to determine at what point during the donation appointment, the experience of these emotions is most influential., Study Design and Methods: A sample of 442 first-time whole-blood donors (57.7% female; mean ± SD age 30.7 ± 11.7 years) completed a survey in the waiting area and before venepuncture in the donation chair to assess their current emotional experience. The survey data were matched with routinely-collected demographic, donation, and donor adverse event information. A generalized estimating equations model was used to identify emotions associated with the occurrence of a VVR., Results: A total of 56 (12.7%) participants experienced a VVR. The occurrence of a VVR was significantly associated with lower love/closeness/trust (OR: 0.53, 95%CI: 0.34-0.82) and higher scared/fearful/afraid (OR: 1.96, 95%CI: 1.18-3.25) states. Significant interaction effects suggested that the effect of scared/fearful/afraid decreased while stressed/nervous/overwhelmed increased from the waiting area to before venepuncture on the likelihood of a VVR., Discussion: To effectively reduce donor VVR risk, blood collection agencies need to address a broader range of emotions at different points during the donation process., (© 2022 AABB.)

Blood sampling from a peripheral vein in children can be significant. Pediatric nurses should be able to use the techniques which decrease the pain and fear duration of the blood sampling. This research studied the effect of vibration bee and whistling (concentrate on breathing) blood sampling on pain and fear in the children's emergency. In this randomized clinical trial study, 120 children ages 3-6 years referred to a pediatric ward in Najaf, Iraq, using Random Blocking Method, were divided into three groups; vibration bee, whistling, and control group. A musical vibration bee, with the cold bag attached to it, was closed for 5 minutes at approximately 5-10 cm above the blood sampling site. A final minute, the vibration was applied; then, the procedure was done. The pain severity was measured by Wong Baker Faces scale. Data were analyzed by SPSS19 software at the significant level of 95%. There was a significant difference in pain intensity between the control groups and the intervention groups ( p  = .000). Moreover, there was a significant difference in children's medical fear scale between the control groups and the intervention groups ( p  = .000). Whistling (concentrate on breathing) may be an easily accessed, inexpensive, and effective technique to control or reduce pain and fear in young children. But, vibration bee with cold has a greater effect for reducing pain and fear. It is suggested to use vibration bee (with cold) in painful aggressive procedures in children.

Background: Anemia is a nearly universal diagnosis in preterm infants, caused by phlebotomy, and exacerbated by the underlying erythropoietic immaturity. Newborn infants are exposed to the unique stressor of fetal-to-neonatal transition, which requires significant adaptation ex utero. Accordingly, the preterm infant's response to anemia may alter the ability to confront underlying illness. This study utilized our preclinical mouse model of phlebotomy-induced anemia (PIA) to comprehensively investigate associated hematological changes., Methods: C57BL/6 mice were subjected to timed phlebotomy between postnatal days 2--10 to induce severe anemia. Complete blood counts were determined by the Sysmex XT-2000iV analyzer., Results: Anemic pups showed a gradual reduction of RBC and hemoglobin (Hb) and increased reticulocyte (RET) counts and red cell distribution width (RDW), however, with reduced RET-Hb from postnatal day (P) of 4 onwards. Elevated levels of high fluorescent RET and immature reticulocyte fraction (IRF) were noted in anemic mouse pups, but low and medium fluorescent RET were reduced. Also, the reduction of mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), and mean corpuscular hemoglobin concentration (MCHC) were noted in anemic pups. No changes were seen in lymphocytes, but monocytes and neutrophils were significantly elevated from P4-P6., Conclusions: PIA in mouse pups is associated with hematological changes that may be exacerbating factors in neonatal diseases., Impact: Anemia is common and often severe in premature infants. Investigation of hematological parameters in settings of preclinical anemia may be an index of therapeutic strategies. Preclinical model evaluating the effects of neonatal anemia on the remainder of complete blood count. Detailed time kinetic phlebotomy-induced anemic mice enable us to study the impact on developmental delays in erythropoiesis and possible strategic intervention. Hematological effects of severe anemia in mice might provide insight on how best to investigate anemia in preterm infants., (© 2022. The Author(s), under exclusive licence to the International Pediatric Research Foundation, Inc.)

Background: Deep venipuncture catheterization is widely used in clinical anesthesia. However, it is worth thinking about how to improve the rate of successful catheter insertion, and relieve patients' discomfort. This paper aimed to compare the clinical advantages between trocar and steel needle., Methods: Total 503 adult patients were recruited and randomly assigned. The control group was punctured with steel needle, and the experimental group was punctured with trocar needle. Clinical and followed-up information was recorded. Pearson's chi-squared and spearman test were performed to analyze the correlation between intervention and relative parameters. Univariate logistic regression was performed to verify the odds ratio of trocar needle compared with steel needle., Results: Pearson's chi-square test and Spearman's correlation test showed a significant correlation between puncture success, puncture comfort, successful catheter insertion, puncture time, thrombosis, catheter fever, bleeding, infection and interventions (P < .05). Univariate logistic regression showed that there existed better puncture comfort (odds ratio [OR] = 6.548, 95% confidence interval [CI]: 4.320-9.925, P < .001), higher successful catheter insertion (OR = 6.060, 95% CI: 3.278-11.204, P < .001), shorter puncture time (OR = 0.147, 95% CI: 0.093-0.233, P < .001), lesser thrombosis (OR = 0.194, 95% CI: 0.121-0.312, P < .001), lesser catheter fever (OR = 0.263, 95% CI: 0.158-0.438, P < .001), lesser bleeding (OR = 0.082, 95% CI: 0.045-0.150, P < .001) and lesser infection (OR = 0.340, 95% CI: 0.202-0.571, P < .001) in trocar group compared with steel needle group., Conclusion: Trocar application in deep venipuncture catheterization can improve successful catheter insertion, relieve pain and discomfort of patients, reduce incidence of complications, and provide better security for patients., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Secondary erythrocytosis is one of the most common adverse events associated with testosterone therapy (TT). Upon encountering this, clinicians will often either adjust TT dosing, stop therapy, order a phlebotomy, or recommend a combination of these. Despite this, the evidence for secondary polycythemia causing harm during TT is scarce, and the hematocrit-based cutoffs present in multiple guidelines appear to be arbritrarily chosen. In this review, we present the pathophysiology behind TT and secondary erythrocytosis, the evidence connecting TT, secondary erythrocytosis and major adverse cardiovascular events (MACE), and the data supporting varying interventions upon diagnosis of secondary erythrocytosis., (© 2021. The Author(s), under exclusive licence to Springer Nature Limited.)

