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of Table 8

Synthesis Table-8: Topical Anesthetics

Practice Area: Topical Anesthetics: Needlesticks/Procedures

Topic / Citation / Sample / Key Findings / Comments
Pain Response to EMLA / Arts, SE
Age Related Response to EMLA Emulsion and Effect of Music on Pain of Intravenous Cannulation. / Prince of Wales Hospital, Australia
180 Children ages 4-16 years / Results show that Lidocaine-prilocaine emulsion is highly effective in preventing pain from venipunctures in young children, the group most in need of prevention. The efficacy of music is greater in older children. / Study compared mean pain scores
-use of EMLA : FPS 1.42
-use of placebo:FPS2.58
-use of music distraction
FPS 2.62
(FPS-Face Pain Scale)
Topical
EMLA and LMX4 / Klieber, C, Scutte, DL McCarthy, A M et al
Predictors of topical anesthetic effectiveness in children.
The Journal of Pain, 2007: 8(2) : 168-174. / Children 4-10 yrs
218 N (mean age) undergoing IV insertion.
Low pain score 0-3 Oucher scale
High pain score 4-10 Oucher scale. / Children in the high pain groups were young, more active and scored higher for trait anxiety and had the EDNRA phenotype
EMLA- (lidocaine/prilocaine).Dose must be correct and med should be covered with an occlusive dressing x 60 min.
LMX-4 used if less than an hour was available.
No detectable difference in pain scores between the 2 products.
Mean pain score 3.34+3.38
Children who were more active and had TT genotype were more likely to report higher pain scores. Gender, ethnicity, # of previous painful procedures and type of topical anesthesia were not associated with pain scores.
Lidocaine does not remove pain for some children. / Variation in anesthesia effectiveness despite application of best practices-topicals
Do not tell a child that the lidocaine will take all of the pain away—
“ Lots of children don’t feel much pain at all after having the cream on”
Reported variability in children’s pain perception. Topical lidocaine is more successful for some children than others. Anxiety and genetics play a factor in pain sensation.
PICC insertion difficulties with topical anesthesia / Bahruth, A
Peripherally Inserted Central Catheter Insertion Problems Associated with Topical Anesthesia.
Journal of Intravenous Nursing
Jan/Feb 1996, Vol 19, 32-34 / Saint Barnabas Medical Center, New Jersey
66 Adults
9 Children / PICC usually inserted at this institution without use of topical or any local anesthesia.
All 6 PICC insertions that were unsuccessful with topical cream were successfully inserted next day. There is no documentation to date of topical anesthetic before venipuncture causing vaso constriction or vaso spasm. without use of topical cream. / Total Number PICC insertions=75
Without topical Cream and no problems with insertion=51
With topical cream no problems with insertion=24
With cream, problems with insertion=6
Successful insertion after failed attempt with top cream=3
Topical Anesthetic / Kleiber, Charmaine
Pediatrics 2002;110;758-761
Topical Anesthetics for Intravenous Insertion in Children: A Randomized Equivalency Study / 30 well children (14 girls and 16 boys) between the ages of 7-13 yrs)
EMLA applied to 1 hand for 60 min
ELA-Max to the other hand for 30 min / No sig difference in pain ratings between EMLA and ELA-Max and there was no difference for the difficulty in vein cannulation.
Some children rated IV pain high for both hands (60- on a 0-100 pain score) despite anesthetic tx. Preprocedural anxiety may affect the perception and/or rating of pain. / Pain scores on the Oucher pain scale ranged from 0-70 (mean 20.5 +22.7) for the hand tx with EMLA
0-60 (mean 24 + 17.6) for the hand tx with ELA-Max.
Use of Lido to improve procedural success / Taddio
CMAJ 2005;172(13)
Liposomal lidocaine to improve procedural success rates and reduce procedural pain among children: a randomized controlled trial / Double –blind randomized controlled trial children ages 1 month-17 years. / Cannulation after 1st attempt 74% with Lido
55% with placebo
Children > 5 years old reported lower mean pain scores during cannulation / Total procedural pain was also lower for patients receiving lido vs placebo. Routine use should be considered when feasible.
Distraction vs Topical / Cohen, LL, Blount, RL, Cohen, RJ, Schaen, ER & Saff, JF
Compartive Study of Distraction Versus Topical Anesthesis for Pediatr Pain Management During Immunizations
Health Pyschology, 1999, 18(60 501-598. / 39
4th graders
3 vaccinations over 3 months
RCT / Distraction resulted in more nurse coaching and child coping and less child distress than did EMLA or typical care / Decrease in nurse coaching during EMLA treatment may have a negative impact on child coping and distress
* interaction is important
EMLA and ELA-Max comparison / Koh, JL, Harrioan, D, Myers, R. et all
A randomized, couble blind comparison study of EMLA and ELA-Max for topical anesthesia in children undergoing intravenous insertion
Pediatric Anesthesia 2004, 14: 977-982 / 60 children
8-17 yrs of age
IV starts
Anesthesiolgists starting IVs
RCT / ELA-Max for 30 min
EMLA for 60 min
No difference in pain ratings between the 2 groups.
30 minute application of ELA-Max is just as effective as 60 min or EMLA
EMLA / Roger, TL & Ostrow, CL
The use of EMLA Cream to Decrease Venipucnture pain in Children
Journal of Pediatric Nursing 2004(19(1):33-39. / Review article
10 articles with EMLA and IV starts / EMLA is an effective local anesthestic for pediatric venipuncture. When compared to placebo 6 out of 7 of the studies indicated EMLA was more effective. One study found no difference , but sample small and they received distraction / $6.00 per application
EMLA & Distraction / Lal, MK, McClelland, J, Phillip J, Tuab, NA & Beattie, RM
Comparison of EMLA cream versus placebo inchildren receiving distraction therapy for venepuncture
Acta Paediatr 2001, 90: 154-159. / 27 children 4-8 yrs of age
RCT- double blind- placebo / Preparation, positioning, distraction with counting and blowing pin wheel
Pain scores were low in both groups, / Some children may not need EMLA
Good article – explained the distraction steps.
ELA-MAX and EMLA / Eichenfield, LF, Funk, A, Fallon-Friedlander, Cunningham BB
A clinical study to evaluate the efficacy of ELA-Max (4% Liposomal Lidocaine) as campared with eutectic meixture of local anesthestics cream for pain reducation of venipuncture in children
Pediatrics 2001: 109: 1093-1099. / 127 children
240 obsrvation
4 treatment / ELA_MAX fro 30 min with no occlusion; ELA-MAX for 60 min with occlusion; EMLA for 30 or 60 minutes with occlusion.
No differences between groups with pain scores / ELA – MAX at 30 minutes had lower pain scores than EMLA at 30 minutes
Occlusion may help keep ELA-MAX cream in place
EMLA and Infants / Stevens, BS, Johnston, C, Taddio, AN, Jack, A et al.
Management of pain from Heel Lance with Lidocaine-Prilocaine (EMLA) Cream: Is it Safe and efficacious in Preterm Infants/
Journal of Dev Behav Pediatric 1999, 20(4): 216-221. / 120 infants randomized to receive EMLA or placebo cream
RCT / 30 minute or 60 min application
Methemoglobin concentration * hrs after EMLA pplication
No differences between groups on the PIPP, No clinical signs of Methemoglobinemia. 10% of infants had minor skin problems / Safe but not efficacious