The use of EMLA cream to decrease venipuncture pain in children

Venipuncture is one of the most painful medical procedures for a child, and it is one of the most frequently performed. This literature synthesis reviews evidence for the use of eutectic mixture of local anesthetics (EMLA) cream to reduce the pain children experience during venipuncture. EMLA cream was compared with placebo, iontophoresis, and amethocaine cream and was found to be an effective local anesthetic for pediatric venipuncture pain during both intravenous cannulation and phlebotomy.     

Eutectic mixture of local anesthetics reduces pain during intravenous catheter insertion in the pediatric patient.

OBJECTIVE: The objective of this study was to explore the relation between the application of a mixture of lidocaine/prilocaine cream (eutectic mixture of local anesthetics [EMLA]) before intravenous cannula insertion and perceived pain in the pediatric patient. DESIGN: Double-blind placebo-controlled trial. SETTING: A general inpatient pediatric ward. PATIENTS: We examined 26 male and 31 female patients between the ages of 4 and 12 years who required intravenous cannula insertion. Intravenous insertion was performed on 57 patients, with 29 patients in the placebo group (mean age, 8.1 years) and 28 in the EMLA group (mean age, 8.0 years). INTERVENTIONS: Application of either EMLA cream or placebo 45 minutes before intravenous cannulation. OUTCOME MEASURES: Pain was scored by the patients using a 0- to 10-cm visual analogue scale combined with a Faces pain scale as well as visual observation by a nurse. Adverse side effects were recorded in a separate table. RESULTS: Data collected and the differences between the placebo and treated groups were tested using a Mann-Whitney U test. Those children in the EMLA group (mean pain score, 1.25) experienced less pain than those in the placebo group (mean, 8.39). There was no statistical significance between age, sex, and race. CONCLUSIONS: The authors conclude that a topical preparation of lidocaine/prilocaine significantly reduces children's pain during intravenous cannula insertion when applied to an intact dermal layer of the skin and that this effect occurs within 45 minutes.     

Comparison of topical anaesthesia methods for venous cannulation in adults.

A prospective, randomized clinical trial was performed in order to assess the efficacy and side-effects of commonly used topical anaesthesia methods in adults receiving peripheral venous cannulation. The study was double-blinded to the degree that the methodologies allowed. One hundred and fifty healthy adults undergoing elective surgery were allocated at random to five groups: EMLA cream, ethyl chloride spray, intracutaneous infiltration with 2% lidocaine, placebo cream and no treatment. Venipuncture was performed with a 18G cannula on the dorsal side of the hand. Puncture pain and pain caused by the topical treatment itself were measured using a visual analogue scale (VAS, range: 0-100 mm). Haemodynamic response, difficulties in performing the puncture and side-effects were recorded. All analgesic techniques were well tolerated. Haemodynamic response and degree of puncture difficulty showed no differences among the groups. Puncture pain (median mrnVAS) following infiltration (1.0) and EMLA (10.0) was significantly lower than no treatment (30.0) or placebo (30.0). The benefit of local infiltration was altered by injection pain (11.5). Spray did not significantly lower puncture pain (26.5) and, in addition, was associated with discomfort (10.5). In adults, EMLA cream significantly reduces puncture pain and represents an acceptable alternate method for topical anaesthesia in venous cannulation. Local lidocaine infiltration is impaired by applicational pain, whereas spraying the puncture site with ethyl chloride has no analgesic benefit.     

A comparison of EMLA cream and amethocaine gel for topical cutaneous analgesia in children

The efficacy of EMLA cream and amethocaine gel was compared using application times of greater than 60 minutes. Eighty eight patients received EMLA cream and 89 received amethocaine gel. Pain during venous cannulation was assessed by a single observer using a four point observational scale. Sixty nine (78%) patients in the amethocaine group underwent pain-free venepuncture compared with 46 (52%) patients in the EMLA cream group (p<0.001). No serious side effects occurred in any patient. As well as having a faster onset of action, amethocaine gel also appears to be a more effective analgesic than EMLA cream prior to venous cannulation in children.     