Objectives: Blunt abdominal trauma (BAT) is a leading cause of morbidity in children with higher hemodynamic stabilities when compared with adults. Pediatric patients with BAT can often be managed without surgical interventions; however, laboratory testing is often recommended. Yet, laboratory testing can be costly, and current literature has not identified appropriate pathways or specific tests necessary to detect intra-abdominal injury after BAT. Therefore, the present study evaluated a proposed laboratory testing pathway to determine if it safely reduced draws of complete blood counts, coagulation studies, urinalysis, comprehensive metabolic panels, amylase and lipase levels orders, emergency department (ED) length of stay, and cost in pediatric BAT patients., Methods: A retrospective review of levels I, II, and III BAT pediatric patients (n = 329) was performed from 2015 to 2018 at our level I, pediatric trauma center. Patients were then grouped based on pre-post pathway, and differences were calculated using univariate analyses., Results: After implementation of the pathway, there was a significant decrease in the number of complete blood counts, coagulation studies, urinalysis, comprehensive metabolic panels, amylase, and lipase levels orders ( P < 0.05). Postpathway patients had lower average ED lengths of stay and testing costs compared with the pre pathway patients ( P < 0.05). There was no increase in rates of return to the ED within 30 days, missed injuries, or readmissions of patients to the ED., Conclusions: Results displayed that the adoption of a laboratory testing pathway for BAT patients reduced the number of laboratory tests, ED length of stay, and associated costs pediatric patients without impacting quality care., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Hematological control, incidence of complications, and need for cytoreduction were studied in 453 patients with low-risk polycythemia vera (PV) treated with phlebotomies alone. Median hematocrit value decreased from 54% at diagnosis to 45% at 12 months, and adequate hematocrit control over time (< 45%) was observed in 36%, 44%, and 32% of the patients at 6, 12, and 24 months, respectively. More than 5 phlebotomies per year in the maintenance phase were required in 19% of patients. Worsening thrombocytosis, age > 60 years, and microvascular symptoms constituted the main indications for starting cytoreduction. Median duration without initiating cytoreduction was significantly longer in patients younger than 50 years (< 0.0001). The incidence rate of thrombosis under phlebotomies alone was 0.8% per year and the estimated probability of thrombosis at 10 years was 8.5%. The probability of arterial thrombosis was significantly higher in patients with arterial hypertension whereas there was a trend to higher risk of venous thrombosis in cases with high JAK2V617F allele burden. Rates of major bleeding and second primary neoplasm were low. With a median follow-up of 9 years, survival probability at 10 years was 97%, whereas the probability of myelofibrosis at 10 and 20 years was 7% and 20%, respectively. Progression to acute myeloid leukemia was documented in 3 cases (1%). Current management of low-risk PV patients is associated with low rate of thrombosis and long survival. New treatment strategies are needed for improving hematological control and, in the long term, reducing progression to myelofibrosis., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Anemia is common in critically ill patients and may be exacerbated through phlebotomy-associated iatrogenic blood loss. Differences in phlebotomy practice across patient demographic characteristics, clinical features, and practice environments are unclear. This investigation provides a comprehensive description of contemporary phlebotomy practices for critically ill adults., Methods: This is an observational cohort study of adults ≥18 years of age requiring intensive care unit (ICU) admission between January 1, 2019, and December 31, 2019, at a large academic medical center. Descriptive statistics were utilized to summarize all phlebotomy episodes throughout hospitalization, with each phlebotomy episode defined by unique peripheral venous, central venous, or arterial accesses for laboratory draws, exclusive of finger sticks. Secondarily, financial costs of phlebotomy and the relationships between phlebotomy practices, hemoglobin concentrations, and red blood cell (RBC) transfusions were evaluated., Results: A total of 6194 patients were included: 59% were men with a median (interquartile range) age of 66 (54-76) years and median ICU and hospital durations of 2.1 (1.4-3.9) and 7.1 (4.3-11.8) days, respectively. The median number of unique laboratory draws was 41 (18-88) throughout hospitalization, with a median volume of 232 (121-442) mL, corresponding to 5.2 (2.6-8.8) draws and 29 (19-43) mL per day. Waste (ie, discard) volume was responsible for 10.8% of total phlebotomy volume. Surgical patients had a higher number of phlebotomy episodes and greater total phlebotomy volumes compared to nonsurgical patients. Phlebotomy practices differed across ICU types, with the greatest frequency of laboratory draws in the cardiac surgical ICU and the greatest daily phlebotomy volume in the medical ICU. Across hospitalization, ICU environments had the greatest frequency and volumes of laboratory draws, with the least intensive phlebotomy practice observed in the general hospital wards. Patients in the highest quartile of cumulative blood drawn experienced the longest hospitalizations, lowest nadir hemoglobin concentrations, and greatest RBC transfusion utilization. Differences in phlebotomy practice were limited across patient age, gender, and race. Hemoglobin concentrations declined during hospitalization, congruent with intensity of phlebotomy practice. Each 100 mL of phlebotomy volume during hospitalization was associated with a 1.15 (95% confidence interval [CI], 1.14-1.17; P < .001) multiplicative increase in RBC units transfused in adjusted analyses. Estimated annual phlebotomy costs exceeded $15 million (approximately $2500 per patient admission)., Conclusions: Phlebotomy continues to be a major source of blood loss in hospitalized patients with critical illness, and more intensive phlebotomy practices are associated with lower hemoglobin concentrations and greater transfusion utilization., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 International Anesthesia Research Society.)

