Efficacy and Safety of EMLA Cream for Pain Control Due to Venipuncture in Infants: A Meta-analysis

Optimizing pediatric periprocedural pain management part I-Evolving ethics and topical anesthetics

Pediatric procedure-related pain management is often incompletely understood, inadequately addressed, and critical in influencing a child's lifelong relationship with the larger health care community. We highlight the evolution of ethics and expectations around optimizing periprocedural pain management as a fundamental human right. We investigate the state-of-the-art of topical anesthetics, reviewing their mechanisms of action and providing comparisons of their relative safety and efficacy data to help guide clinical selection. In total, this two-part review offers a combination of conventional approaches and innovative techniques that should be used multimodally-in series and in parallel-to help optimize pain management and provide alternatives to sedation medication and general anesthesia.

Measurement of plasma total calcium before plasma free ionized calcium - a possibility with affordable pitfalls

Free ionized calcium (fCa) is considered the gold standard for assessing calcium status in patients, but it is relatively expensive and is associated with several preanalytical and analytical error sources. We investigated the feasibility of using a reflex test that involves first measuring total calcium (tCa) and if out of reference range, then measure fCa, with expectation of reducing the number of fCa measurements. We used data from 1815 unique patients with concurrent measurement of fCa, tCa and albumin adjusted calcium (aCa). Patients were stratified by albumin level, and the association of fCa to tCa and aCa respectively was assessed with linear regression. The regression analysis showed the best linearity for tCa and aCa at albumin <35 g/L (R2: 0.80-0.90), and the poorest at albumin >40 g/L (R2: tCa 0.58; aCa 0.59). We examined the accuracy of hypo- and hypercalcemia classifications for tCa, aCa and the reflex test. aCa had more misclassifications of hypo- and hypercalcemia than tCa, with respectively 25% and 21%. Implementation of the reflex test would correct any false hypo- or hypercalcemia classified by tCa, leaving only false negative results corresponding to 9% of all tCa measurements. False negative results were on average 0.04 mmol/L above or below the reference range of fCa. Implementation of the reflex test reduces the number of fCa by 68% without major errors diagnosing hyper- or hypocalcemia.

Increasing the use of anxiolysis and analgesia for paediatric procedures in a community emergency department network: a quality improvement initiative

Prior reports describe the care children receive in community EDs (CEDs) compared with paediatric EDs (PEDs) as uneven. The Emergency Medical Services for Children (EMSC) initiative works to close these gaps using quality improvement (QI) methodology. Project champion from a community hospital network identified the use of safe pharmacological and non-pharmacological anxiolysis and analgesia (A&A) as one such gap and partnered with EMSC to address it. Our primary Specific, Measurable, Achievable, Relevant and Time-Bound (SMART) aim was to increase intranasal midazolam (INM) use for common, anxiety-provoking procedures on children <8 years of age from 2% to 25% in a year.EMSC facilitated a QI team with representation from the CED and regional children's hospitals. Following the model for improvement, we initiated a process analysis of this CED A&A practice. Review of all paediatric procedural data identified common anxiety-provoking simple procedures as laceration repairs, abscess drainage and foreign body removal. Our SMART aims were benchmarked to two regional PEDs and tracked through statistical process control. A balancing metric was ED length of stay (ED LOS) for patients <8 years of age requiring a laceration repair. Additionally, we surveyed CED frontline staff and report perceptions of changes in A&A knowledge, attitudes and practice patterns. These data prioritised and informed our key driver diagram which guided the Plan-Do-Study-Act (PDSA) cycles, including guideline development, staff training and cognitive aids.Anxiety-provoking simple procedures occurred on average 10 times per month in children <8 years of age. Through PDSA cycles, the monthly average INM use increased from 2% to 42%. ED LOS was unchanged, and the perceptions of provider's A&A knowledge, attitudes and practice patterns improved.A CED-initiated QI project increased paediatric A&A use in a CED network. An A&A toolkit outlines our approach and may simplify spread from academic children's hospitals to the community.

Dermal effects and pharmacokinetic evaluation of the lidocaine/prilocaine cream in healthy Chinese volunteers

BACKGROUND

EMLA cream is a local anesthetic. The pharmacokinetics and dermal effects of a topical anesthetic formulation has not been evaluated in healthy Chinese volunteers.