Minimum clinically significant VAS differences for simultaneous (paired) interval serial pain assessments

We conducted two studies to determine whether the minimum clinically significant difference in the visual analog scale (VAS) for nearly simultaneous and brief-interval serial assessments of pain is less than that for pain assessment at 20- to 30-minute intervals, using a 10-cm VAS. The first study was a blinded, randomized, placebo-controlled paired trial comparing the pain of intravenous cannulation in both hands (20-minute application of a eutectic mixture of local anesthetics v placebo) of study subjects. The second study was a non-blinded, randomized, paired trial of different treatments for jellyfish stings. In the first study, 37 of 40 subjects indicated that one hand experienced more pain than the other. Eleven of these 37 subjects (30%) indicated differences in VAS values of 1.0 cm or less, with a minimum value of 0.5 cm. In the second study, for all the VAS-based pain comparisons, VAS differences of 相似文献   

Effect of Topical Analgesia on Desensitization Following 8% Topical Capsaicin Application

To prevent pain associated with 8% capsaicin application, pretreatment with local anesthetics, such as EMLA (eutectic mixture of lidocaine 2.5% and prilocaine 2.5%), is considered an option. However, there is contradicting evidence regarding the effects of local analgesia on capsaicin-induced desensitization. In session 1, 2 skin areas in each forearm of 24 healthy volunteers were randomized to 2-hour pretreatment with EMLA/placebo cream. After pretreatment, 8% capsaicin patches were applied for 3 hours in 1 placebo and 1 EMLA pretreated area, obtaining the following four areas: Capsaicin + EMLA, Capsaicin + Placebo, EMLA alone, and Placebo. Pain intensity scores were assessed during the 3-hour application of capsaicin. Warmth detection, heat pain sensitivity, and microvascular reactivity were measured after the removal of capsaicin. After 24 hours, in session 2, all tests were repeated followed by histamine application in each area to examine itch intensity and neurogenic flare.Overall, EMLA caused significant reductions in capsaicin-induced pain compared with placebo (P= .007) and enhanced the capsaicin-induced increase in superficial blood perfusion immediately after the 3-hour capsaicin application (P< .01). Regardless of pretreatment, capsaicin induced heat hyperalgesia immediately after the application (P< .001). Twenty-four hours post application, heat pain sensitivity was normalized. However, WDT increased significantly (P< .001). Capsaicin tended to reduce the itch intensity and significantly reduced the neurogenic flare (P< .05) induced by histamine compared with EMLA alone. The findings suggest that pretreatment with topical analgesic cream reduces application site pain without interfering with the 8% topical capsaicin-induced desensitization.PerspectivePretreatment with local anesthetic EMLA cream might be considered a good therapeutic option to reduce the pain associated with 8% capsaicin application currently used for treatment of neuropathic pain syndromes. This study also suggests the existence of a synergistic effect of capsaicin and EMLA on the process of neurogenic inflammation.     

Relieving the pain of sentinel lymph node biopsy tracer injection

Sentinel lymph node biopsy (SLNB) has been reliably accurate as a minimally invasive surgical alternative for identifying lymphatic breast metastasis. During mapping, the injection of a radioactive tracer or isosulfan blue dye to differentiate the SLN is acutely painful. The use of the eutectic mixture of lidocaine and prilocaine (EMLA) cream to reduce tracer injection pain has been reported anecdotally. A retrospective study compared injection discomfort of 20 women who had undergone SLNB without EMLA and 20 women who had undergone SLNB with the EMLA protocol. Results indicated a significant difference in mean pain rating. Standards of care should include the use of EMLA prior to intradermal SLN tracer injection unless contraindicated.     

Effect of eutectic mixture of local anesthetics (EMLA) for pain relief during suprapubic aspiration in young infants: a randomized, controlled trial

OBJECTIVES: The purpose of this study was to determine whether a eutectic mixture of local anesthetics (EMLA) cream reduce the pain experienced by newborns and young infants undergoing suprapubic aspiration (SPA). METHODS: A single-center, randomized, placebo-controlled, double-blind, prospective study including 52 infants 1 to 60 days of age undergoing SPA to obtain urine for culture. Twenty-four infants were randomly assigned to receive 1-g EMLA cream 1 hour before the procedure, whereas 28 were randomly assigned to receive placebo cream 1 hour before the planned procedure. Pain symptoms were measured using the Premature Infant Pain Profile (PIPP). RESULTS: The mean PIPP scores were significantly lower in the EMLA group compared with the placebo group (8.90+/-3.04 vs. 10.46+/-2.29; P=0.038). There were significantly fewer patients in the EMLA group who were scored as having some degree of pain (defined as PIPP score >6) in comparison with the placebo group (70% vs. 96%; P=0.025). DISCUSSION: Newborns and infants undergoing SPA experience pain during the procedure. Application of EMLA cream 1 hour before SPA is effective in reducing the pain associated with SPA. In situations in which an SPA is not emergent, strong consideration should be given to the use of EMLA.     