Background: Phlebotomy-induced anemia (PIA) is universal and variable in degree among preterm infants and may contribute to neurodevelopmental risk. In mice, PIA causes brain tissue hypoxia, iron deficiency, and long-term sex-dependent neurobehavioral abnormalities. The neuroregulatory molecular pathways disrupted by PIA underlying these effects are unknown., Methods: Male and female pups were phlebotomized daily from postnatal day (P)3-P14 via facial venipuncture to target hematocrits of 25% (moderate, mPIA) and 18% (severe, sPIA). P14 hippocampal RNA from non-bled control and PIA mice was sequenced by next-generation sequencing to identify differentially expressed genes (DEGs) that were analyzed using Ingenuity Pathway Analysis., Results: mPIA females showed the least DEGs (0.5% of &gt;22,000 genes) whereas sPIA females had the most (8.6%), indicating a dose-dependent effect. mPIA and sPIA males showed similar changes in gene expression (5.3% and 4.7%, respectively), indicating a threshold effect at mPIA. The pattern of altered genes induced by PIA indicates sex-specific and anemia-dose-dependent effects with increased pro-inflammation in females and decreased neurodevelopment in males., Conclusion: These gene-expression changes may underlie the reduced recognition memory function in male and abnormal social-cognitive behavior in female adult mice following neonatal PIA. These results parallel clinical studies demonstrating sex-specific behavioral outcomes as a function of neonatal anemia., Impact: Phlebotomy-induced anemia (PIA) in neonatal mice results in an altered hippocampal transcriptome and the severity of changes are dependent upon degree of anemia and sex of neonatal mice. The reported findings provide context to the sex-specific outcomes that have been reported in transfusion threshold clinical trials of preterm infants and therefore may inform treatment strategies that may be based on sex. These data advance the field by showing that consequences of PIA may be based in sex-specific transcriptomic alterations. Such changes may also result from other causes of neonatal anemia that also affect term infants., (© 2021. The Author(s), under exclusive licence to the International Pediatric Research Foundation, Inc.)