MATERIALS AND METHODS

The Pharmacokinetics of the lidocaine/prilocaine test (T) or reference (R, EMLA) cream were evaluated in a fasting, single-dose, two-period crossover bioequivalent study conducted in 40 healthy Chinese volunteers. Meanwhile, the dermal effects including blanching, erythema, temperature sensation, edema, and skin rash were also evaluated during the study.

RESULTS

After applied 15 g of the cream for 4 h to a 100 cm2 area under plastic occlusive film on the skin of the thigh of healthy volunteers, the results of the pharmacokinetic study showed that the active components absorbed in skin from topical products was relatively low compared with most system absorption drugs. After the removal of the residual anesthetic cream, there was a vascular biphasic response with initial transient blanching which reaches a peak at 4.5 h and later more persisting period erythema. The change of temperature sensory sensitivity reached the peak value at 4.5-6 h.There was no statistically significant difference of the changes after application the lidocaine/prilocaine T or R cream in subjects. In general, the lidocaine/prilocaine T or R cream was well tolerated.

CONCLUSION

The method described a model for investigations of pharmacokinetics and pharmacodynamics of topical lidocaine/prilocaine cream. Except the plasma drug level indicator, these pharmacodynamics data should also be evaluated in the anesthetic transdermal pharmacokinetics study.

CLINICAL TRIAL REGISTRATION

CTR20211544; registered in http://www.chinadrugtrials.org.cn/ at September 2021.

Registered Nurses' Association of Ontario (RNAO) best practice guideline on the assessment and management of vascular access devices

INTRODUCTION

Vascular access is the most common invasive procedure performed in health care. This fundamental procedure must be performed in a safe and effective manner. Vascular access devices (VADs) are often the source of infections and other complications, yet there is a lack of clear guidance on VADs for health providers across different settings. A Best Practice Guideline (BPG) was developed by the Registered Nurses' Association of Ontario (RNAO) to provide evidence-based recommendations on the assessment and management of VADs.

METHODS

RNAO BPGs are based on systematic reviews of the literature following the GRADE approach. Experts on the topic of vascular access were selected to form a panel. Systematic reviews were conducted on six research areas: education, vascular access specialists, blood draws, daily review of peripheral VADs, visualization technologies, and pain management. A search for relevant research studies published in English limited to January 2013 was applied to eight databases. All studies were independently assessed for eligibility and risk of bias by two reviewers based on predetermined inclusion and exclusion criteria. The GRADE approach was used to determine certainty of the evidence.

RESULTS

Over 65,000 articles were screened related to the six priority research questions. Of these, 876 full-text publications were examined for relevance, with 174 articles designated to inform nine recommendations in the BPG on the subject areas of: comprehensive health teaching, practical education for health providers, blood draws, daily review of peripheral VADs, visualization technologies, and pain management. In June 2021, the RNAO published the BPG on vascular access, which included the recommendations and other supporting resources.

CONCLUSION

The vascular access BPG provides high quality guidance and updated recommendations, and can serve as a primary resource for health providers assessing and managing VADs.

Evaluation and Treatment of Pain in Fetuses, Neonates and Children

The perception of pain is individual and differs between children and adults. The structures required to feel pain are developed at 24 weeks of gestation. However, pain assessment is complicated, especially in neonates, infants and preschool-age children. Clinical scales adapted to age are the most used methods for assessing and monitoring the degree of pain in children. They evaluate several behavioral and/or physiological parameters related to pain. Some monitors detect the physiological changes that occur in association with painful stimuli, but they do not yet have a clear clinical use. Multimodal analgesia is recommended for pain treatment with non-pharmacological and pharmacological interventions. It is necessary to establish pharmacotherapeutic protocols for analgesia adjusted to the acute or chronic, type and intensity of pain, as well as age. The most used analgesics in children are paracetamol, ibuprofen, dipyrone, opioids (morphine and fentanyl) and local anesthetics. Patient-controlled analgesia is an adequate alternative for adolescent and older children in specific situations, such as after surgery. In patients with severe or persistent pain, it is very important to consult with specific pain services.