Laser-assisted Anesthesia Prior to Intravenous Cannulation in Volunteers: A Randomized, Controlled Trial

Background: Intravenous cannulation is common and painful. Absorption of topical anesthetics is limited by the stratum corneum, the outermost layer of the epidermis. A single pulse of an erbium:yttrium–aluminum–garnet (Er:YAG) laser irradiation can remove an area of the stratum corneum, leading to enhanced uptake of topical agents, such as lidocaine, while leaving the rest of the epidermis intact. Objective: The authors hypothesized that pretreatment of the skin with laser‐assisted anesthesia would reduce the pain of venous cannulation. Methods: This was a blinded, randomized, controlled clinical trial. Subjects were 30 healthy adult volunteers. Standardized venous cannulation was performed on the dorsum of both of each subject's hands. In the study hand, the area over the target vein was pretreated with a lightweight, portable Er:YAG unit, with a fluence of 3.5 J/cm², a pulse width of 600 microseconds, and a spot diameter of 6 mm. Lidocaine 4% cream was applied to the area. After 5 minutes, the cream was wiped off and a nurse inserted an intravenous (IV) catheter and verified placement. In the control hand, a sham laser was used. Pain of laser application and pain of IV cannulation were recorded on a validated 100‐mm visual analog scale (VAS) marked “most pain” at the high end. The presence of burns, infection, and scarring at one week and at three months after the study was also noted. The levels of pain of cannulation were compared using a paired t‐test. Results: Mean subject age was 32 years; 43% were female. The mean pain of cannulation after laser‐assisted lidocaine application (13 mm, 95% CI = 8 to 19) was significantly less than after application of sham laser (29 mm, 95% CI = 22 to 36; mean difference, 15 mm, 95% CI = 6 to 24). No subject had persistent erythema or scarring. Conclusions: Pretreatment of the skin with a laser device followed by a 5‐minute topical lidocaine application reduces the pain of IV cannulation in volunteers.     

Cutaneous Tape Stripping to Accelerate the Anesthetic Effects of EMLA Cream: A Randomized, Controlled Trial

Abstract. Most medications are not absorbed topically due to the stratum corneum barrier. While effective as a topical anesthetic, EMLA cream is absorbed slowly, delaying its effects for up to one hour, thereby limiting its usefulness.
Objective: To determine whether removal of the cornified layer of the skin by tape stripping (TS) would allow more rapid onset of anesthesia after topical application of EMLA cream prior to IV catheterization (IVC).
Methods: This was a prospective, randomized, controlled trial comparing the levels of pain of IVC 15 minutes after topical application of EMLA cream in patients who had TS vs patients who did not. The setting was a suburban university-affiliated ED. A convenience sample of 68 alert adult patients requiring IVC were enrolled. The primary outcomes measured were pain of IVC and pain of TS using a previously validated 100-mm visual analog scale as well as the IVC success rate.
Results: The pain of IVC was less for TS vs control patients [29.7 mm (95% CI = 20.4 to 39.0 mm) vs 15.9 mm (95% CI = 9.1 to 22.6 mm), p = 0.017]. The mean pain of TS was 4.8 ± 7.4 mm. The IVC success rate for TS vs control patients was 91% vs 74% (p = 0.056). There were no adverse events after TS.
Conclusions: Removal of the cornified layer of the skin resulted in a more rapid anesthetic effect of EMLA cream as evidenced by lower IVC pain scores after TS. The effectiveness of TS for enhanced absorption of other medications should be investigated.     