Background: Venipuncture is a common procedure resulting in intense discomfort, anxiety, and pain in children. In this regard, we examined the effectiveness of a simple and practical art-based intervention on pain and anxiety in children who underwent venipuncture procedures., Method: In this parallel randomized control trial, children aged 6-12 years were randomly allocated to either an intervention or a control group. The intervention group (n = 73) received an art-based intervention called Trace Image and Coloring for Kids-Book (TICK-B) during the venipuncture procedure compared to no intervention in the control group (n = 71). The children, their parents, and an observer nurse rated the outcomes 1-2 min after the venipuncture procedure was finished., Findings: The patients in the intervention group had a substantially lower mean value of pain and anxiety-as rated by children, their parents, and an observer nurse-compared to the control patients. The average values of pain reported by the children, parents, and observer nurse were 3.50, 3.52, and 3.49 in the intervention group in contrast to 6.53, 6.59, and 6.45 in the control group (a large effect). Similarly, the patients in the intervention group had significantly lower mean values of anxiety compared to the control group: 0.88, 1.43, and 1.42 vs. 3.09, 2.52, and 2.52, respectively., Conclusions: This study showed that TICK-B is an effective technique to reduce the levels of pain and anxiety in children undergoing venipuncture procedures., Practice Implications: The TICK-B can be used easily by nurses to relieve the pain of children during venipuncture procedures., Trial Registration: Clinical Trial Registry, NCT04690257. Registered on December 30, 2020., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Purpose: This study aimed to compare the effects of bubble-blowing (active distraction) and cartoon watching (passive distraction) techniques on pain, anxiety, and fear during venipuncture in children aged 6-8 years., Design and Methods: This experimental study randomly assigned 56 children aged 6-8 years to cartoon watching or bubble-blowing groups. The child, parent, and researcher assessed pain using the Wong-Baker FACES Pain Rating Scale, anxiety using the Children's State Anxiety Scale, and fear using the Children's Fear Scale. The study data were analyzed using the Chi-square tests and independent Sample t-tests., Results: The groups were similar in clinical and demographic characteristics. The scores on pain, anxiety, and fear during the procedure were lower in the cartoon watching group than in the bubble-blowing group (pain t(47) = 2.638, p = .013; anxiety t(47) = 2.358, p = .023; and fear t(47) = 2.784, p = .008)., Conclusion: This study revealed that cartoon watching as a passive distraction method was more effective in reducing pain, anxiety, and fear during venipuncture in children aged 6-8 years compared to bubble-blowing as an active distraction method., Practice Implications: The cartoon watching technique, which is affordable, easy to access, and effective (in reducing pain, anxiety, and fear), can be safely used during venipuncture in children aged 6-8 years., Competing Interests: Declaration of Competing Interest Authors declare no competing interests., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Among the distraction techniques used for the non-pharmacological management of acute pediatric pain, one of the most performed is clown therapy. Despite the presence in the literature of some systematic reviews that evaluate its effectiveness, none of them examines its outcomes on procedural pain which has therefore been investigated in this study. The literature search for randomized controlled trials (RCTs) was performed on the Cochrane Library, MEDLINE, EMBASE, CINAHL, PsycINFO, Web of Science, and Scopus over a time frame ranging from each database setup date to 31 July 2021. The primary outcome was the procedural pain of children. We used the Cochrane Risk of Bias tool to assess the risk of bias of the included studies. Six RCTs were selected for this review, which included a total of 517 pediatric subjects. Children undergoing clown therapy during the venipuncture or peripheral vein cannulation procedure reported less pain than those exposed to the standard of care (SMD =  -0.55; 95% CI: -1.23, 0.13) but the result was not found to be statistically significant. School-aged children and adolescent reported significantly less pain (SMD =  -0.51; 95% CI: -0.92, -0.09). Compared to the standard of care, children's anxiety was significantly lower with clown therapy (SMD =  -0.97; 95% CI: -1.38, -0.56)., Conclusion: Clown therapy seems effective in reducing procedural pain in children, particularly for older age groups, but due to poor methodological quality and the high risk of bias of the studies included, the results obtained should be considered with caution., What Is Known: • Clown therapy is one of the most used techniques in the non-pharmacological management of acute pediatric pain. • Laughter physiologically stimulates the production of beta-endorphins, substances with an effect similar to opiates., What Is New: • Clown therapy seems effective in reducing procedural pain and anxiety in children. • The intervention in school-age children or adolescents produces a statistically significant decrease in the symptom., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background & Objective: Infants undergo painful procedures while receiving care and treatment. Blood sampling is the most common painful procedure for infants. Pain control plays a significant role in preventing unwanted physical and psychological effects. Therefore, this study aimed to investigate the effect of concurrent use of swaddle and sucrose taste on the pain intensity during venous blood sampling in neonates., Methods: In this clinical trial study, 60 infants admitted to the neonatal ward of Amirkola Hospital were randomly divided into four groups of 15 patients. In the first group, the infants were swaddled before blood sampling. In the second group, sucrose was administered to infants. In the third group, the neonates were swaddled and given sucrose simultaneously, and in the fourth group (control), blood sampling was performed routinely. PIPP pain scale and demographic questionnaire were used to collect the data. Data analysis was performed using SPSS23., Results: The results showed a significant difference between the mean pain intensity in neonates in the sucrose-swaddle group (4.53 ± 1.30) and the sucrose (7.73 ± 2.73), swaddle (9.86 ± 33.33), and control (12.13 ± 2.06) groups during blood sampling (P < 0.001). Besides, after blood sampling, there was a significant difference between the mean pain intensity in neonates in the sucrose-swaddle group (4.33 ± 1.23) and the sucrose (8.13 ± 2.66), swaddle (7.73 ± 2.78), and control (10.00. ± 1.96) groups (P < 0.001)., Conclusion: The present study showed that pain severity during and after venous blood sampling was lower in the swaddle-sucrose group than in other groups. Therefore, it is recommended that the combined method of swaddle-sucrose be used in infants as a better pain reliever when intravenous blood sampling is performed., (© 2022. The Author(s).)

Objective: To compare 2% aqueous chlorhexidine gluconate (AQC) vs. 2% chlorhexidine gluconate in 70% isopropyl alcohol (ALC) for pre-venipuncture skin antisepsis in very-low-birth-weight neonates (VLBW, birth-weight <1500 grams)., Study Design: Double-blind, non-inferiority trial randomized 199 VLBW neonates, age 2-28 days, to receive pre-venipuncture skin preparation using single application of swabstick impregnated with AQC (n = 99) or ALC (n = 100). Skin clearance rate (percentage post-cleansing skin swabs with <15 bacterial colony forming units) with a 10% non-inferiority margin for AQC was primary outcome. Absolute and relative CFU reduction and adverse skin reactions were compared., Results: AQC's clearance was non-inferior to ALC (91% vs. 88%; 95% CI -6.6%, +12.4%). Median (interquartile range) absolute [61 (16, 110) vs. 63 (18, 100); p = 0.65] and relative [100% (97%, 100%) vs. 100% (99.7%, 100%); p = 0.20] CFU reductions were similar. Neither group experienced any adverse reactions., Conclusion: AQC may provide non-inferior skin disinfection to ALC in VLBW neonates., Clinical Trial Registration: ClinicalTrials.gov NCT01270776., (© 2022. The Author(s), under exclusive licence to Springer Nature America, Inc.)

