Venipuncture is a common invasive clinical procedure, and pain management during puncture has been of interest to healthcare professionals. The purpose of this systematic review and meta-analysis was to evaluate the efficacy and safety of the Valsalva maneuver (VM) for the relief of venipuncture pain in children and adults. PubMed, Embase, Web of Science, Cochrane Library, CNKI, Wanfang, VIP database, and CBM were searched from inception to December 2023 for all available randomized controlled trials (RCTs) that evaluated the impact of VM on venipuncture. Two reviewers independently performed study selection, data extraction, and risk of bias assessment. Continuous variables were analyzed by mean differences (MD) or standardized mean differences (SMD), whereas dichotomous variables were analyzed by risk ratios (RR). A total of 22 studies involving 1740 participants were included. The pooled results showed that VM relieved pain intensity during venipuncture in children (SMD = −0.89, 95% CI = −1.47 to −0.30, p = 0.003) and adults (SMD = −1.11, 95% CI = −1.46 to −0.77, p < 0.00001), reduced anxiety intensity (SMD = −1.07, 95% CI = −1.68 to −0.47, p = 0.0005), and shortened puncture time (MD = −13.52, 95% CI = −21.14 to −5.90, p = 0.0005). There was no significant difference in the success rate of venous cannulation, MAP, HR, or incidence of adverse events in subjects who performed VM compared to controls. VM was an effective and safe method of pain management that reduced pain intensity during venipuncture in children and adults without significant adverse effects. The results of this meta-analysis need to be further validated by more rigorous and larger RCTs.
WellsCZhangZChanC, et al. Impact of a peripheral vascular access service on device use. Am J Crit Care2021; 30(4): 295–301.
2.
DuncansonELe LeuRKShanahanL, et al. The prevalence and evidence-based management of needle fear in adults with chronic disease: a scoping review. PLoS One2021; 16(6): e0253048.
3.
KettwichSCSibbittWLBrandtJR, et al. Needle phobia and stress-reducing medical devices in pediatric and adult chemotherapy patients. J Pediatr Oncol Nurs2007; 24(1): 20–28.
4.
OarELFarrellLJOllendickTH.One session treatment for specific phobias: an adaptation for paediatric blood-injection-injury phobia in youth. Clin Child Fam Psychol Rev2015; 18(4): 370–394.
5.
MacarioAWeingerMTruongP, et al. Which clinical anesthesia outcomes are both common and important to avoid? The perspective of a panel of expert anesthesiologists. Anesth Analg1999; 88(5): 1085–1091.
6.
SupanWOngiemAPrawatviteesukA, et al. Comparison of the effectiveness between 5% eutectic mixture of local anesthetic cream and ethyl chloride spray applied on the skin prior to intravenous cannulation. J Med Assoc Thai2021; 104(1): 73–78.
7.
SelbyIRBowlesBJ.Analgesia for venous cannulation: a comparison of EMLA (5 minutes application), lignocaine, ethyl chloride, and nothing. J R Soc Med1995; 88(5): 264–267.
8.
BiroPMeierTCumminsAS.Comparison of topical anaesthesia methods for venous cannulation in adults. Eur J Pain1997; 1(1): 37–42.
9.
TimmermansMWBruynzeelDPRustemeyerT.Allergic contact dermatitis from EMLA cream: concomitant sensitization to both local anesthetics lidocaine and prilocaine. J Dtsch Dermatol Ges2009; 7(3): 237–238.
10.
AgarwalASinhaPKTandonM, et al. Evaluating the efficacy of the valsalva maneuver on venous cannulation pain: a prospective, randomized study. Anesth Analg2005; 101(4): 1230–1232.
11.
GuptaDAgarwalADhiraajS, et al. An evaluation of efficacy of balloon inflation on venous cannulation pain in children: a prospective, randomized, controlled study. Anesth Analg2006; 102(5): 1372–1375.
12.
KirchnerAStefanHBastianK, et al. Vagus nerve stimulation suppresses pain but has limited effects on neurogenic inflammation in humans. Eur J Pain2006; 10(5): 449–455.
13.
HosseiniSJManzariZSKarkhahS, et al. The effects of Valsalva maneuver on pain intensity and hemodynamic status during short peripheral cannula insertion in adults: a systematic review and meta-analysis. J Vasc Access. Epub ahead of print 27 December 2022. DOI: 10.1177/11297298221145982.
14.
SahinerNCBalMD.The effects of three different distraction methods on pain and anxiety in children. J Child Health Care2016; 20(3): 277–285.
15.
BombardiniTPicanoEMagagniniE.Reduced time for femoral venipuncture by simple bedside application of Valsalva maneuver (the poor cardiologist’s smart needle). Am J Cardiol1994; 73(13): 1023–1024.
16.
PageMJMcKenzieJEBossuytPM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Int J Surg2021; 88: 105906.
17.
HigginsJThomasJChandlerJ, et al. Cochrane Handbook for Systematic Reviews of Interventions version 6.3 (updated February 2022), www.training.cochrane.org/handbook (2022, accessed 17 July 2023).
18.
LuoDWanXLiuJ, et al. Optimally estimating the sample mean from the sample size, median, mid-range, and/or mid-quartile range. Stat Methods Med Res2018; 27(6): 1785–1805.
19.
WanXWangWLiuJ, et al. Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range. BMC Med Res Methodol2014; 14: 135.
20.
AkdasOBasaranogluGOzdemirH, et al. The effects of Valsalva maneuver on venipuncture pain in children: comparison to EMLA® (lidocaine-prilocaine cream). Ir J Med Sci2014; 183(4): 517–520.
21.