EMLA cream and oral glucose for immunization pain in 3-month-old infants

The objective of this study is to determine whether use of lidocaine-prilocaine 5% cream (EMLA) and oral glucose decreases pain associated with diphteria-pertussis-tetanus (DPT) immunization in 3-month-old infants. DESIGN: randomized, double-blind, controlled trial in outpatient paediatric practice in northern Sweden. EMLA or placebo was applied to the infant's lateral region of the right thigh and covered with an occlusive dressing 1h before the immunization. In addition, 1 ml of glucose (300 mg/ml) or placebo (water) was instilled on the baby's tongue within 2 min before the DPT-injection. Forty-five infants received EMLA and glucose and 45 infants placebo cream and water. ECG was recorded and stored in a computer and the procedure was videotaped. The parents and the nurse assessed the infants' pain on a visual analogue scale (VAS) after the immunization. Heart rate and heart rate variability pre- and post-injection were calculated. From the videotapes, the modified behavioural pain scale (MBPS) was used to assess pain scores during baseline and after immunization. The latency of the first cry and total crying time were measured. The parents and the nurse scored the infants' pain on the VAS significantly lower in the treatment group than in the placebo group. The infants' responses to the immunization measured as the difference in MBPS scores pre- and post-injection were significantly lower in the EMLA-glucose group compared with the placebo group. More infants cried after the immunization in the placebo group compared with the EMLA-glucose group and the latency of the first cry after the injection was shorter in the placebo group. A biphasic transient heart rate response with a marked deceleration followed by a subsequent acceleration was seen more frequently in the placebo group compared to the EMLA-glucose group. EMLA and glucose alleviate immunization pain in 3-month-old infants.     

国产盐酸丁卡因凝胶用于介入治疗动脉插管术前皮肤局部麻醉作用的临床研究

目的 研究盐酸丁卡因凝胶用于介入治疗动脉插管术前的麻醉效果及临床安全性。方法 选取需行动脉穿刺插管病人40例。采用单盲随机平行对照观察方法分为两组。其中试验组和对照组各20例。用药后穿刺右股动脉，观察局部麻醉作用、插管时瞬间疼痛及不良反应。结果 两组病人局部麻醉作用显效率分别为85％、90％，有效率均为100％。插管时瞬间疼痛比较镇痛有效率分别为95％、100％。两组均未出现不良反应。结论 盐酸丁卡因凝胶麻醉效果好，操作简单，无创伤无痛苦，临床安全性好，无明显不良反应，可用于介入治疗动脉插管术前的局部麻醉。     

Reducing venipuncture and intravenous insertion pain with eutectic mixture of local anesthetic: a meta-analysis

BACKGROUND: The eutectic mixture of local anesthetics (EMLA), by producing dermal anesthesia through contact with intact skin, has become a major indication for the reduction of pain experienced during venipuncture (VE) and intravenous (IV) insertion. OBJECTIVES: The purpose of the study was to determine the mean effect sizes and moderators of EMLA cream application in reducing VE and IV insertion pain. METHOD: A meta-analysis of 20 studies was conducted to determine the magnitude of the effect of EMLA cream on VE and IV insertion pain. Effect sizes were calculated three ways: weighted, unweighted, and weighted by quality index score. Potential moderating variables of sample age, premedication, therapist control, insertion site, application duration, research design, pain scale, and funding, were investigated for their influence on EMLA's effect. RESULTS: EMLA cream had a large significant effect on VE pain (d = 1.05) with a 95% confidence interval from.92 to 1.34 and a large significant effect on IV insertion pain (d = 1.04) with a 95% confidence interval from.84 to 1.46. Subject age (child versus adult), type of pain scale, number of therapists, location of insertion site, premedication, funding, or study design did not appear to act as effect modifiers. CONCLUSIONS: EMLA cream can significantly decrease VE and IV insertion pain in 85% of the population.     

Topical benzydamine cream and the relief of pressure pain

OBJECTIVE: To determine whether topical benzydamine hydrochloride 3% cream is more effective than placebo in reducing pain related to pressure areas in palliative care patients. DESIGN: Randomized double-blind, placebo-controlled trial. SETTING: Three specialist palliative care units in the north of England, with local ethical committee approval for all sites. SUBJECTS: Hospice in-patients with pain related to pressure areas. INTERVENTIONS: A single application of either benzydamine hydrochloride 3% cream or placebo cream to the painful pressure area. MAIN OUTCOME MEASURES: Pain assessed using 100 mm VAS, an 11-point numerical pain score and a five-point pain relief score. RESULTS: There was no statistically significant difference between topical benzydamine hydrochloride 3% cream and placebo cream in reducing pain related to pressure areas in palliative care patients. CONCLUSIONS: This study does not demonstrate a statistically significant difference between the two treatments. However the study does provide reliable information with respect to the use of different pain measurement tools in late-stage palliative patients. It also provides information regarding the baseline characteristics of this group of patients which may be useful in the planning of any future similar studies.     

1% lidocaine injection, EMLA cream, or "numby stuff" for topical analgesia associated with peripheral intravenous cannulation.