Background and Objectives: The study was planned to determine the incidence and analyze how various epidemiological factors tend to be associated with delayed adverse donor reactions (ADR)., Material and Methods: The prospective observational study was conducted in Department of Transfusion Medicine of tertiary care hospital from January to December 2019. Eligible blood donors were observed for any adverse reactions after 15 minutes of removal of phlebotomy needle. Further, telephonic calls were made to each enrolled blood donor on day-2 and day-7 of the whole blood donation. For each day, two calls were made at an interval of 4 hours before declaring the participant to be non-responder., Results: A total of 1540 (84.1%) blood donors responded on day-2 and 1610 (87.9%) responded on day-7 of follow-up. Total 180 (11.2%) blood donors experienced delayed ADRs. Two donors (1.1%) experienced on-site while 178 (98.89%) reported off-site delayed ADRs when followed-up telephonically. The commonest delayed ADRs reported were bruise (n=72; 30.9%), arm-pain (n=61; 26.2%) and generalised weakness (n=44; 18.9%). Female donors (27.3% vs. 11.2%; P=0.004), first time donors (15.2 vs. 9.9%; P=0.002), donors with low body-weight (range of 45-60kg; 15.9% vs. 11.5% vs. 6.1%; P=0.011) and body mass index<18.5 (24% vs. 12.5% vs. 9.7% vs. 11.3%; P=0.028) experienced more delayed ADRs., Conclusion: Blood donors do experience delayed ADRs but these are not reported to the blood centers as these are usually mild. However, it is important to capture these delayed adverse donor reactions and report it to National Hemovigilance Program so that strategies can be formulated to prevent their occurrence and recurrence., (Copyright © 2021 Société française de transfusion sanguine (SFTS). Published by Elsevier Masson SAS. All rights reserved.)

Background: Liver transplantation is associated with major bleeding and red blood cell (RBC) transfusions. No well-designed causal analysis on interventions used to reduce transfusions, such as an intraoperative phlebotomy, has been conducted in this population., Methods: We conducted a historical cohort study among liver transplantations performed from July 2008 to January 2021 in a Canadian centre. The exposure was intraoperative phlebotomy. The outcomes were blood loss, perioperative RBC transfusions (intraoperative and up to 48 hr after surgery), intraoperative RBC transfusions, and one-year survival. We estimated marginal multiplicative factors (MFs), risk differences (RDs), and hazard ratios by inverse probability of treatment weighting both among treated patients and the whole population. Estimates are reported with 95% confidence intervals (CIs)., Results: We included 679 patients undergoing liver transplantations of which 365 (54%) received an intraoperative phlebotomy. A phlebotomy did not reduce bleeding, transfusion risks, or mortality when estimated among the treated but reduced bleeding and transfusion risks when estimated among the whole population (MF, 0.85; 95% CI, 0.72 to 0.99; perioperative RD, -15.2%; 95% CI, -26.1 to -0.8; intraoperative RD, -14.7%; 95% CI, -23.2 to -2.8). In a subgroup analysis on 584 patients with end-stage liver disease, slightly larger effects were observed on both transfusion risks when estimated among the whole population while beneficial effects were observed on the intraoperative transfusion risk when estimated among the treated population., Conclusion: The use of intraoperative phlebotomy was not consistently associated with better outcomes in all targets of inference but may improve outcomes among the whole population., Study Registration: www., Clinicaltrials: gov (NCT04826666); registered 1 April 2021., (© 2022. Canadian Anesthesiologists' Society.)

Background and Objectives: The EPISoDe (Experience Success in Donation) study investigated the effect of interventions on self-reported vasovagal reactions (VVRs) in first-time and novice (second to fourth donation) whole blood donors aged ≤30 years, demonstrating a 23% reduction of VVR from water drinking shortly before donation in the novice donors. Because donation experience and complications affect donor retention, we analysed intervention group donors' return for subsequent donation, a predefined secondary outcome., Materials and Methods: The interventions were as follows: 330 ml water, 500 ml water, ball squeezing before phlebotomy (placebo) and a control group. All donors received an online questionnaire about their experience within a week after donation. In the Netherlands, eligible donors are invited at least yearly depending on hospitals' needs. We analysed attendances within 421 days through return percentages and binomial logistic regression., Results: Of the 8300 EPISoDe participants, 6538 (78.8%) returned within 421 days. Return did not differ between the two water groups, whereas odds for return were significantly higher in both water and placebo intervention donors compared to the control group (odds ratio [OR] 1.14, 95% confidence interval [CI] 1.00-1.29 and 1.22, 1.05-1.43, respectively) after adjustment for occurrence of VVR, unsuccessful collection, gender and donation history. Staff-recorded or self-reported VVR at index donation was associated with reduced odds for return (OR 0.47, 95% CI 0.37-0.60 and OR 0.53, 95% CI 0.46-0.61, respectively)., Conclusion: In this cohort of younger inexperienced blood donors, 78.8% returned for subsequent donation. Donors who received an active study intervention, either water or placebo, were more likely to return than control group donors., (© 2021 International Society of Blood Transfusion.)

Competing Interests: Competing interests: None declared.

The current study evaluated the effectiveness of VR analgesia among pediatric and adolescent patients with kidney disease undergoing venipuncture. Patients at an Italian Children's hospital (N = 82, age range 7-17 years) undergoing venipuncture were randomly assigned to a No VR group (non-medical conversation) vs. a Yes VR group (VR analgesia). After the procedure, patients gave 0-10 Verbal Numeric Pain Scale ratings. Compared with patients in the No VR Group, patients in the Yes VR group reported significantly lower "Pain intensity"(No VR mean = 2.74, SD = 2.76 vs. Yes VR mean = 1.56, SD = 1.83) and the VR group also rated "Pain unpleasantness" significantly lower than the No VR group (No VR mean = 2.41, SD = 0.94 vs. Yes VR mean = 1.17, SD = 1.80). Patients distracted with VR also reported having significantly more fun during the venipuncture procedure. No side effects emerged. In addition to reducing pain intensity, VR has the potential to make venipuncture a more fun and less unpleasant experience for children with CKD, as measured in the present study for the first time. Finally, in exploratory analyses, children aged 7-11 in the VR group reported 55% lower worst pain than control subjects in the same age range, whereas children aged 12 to 17 in the VR group only reported 35% lower worst pain than control subjects. Additional research and development using more immersive VR is recommended.