Near-infrared system's efficiency for peripheral intravenous cannulation in a level III neonatal intensive care unit: a cross-sectional study

Venipuncture is a painful and invasive procedure for hospitalised newborns and represents a challenge for neonatal healthcare professionals. This study evaluated the most efficient cannulation method based on the proportion of success at the first attempt, standard care or near-infrared (NIR) device use, and pain assessment. An observational study with two arms was conducted in the neonatal intensive care unit (NICU) of a tertiary-care university hospital in Italy. All newborns undergoing peripheral vein cannulation and only nurses with more than 5 years of professional experience in the NICU were eligible for the first arm. Only newborns with a body weight of >2500 g at cannulation and all nurses working in the NICU were involved in the second arm. In the first arm of the study, no statistically significant differences between the NIR and control groups were found in terms of proportion of successful at the first attempt 60.6% (confidence interval [CI] 95%: 48.8; 72.4) vs. 56.1% (CI 95%: 44.1; 68.0) and the mean premature infant pain profile score 6.3 (CI 95%: 5.4-7.1) vs. 5.8 (CI 95%: 5.0-6.6). In the second arm, only among less experienced nurses (<1 year), we observed a significant increase in the proportion of success in the NIR group compared with the control group, nearly tripling the success rate (72.7% [54.1; 91.3] vs. 23.1% [0.2; 46.0]).  Conclusion: This study reported no differences between the NIR and control groups. The results also suggest that using a NIR device may be advantageous for healthcare professionals with less experience during first-time cannulation. What is Known: • Venipuncture is a painful procedure commonly used to place a peripheral venous catheter for administering nutrients or drugs. • Near-infrared light facilitates the visualisation of veins and consequently, the performance of cannulation in the paediatric population. What is New: • The near-infrared light device was not associated with fewer attempts and a lower premature infant pain profile score in placing venous access in newborns than the traditional method. • The near-infrared light device could help nurses with less professional experience place a peripheral venous catheter.

Managing acute pain in children presenting to the emergency department without opioids

Pediatric pain is challenging to assess and manage. Frequently underestimated in children, untreated pain may have consequences including increased fear, anxiety, and psychological issues. With the current opioid crisis, emergency physicians must be knowledgeable in both pharmacologic and non‐pharmacologic approaches to address pain and anxiety in children that lead to enhanced patient cooperation and family satisfaction. This document focuses pain management and distress mitigation strategies for the brief diagnostic and therapeutic procedures commonly performed.

Use of EMLA cream for skin anesthesia and epidural insertion in the patients with cesarean delivery: A prospective double-blind randomized clinical trial

Background:

Pain relief of epidural anesthesia in cesarean delivery is difficult. EMLA, a eutectic mixture of lidocaine and prilocaine, is effective for pain reduction during venipuncture and superficial surgery. However, its effectiveness during epidural insertion is not well elucidated. The aim of this randomized, double-blind study was to evaluate the efficacy of EMLA for epidural insertion in elective cesarean delivery.

Methods:

With Institutional Review Board approval and written patients’ informed consent, forty-two ASA physical status 2 patients (aged 23–45) scheduled for elective cesarean section were included in this study. The patients were randomized to applied ELMA (EMLA group) or placebo cream (Placebo group) about one hour prior to anesthesia. Pain during skin infiltration with 1% mepivacaine and subsequent insertion of Tuohy needle was assessed immediately after each procedure. The presence of patient's response with physical withdrawal on both procedures was recorded. Statistical analysis was performed using Mann–Whitney U test and Fisher's exact test. A value of P < 0.05 was considered significant.

Results:

Median VAS values on skin infiltration and on insertion of Tuohy needle did not differ between groups. The incidence of patient's response with physical withdrawal on skin infiltration was not different between groups. However, that on insertion of Tuohy needle was significantly lower in EMLA group than in Placebo group (0%, 21%).

Conclusions:

EMLA cream could not reduce the pain during epidural insertion.

Techniques to Relieve Pain Associated With Botulinum Injections for Palmar and Plantar Hyperhidrosis

BACKGROUND

Palmar and plantar hyperhidrosis (HH) is a common condition characterized by excessive sweating of the palms and soles. Botulinum neurotoxin (BTX) is a very effective and safe treatment. However, the associated intense injection pain is a major limiting factor deterring patients from selecting this treatment.

OBJECTIVE

The aim of this study was to review the numerous techniques used to minimize pain accompanying injections for palmoplantar HH. Additionally, the advantages and limitations of each modality will be discussed.

MATERIALS AND METHODS

The authors performed a comprehensive literature search in PubMed/MEDLINE, Embase, Cochrane Central, and Google Scholar on randomized controlled trials, cohort studies, and case series on techniques to relieve pain of BTX injections for treatment of palmar and plantar HH.