The purpose of this study was to assess patient's perception of pain associated with peripheral intravenous (i.v.) cannulation, using 3 methods of applying local anesthetics. A prospective, randomized, quasi-experimental study was conducted, using a convenience sample of men and women, ASA physical status I, II, or III, undergoing outpatient or same-day surgery. Group 1 received a subcutaneous injection of 1% lidocaine, group 2 received topical EMLA cream for 45 to 60 minutes, and group 3 received treatment with "Numby Stuff" for 40 mA minutes. After the intended analgesic treatment was complete, the patient was asked to rate the pain experienced during the skin-numbing process. An i.v. was then started using an 18-gauge i.v. catheter, and the patient again was asked to rate the amount of pain experienced with the catheter insertion. A visual analog scale was used as the tool of measurement for pain. Results of the study showed that group 1 experienced a higher treatment pain score than either group 2 or group 3, while group 2 experienced a higher pain score when the i.v. was started than either group 1 or group 3. Of the 3 methods tested, results seem to indicate that the Numby Stuff system using iontophoresis is the superior method for decreasing the pain associated with peripheral i.v. cannulation, and application of the analgesic method does not cause significant pain.     

Topical ketamine as a local anesthetic agent in reducing venipuncture pain: A randomized controlled trial

AimPain 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 methodsIn 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.ResultsThe 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).ConclusionThis study showed that local cutaneous ketamine is as effective as EMLA in relieving pain during venipuncture.     

No more tears: a randomized controlled double-blind trial of Amethocaine gel vs. placebo in the management of procedural pain in neonates

AIM: During a comparative double-blind study, the efficacy of Amethocaine local anaesthetic gel was compared with that of a placebo gel to establish their effect on the reduction of behavioural and physiological responses to pain in neonates. METHOD: Forty infants were included in the trial, 20 being randomly assigned to each group. After topical application of either Amethocaine or the placebo for 30 minutes, cannulation was performed using a 24 gauge cannula. Assessment of pain was made with the aid of four point assessment tool incorporating facial expression, cry and heart rate changes and ease of cannulation. Additional baseline data were obtained including sex, gestation, weight and previous experience of cannulation, and analysed using Statistical Package for Social Sciences (SPSS). RESULTS: Good analgesic effects were demonstrated in the Amethocaine group, as there was a high level of significance (P < 0.01) in the difference in pain scores between the two groups using a Mann-Whitney U-test. There was no correlation between gestation or weight and the degree of pain experienced during painful procedures. No significant relationship was found between cannulation and the degree of pain experienced. CONCLUSION: It can, therefore, be concluded that Amethocaine gel is an effective local anaesthetic in the management of skin puncturing procedural pain in neonates, and that all infants regardless of maturity, weight or previous experiences probably experience a similar degree of pain and therefore warrant effective and appropriate analgesic intervention.     

Assessment of the effect of EMLA during venipuncture in the newborn by analysis of heart rate variability

The objective of this study was to investigate the effect of EMLA on the pain response when venipuncture was performed in 60 3-day-old healthy newborns. EMLA/placebo was applied to the back of the baby's hand, following a randomized, double-blind procedure. ECG and crying were recorded during the test. The incidence of crying, heart rate (HR) and spectral analysis of heart rate variability were used to characterize the reaction of the baby to the venipuncture procedure. The occurrence of crying during venipuncture did not differ significantly between the EMLA and the placebo groups. The placebo-treated group showed a statistically significant higher HR, and a decrease in variance (total power) and power in the low-frequency band (0.02-0.15 Hz) when compared with the EMLA group. We conclude that EMLA decreases the stress response during venipuncture in newborn infants.     

Pain management of arteriovenous fistula cannulation in haemodialysis children: Efficacy of EMLA anaesthetic cream

The aim of the present study was to evaluate the efficacy of EMLA cream (containing a eutectic mixture of local anaesthetics) in controlling pain due to arteriovenous fistula cannulation in teenagers undergoing chronic haemodialysis. The study was conducted in two phases, one prospective, the other a blind randomized trial, at the Paediatric Haemodialysis service of the Paediatrics Department of Padua University, Italy. It involved six teenagers, aged 12–18 years. Pain was measured using the visual analogue scale, indirect evaluation by nurses and a four-category verbal rating scale. Results showed that: (1) the visual analogue scale calls for an adequate training period; and (2) the EMLA cream might be effective in controlling cannulation-related pain but emotional factors, such as uncontrolled fear and stress, can interfere with the global efficacy of the analgesic approach.