Objective: Distraction can reduce pain and distress associated with painful procedures but has never been studied in children with solid organ transplants. We aimed to determine whether there is a difference in pain and distress associated with venipuncture in pediatric posttransplant patients who receive distraction compared with those who do not., Methods: Randomized controlled trial of children aged 4 to 17 years with solid organ transplants undergoing venipuncture in the outpatient setting. Patients were randomized to receive distraction or no distraction. The primary outcome was the Faces Pain Scale-Revised. Secondary outcomes were the Observational Scale of Behavioral Distress-Revised; Faces, Leg, Activity, Cry, Consolability; and Children's Hospital of Eastern Ontario Pain Scale. Exploratory outcomes included the number of venipuncture attempts, time to successful venipuncture, and satisfaction of phlebotomists and parents., Results: Median age of the 40 children enrolled was 11.5 years. Type of transplants included the heart (67.5%), kidney (22.5%), liver (7.5%), and more than 1 organ (2.5%). There was no difference between the Faces Pain Scale-Revised scores in distraction and no distraction groups (1.4; 95% confidence interval, 0.9-1.9; and 1.3, 95% confidence interval, 0.5-2.1, respectively). There was also no difference in the Observational Scale of Behavioral Distress-Revised; Faces, Leg, Activity, Cry, Consolability; and Children's Hospital of Eastern Ontario Pain Scale scores, number of venipuncture attempts, or time to successful venipuncture. Phlebotomists were more satisfied with the venipuncture when distraction was implemented., Conclusions: In children with solid organ transplants, there was no difference in pain and distress associated with venipuncture between those who did and did not receive distraction. There was also no difference in other procedure-related outcomes except for greater phlebotomist satisfaction when distraction was implemented., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: to identify the occurrences related to peripheral venipuncture and hypodermoclysis among patients hospitalized in a general hospital and in an exclusive hospital institution for the care of patients in palliative cancer care., Method: an observational, descriptive and multicenter study. The consecutive and non-probabilistic sample consisted of 160 cancer patients hospitalized in Palliative Care. The outcome variable corresponded to the occurrences and complications related to each type of puncture. A questionnaire containing the sociodemographic and clinical variables and a structured script for monitoring and daily evaluation of the puncture were used. Descriptive statistics were employed for data analysis., Results: the occurrences related to venipuncture at a general hospital were blood soiling at catheter insertion (17.4%) and expired use period (15.8%), while at a specific service for the care of patients under palliative care they were expired use period (32%) followed by infiltration (18.9%). As for hypodermoclysis, there were two subcutaneous punctures with phlogistic signs (1.0%) at the general hospital and a hematoma at the catheter insertion site (0.5%). At the specific service for the care of patients under palliative care there were three subcutaneous punctures with phlogistic signs (5.7%)., Conclusion: the number of occurrences related to peripheral venipuncture was higher than those related to hypodermoclysis.

Purpose: Venipuncture is an invasive procedure for diagnosis and treatment, which is often attributed to pain and anxiety. In this study, a thermoelectric element (TEE) band was developed to apply heat therapy (40∼45°C), cold therapy (0∼10°C), or thermal grill illusion (TGI) therapy (40∼45°C, 0∼10°C) to cause an illusion of pain by simultaneously applying heat and cold. This band was subsequently used to investigate its effect on patient pain, anxiety, and satisfaction., Methods: This was a randomized controlled study. Participants, who were to undergo venipuncture, were randomly assigned to the heat therapy, cold therapy, TGI therapy, or control groups. Each group had 30 participants. The interventions were employed for 10 seconds during venipuncture, and the pain, anxiety, and satisfaction were measured before and after the procedure., Results: Subjective pain, anxiety, and physiological responses after TEE band intervention were not significantly different between the four groups. However, there was a significant difference in satisfaction (F = 4.21, p = .007) between the four groups, and the cold therapy group showed the highest satisfaction., Conclusion: In this study, when heat, cold, and TGI therapy were applied with a TEE band, pain and anxiety relief effects were not confirmed, but satisfaction was high. TEE band is a newly developed product that can easily apply hot and cold treatments without using ice packs or hot water packs. Further studies with various individual characteristics of chronic pain or repeated venipuncture are warranted to evaluate the effect of TEE., Competing Interests: Conflict of interest The authors have no conflicts of interest to declare., (Copyright © 2021. Published by Elsevier B.V.)