AlanNKhorshidL.Evaluation of efficacy of valsalva maneuver during peripheral intravenous cannulation on pain. Pain Manag Nurs2022; 23(2): 220–224.
22.
AydinDSahinerNCCiftciEK.Comparison of the effectiveness of three different methods in decreasing pain during venipuncture in children: ball squeezing, balloon inflating and distraction cards. J Clin Nurs2016; 25(15–16): 2328–2335.
23.
AykanatGBGöII.Reducing pain and fear in children during venipuncture: a randomized controlled study. Pain Manag Nurs2020; 21(3): 276–282.
24.
BabamohamadiHAmeriZAsadiI, et al. Comparison of the effect of EMLA™ cream and the valsalva maneuver on pain severity during vascular needle insertion in hemodialysis patients: a controlled, randomized, clinical trial. Evid Based Complement Alternat Med2022; 2022: 8383021.
25.
BasaranogluGBasaranogluMErdenV, et al. The effects of Valsalva manoeuvres on venepuncture pain. Eur J Anaesthesiol2006; 23(7): 591–593.
26.
HöbekARKuşBDoğukanAG.Effects of valsalva maneuver, emla cream, and stress ball for pregnant women’s venipuncture pain. Altern Ther Health Med2021; 27(5): 108–114.
27.
Mohammed MahmoudHElsayed MosaadSMohamed ElghareebS. Effectiveness of Valsalva maneuver on pain among patients undergoing peripheral intravenous cannulation. Egypt J Health Care2021; 12(4): 530–538.
28.
MutluBBalciS.Effects of balloon inflation and cough trick methods on easing pain in children during the drawing of venous blood samples: a randomized controlled trial. J Spec Pediatr Nurs2015; 20(3): 178–186.
29.
ShivashankarANaliniKBRathP.The role of nonpharmacological methods in attenuation of pain due to peripheral venous cannulation: a randomized controlled study. Anesth Essays Res2018; 12(1): 7–10.
30.
SrivastavaAKumarSAgarwalA, et al. Evaluation of efficacy of Valsalva for attenuating needle puncture pain in first time nonremunerated voluntary plateletpheresis donors: a prospective, randomized controlled trial. Asian J Transfus Sci2021; 15(1): 68–74.
31.
SulemanSKYahyaNBNilssonS, et al. Comparison of trace image colors for kids-book with two active distractions in reducing pain and fear of children during the venipuncture procedure. Eur J Pediatr. Epub ahead of print 14 October 2023. DOI: 10.1007/s00431-023-05271-y.
32.
SundaranJKhanFBansalP, et al. An experimental study to assess the effectiveness of Valsalva maneuver prior to intravenous cannulation on pain perception among patients undergoing venous cannulation at HAHC Hospital in Delhi. Res Rev J Surg2016; 5: 1–6.
33.
SurenMKayaZOzkanF, et al. Comparison of the use of the Valsalva maneuver and the eutectic mixture of local anesthetics (EMLA®) to relieve venipuncture pain: a randomized controlled trial. J Anesth2013; 27(3): 407–411.
34.
TaparHKaramanTDogruS, et al. Evaluating the efficacy of Valsalva’s maneuver and music therapy on peripheral venous cannulation: a prospective study. Anaesth Pain Intensive Care2018; 22(2): 219–223.
35.
YılmazDGüneşÜY.The effect on pain of three different nonpharmacological methods in peripheral intravenous catheterisation in adults. J Clin Nurs2018; 27(5–6): 1073–1080.
36.
GengGLiHGengW.Effect of the Valsalva maneuver on the success rate of internal jugular vein puncture. J Clin Anesthesiol2016; 32(7): 704–705. (in Chinese)
37.
GongCChenY.Effect of the Valsalva maneuver on the area of the right internal jugular vein diameter and the effectiveness of puncture placement in patients with bowel preparation. J Fujian Med Univ2014; 4: 282–284. (in Chinese)
38.
GreenlandHPHoskerGLSmithAR.A valsalvometer can be effective in standardising the Valsalva manoeuvre. Int Urogynecol J Pelvic Floor Dysfunct2007; 18(5): 499–502.
39.
LundebergSLundebergT.Pain in infants and children—physiological background and clinical aspects. Acupunct Relat Ther2013; 1(4): 46–49.
40.
PancekauskaitėGJankauskaitėL.Paediatric pain medicine: pain differences, recognition and coping acute procedural pain in paediatric emergency room. Medicina (Kaunas)2018; 54(6): 94.
41.
KumarCMVan ZundertA.Intraoperative Valsalva maneuver: a narrative review. Can J Anaesth2018; 65(5): 578–585.
42.
MiyakeCAraiTMoriK.Internal jugular vein cannulation: time required under ultrasonographic guidance with a valsalva maneuver. J Anesth1991; 5(1): 68–72.
43.
CowlishawPBallardP.Valsalva manoeuvre for central venous cannulation. Anaesthesia2007; 62(6): 640.
44.
DincyurekGNMogolEBTurkerG, et al. The effects of the Trendelenburg position and the Valsalva manoeuvre on internal jugular vein diameter and placement in children. Singapore Med J2015; 56(8): 468–471.
45.
VillaGChelazziCGiuaR, et al. The Valsalva manoeuvre versus tourniquet for venipuncture. J Vasc Access2018; 19(5): 436–440.
46.
PerryBGMündelTCochraneDJ, et al. The cerebrovascular response to graded Valsalva maneuvers while standing. Physiol Rep2014; 2(2): e00233.
47.
ZhangRCrandallCGLevineBD.Cerebral hemodynamics during the Valsalva maneuver: insights from ganglionic blockade. Stroke2004; 35(4): 843–847.
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