Background: Vascular punctures are widely used in clinical applications; however, clinical trials have identified complications and poor prognosis for patients undergoing common peripheral vein puncture as compared to ultrasound-guided peripheral venipuncture and catheterization. Ultrasound-guided peripheral venipuncture and catheterization is accurate, simple, has fewer associated complications, and will gradually take the place of common peripheral vein puncture., Methods: To study the safety of ultrasound-guided peripheral venous catheterization, a meta-analysis was conducted of relevant articles dating from establishment date of the database (such as PubMed, MEDLINE and EMBASE) to March 2021, with the search keywords being peripheral venipuncture, ultrasound guidance, vascular injury rate, and hematoma formation rate. A total of 8 trials were used to determine accuracy indicators, which included puncture failure rate, arterial injury rate, hematoma formation rate, pneumothorax incidence rate, and hemothorax incidence rate., Results: There were statistically significant differences between the two methods for peripheral venipuncture and catheterization in terms of puncture failure rate [odds ratio (OR) =0.08; 95% CI: 0.04-0.16; P<0.00001], incidence of vascular injury (OR =0.15; 95% CI: 0.07-0.32; P<0.00001), probability of hematoma formation during the puncture process (OR =0.24; 95% CI: 0.08-0.69; P=0.008), and probability of pneumothorax during puncture (OR =0.10; 95% CI: 0.02-0.55; P=0.008)., Discussion: Eight articles were included for meta-analysis. Ultrasound-guided peripheral venipuncture and catheterization is a commonly used puncture method for patients needing rapid fluid infusion with pressure or a pressure pump, repeated transfusion of blood product, or multiple daily venous blood drawing test. The results were very clear, and the puncture failure rate and other complications of ultrasound-guided peripheral venipuncture catheterization were low.

Background: Source plasma (SP) is the primary starting material for 87% of plasma-derived medicinal products globally. Plasmavigilance is a program designed to collect, analyze, and monitor donor adverse events (AEs) across the SP collection industry. Donor retention depends on donors having a safe and satisfactory experience. This study analyzes AE rates and SP donor characteristics that may be predictors of an AE., Study Design and Methods: Donation data for 1.1 million donors making 12,183,182 SP donations over a 4-month period were analyzed. This represented approximately 72% of the donations collected by the U.S. plasma industry. The Standard for Recording Donor Adverse Events was used for AE definitions and classifications., Results: The overall AE rate was 15.85/10 4 donations. The two AEs with the highest rates were Hypotensive and Phlebotomy events (8.32 and 5.91/10 4 donations, respectively). Females had higher overall AE rates than males (25.76 vs. 9.85/10 4 donations), and first-time donors had higher overall AE rates than repeat donors (136.66 vs. 12.37/10 4 donations). Weight, body mass index, age, and pre-donation estimated blood volume also were predictors of AE., Discussion: SP donors have low AE rates with 90% being events classified as Hypotensive or Phlebotomy. Special attention and mitigation strategies should be directed to donors who are young, lightweight (between 100 and 124 pounds), female, or first-time donors to further reduce the incidence of AE, continue to ensure the donor has a safe experience, and facilitate donor retention., (© 2021 Plasma Protein Therapeutics Association. Transfusion published by Wiley Periodicals LLC on behalf of AABB.)

Aim: Pain control is an important aspect of ED patient management, and there are many different protocols used around the world influenced by both availability of local resources as well as staff competency and experience. This study aims to evaluate the use of topical ketamine in acute pain reduction by directly comparing it to lidocaine-prilocaine (EMLA) cream., Materials and Methods: In this randomized clinical trial, 300 adult patients classified as level 4 or 5 by ESI triage system were enrolled. These patients were divided randomly into three groups. The site of venipuncture was covered with 2 g of topical ketamine cream 10% in group one, 2 g of 5% EMLA cream in group two, and finally, in group 3 (control group), was covered with placebo (2 g of cold cream). The primary end point of the study was reported pain severity with secondary end points being onset of local anesthesia as well as any side effects noted., Results: The data gathered showed pain score during venipuncture in both intervention groups were significantly lower when compared to the control group (P < 0.05). However, pain score did not differ between the 2 intervention groups (P = 0.395). There was no statistically significant difference between the ketamine or EMLA in onset of local anesthesia (P = 0.419). We noted itching and irritation was significantly higher in the EMLA group when compared to ketamine(P < 0.05)., Conclusion: This study showed that local cutaneous ketamine is as effective as EMLA in relieving pain during venipuncture., Competing Interests: Declaration of Competing Interest The authors have indicated that they have no conflicts of interests regarding the content of this article., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: The aim of this study was to determine if young children with high preprocedural anxiety experience increased pain at venipuncture., Methods: This was secondary analysis of prospectively obtained data from a randomized controlled trial comparing vapocoolant spray with jet-injected lidocaine for venipuncture pain. Children aged 1 to 6 years were enrolled and videotaped. Videos were reviewed and scored for anxiety using the modified Yale Preoperative Anxiety Scale score for preprocedural anxiety (score range, 23-100). High anxiety was defined as greater than 40. Pain at the time of venipuncture was scored using the Face, Legs, Activity, Cry, and Consolability scale (score range 0-10). Moderate to severe pain was defined as greater than 3. Logistic regression assessed patient factors associated with high preprocedural anxiety and evaluated the relationship between preprocedural anxiety and pain during venipuncture., Results: Two hundred five patients were enrolled; 59.5% of patients were male, and 53.7% were White. Mean age was 3.2 years. Prior to the procedure, 67% of patients had high anxiety. Patient age, race, sex, and previous venipuncture were not associated with increased odds of high anxiety. Moderate to severe pain at venipuncture was observed in 65% of children. High preprocedural anxiety was associated with increased odds of moderate to severe pain at venipuncture when controlled for patient characteristics (adjusted odds ratio, 4.62; 95% confidence interval, 2.03-8.54)., Conclusions: Most young children undergoing venipuncture experienced high preprocedural anxiety. Children with high preprocedural anxiety had increased odds of moderate to severe pain at venipuncture. Anxiety-reducing interventions should be explored to reduce pain experienced during venipuncture., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Venipuncture is a common procedure in the neonatal intensive care unit (NICU) and causes significant pain for neonates., Aim: To evaluate the effect of maternal voice on pain caused by venipuncture (including peripheral venipuncture and femoral venipuncture) in neonates hospitalized in the NICU., Design: Experimental, randomized controlled study., Setting: The study was conducted in the NICU of two hospitals in China from November 2017 to January 2019., Methods: One hundred and sixteen neonates were randomly assigned to the maternal voice or routine care groups. The maternal voice group received recorded maternal voice intervention before, during, and after venipuncture. Three phases of procedures were videotaped. Neonatal Infant Acute Pain Assessment Scale (NIAPAS) was assessed by the same evaluator at different phases., Results: The study showed that NIAPAS scores, behavioral indicator scores, and physiological indicator scores in the maternal voice group were significantly lower compared with those in the routine care group., Conclusion: Recorded maternal voice can improve pain caused by venipuncture in neonates. These are simple, rapid, and cost-effective methods that nurses can implement during venipuncture in neonates., (Copyright © 2021 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved.)

Objectives: Venipuncture is one of the most frequently performed painful procedures in children. The aim of this study was to investigate the effectiveness of 2 analgesic strategies for venipuncture in children in a specific setting like a blood-drawing center., Methods: This was a prospective randomized controlled trial. It was conducted in the blood-drawing center of a tertiary level children's hospital in Italy, between November 2014 and February 2015. Eligible patients were children aged from 4 to 12 years referred to the blood-drawing center for venipuncture. Enrolled children were randomized to be distracted by Buzzy device or by playing with a handheld computer. The procedural pain was measured with the faces pain scale-revised by children aged from 4 to 7 years and with a numerical rating scale by children aged from 8 to 12 years., Results: Two hundred children with a median age of 8 years were enrolled in the study. The self-reported procedural pain was not statistically different between the Buzzy group and the handheld computer group: median (interquartile range) = 3.0 (1.0-4.8) and 2.0 (1.0-4.8), respectively (P = 0.72). Children reported significant pain in 25% of cases with both distraction strategies. The procedural success rate at the first attempt was not significantly different in the 2 groups., Conclusions: Analgesia provided by Buzzy or by a handheld computer was not significantly different in children undergoing venipuncture in a blood-drawing center, with the great proportion of them reporting no or mild pain during procedure., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.)

We assessed the feasibility and potential efficacy of a virtual reality (VR) environment using a dome screen as a distraction method in young children during intravenous (IV) placement in the pediatric emergency department. This randomized controlled pilot study enrolled children aged 2 to 6 years who underwent IV placement into either the intervention group or the control group. Children in the intervention group experienced VR using a dome screen during IV placement. The child's pain intensity was measured using the Face, Legs, Activity, Cry, and Consolability (FLACC) scale at four time points of IV placement: immediately after arrival to the blood collection room (base); immediately after the child laid down on the bed (preparation); when the tourniquet was applied (tourniquet); and the moment at which the needle penetrated the skin (venipuncture). The guardian's satisfaction and rating of the child's distress were assessed using a 5-point Likert-type questionnaire. We recruited 19 children (9 in the intervention group and 10 in the control group). Five children in the control group were excluded from the analysis because of missing video recordings (n = 3), failed first attempt at IV placement (n = 1), and the child's refusal to lie on the bed during the procedure (n = 1). No side effects of VR were reported during the study period. Although the average FLACC scale score at each time point (preparation, tourniquet, venipuncture) was lower in the intervention group than the control group, the difference was not statistically significant (2.3, interquartile range [IQR]: 2.0-3.0; vs. 3.3, IQR: 2.7-6.7, P = 0.255). There were no statistically significant differences between the groups in the guardian's satisfaction and anxiety or his/her rating of the child's pain and anxiety. The guardians and emergency medical technicians reported satisfaction with the use of VR with a dome screen and considered it a useful distraction during the procedure. VR using a dome screen is a feasible distraction method for young children during IV placement. A larger clinical trial with further development of the VR environment and study process is required to adequately evaluate the efficacy of VR using a dome screen., Competing Interests: The authors have declared that no competing interests exist.

Background: Fear of blood donation is implicated in vasovagal reactions, donor recruitment, and retention. This study examined the extent to which fear among donors is associated with various donor outcomes in an Australian sample, and whether fear can be addressed on-site to reduce adverse reactions and improve the donation experience., Study Design and Methods: Six hundred and sixty-four donors (age M = 33.4, SD = 12.7; 55% female) participated in a two-center, pragmatic, parallel group, individually randomized controlled trial. Following donor registration and consent, whole-blood (n = 539) and plasma (n = 125) donors were assigned to one of four Conditions: control; fear assessment; fear assessment + brochure; fear assessment + brochure + tailored conversation focused on any self-reported fear and coping strategies. Post-donation questionnaires assessed the donors' experience including positive support, donor self-efficacy, anxiety, fear, venipuncture pain, and vasovagal reactions., Results: Fear among donors predicted higher venipuncture pain, post-donation anxiety, and vasovagal reactions and remained significant after controlling for other established predictors (i.e., total estimated blood volume, age, sex, and donation experience). Mediational analyses showed that exposure to brochures (with or without the tailored conversation) was associated with less pain, with this effect mediated by donor perceptions of more positive support. Venipuncture pain was also associated with vasovagal reactions, reduced likelihood of return within 6 months, and less satisfaction with the donation experience., Conclusion: The current results underline the importance of interventions to address fear among both whole-blood and plasma donors to secure the safety and well-being of donors and the blood supply., (© 2021 AABB.)