RESULTS

Current available techniques in reducing botulinum injection with merits and drawbacks are nerve blocks, Bier blocks, cryoanalgesia, needle-free anesthesia, topical anesthetics, and vibration anesthesia.

CONCLUSION

Topical anesthesia, ice, and vibration are the safest and most convenient noninvasive available methods to relieve pain associated with botulinum injection. Nerve blocks, Bier block, and needle-free anesthesia provide better anesthesia but are limited by the need for training and equipment.

Use of a topical mix of lidocaine and prilocaine during split-thickness skin graft harvest improves postoperative recovery-A prospective randomized controlled trial

PURPOSE

To provide evidence of efficacy and postoperative benefit of topical anesthesia (TA) for harvesting split-thickness skin graft (STSG) in an Asian population.

MATERIALS AND METHODS

Patients with well-granulating wounds with skin grafting were randomized into TA or general anesthesia (GA) groups. In the TA group, an eutectic mixture of lidocaine and prilocaine (EMLA) was applied. Perioperative heart rate, postoperative donor site pain, adverse effects, patients' satisfaction, duration of surgery, and operation room (OR) stay duration were recorded.

RESULTS

Thirty-nine patients (19 males, 20 females; mean age 54.9 ± 17.8) were included. Twenty underwent TA and 19 underwent GA for STSG. The TA group patients had tolerable pain during skin graft harvesting (VAS, 0.85 ± 1.5). Average EMLA exposure duration was 180.3 ± 65.8 min, and the amount applied was 1.72 ± 0.43 g/10 cm². The TA group had lower donor site pain score at one hour postoperatively (1.34 ± 1.49 vs 3.08 ± 1.90, p = 0.005), lower OR stay duration (36.5 ± 6.5 min vs 65.1 ± 17.2 min, p < 0.001) and less adverse effects than the GA group.

CONCLUSION

Harvesting STSG under TA with EMLA is an effective and efficient approach for most Asian patients with less early postoperative donor site pain and fewer adverse effects.

Evaluation of eutectic lidocaine/prilocaine cream for jugular blood sampling in cats

OBJECTIVES

The study aimed to evaluate the efficacy of a eutectic lidocaine/prilocaine cream (EMLA cream; Astra Pharmaceuticals) in reducing pain and reaction to venepuncture during jugular blood sampling in cats after a 30-min topical application time.

METHODS

The study was a prospective, blind, controlled clinical trial. Eighteen healthy client-owned cats were randomly allocated to two study groups. All cats were clipped on the left jugular groove region and then, depending on the study group, either the placebo (liquid paraffin) or EMLA cream was applied to the region. The area was then kept protected for the next 30 mins. Except for the operator who administered the product, all operators were blinded to the study groups. Blood sampling was performed by an experienced operator and a stress score was assigned to each cat according to the reactions observed during the venepuncture. Also, the procedure was classified as being 'easy' or 'difficult' by the same operator.

RESULTS

A significantly reduced stress score was observed in cats that received the EMLA cream compared with those belonging to the placebo group (P = 0.048); withdrawal movements were observed in 1/9 cats treated with the EMLA cream vs 7/9 cats of the placebo group (P = 0.015). The jugular venepuncture was defined as easy in 1/9 cats that received the placebo and in 8/9 cats in the EMLA group (P = 0.015).

CONCLUSIONS AND RELEVANCE

The present study provides evidence for the efficacy of the EMLA cream after a 30-min application time for jugular venepuncture in cats, together with significantly reduced stress for patients. Therefore, this study supports the routine use of EMLA cream as good practice to enhance the welfare of cats and to simplify venepuncture procedures.

Laser-induced transient skin disruption to enhance cutaneous drug delivery

The use of pressure waves (PW) to disrupt the stratum corneum (SC) temporarily is an effective strategy to increase the deposition of drug molecules into the skin. However, given the rather modest outcomes when compared with ablation-assisted drug delivery, its potential has been underestimated. Accordingly, the aim of this study was to examine the impact of Resonant Amplitude Waves (RAWs) on increasing cutaneous delivery. RAW phenomena are triggered by focusing a high-peak-power pulsed laser onto an appropriate transducer structure, under space- and time-controlled resolution. In order to determine the optimal conditions for the generation and use of RAWs, a screening of laser parameters setting and an analysis of different geometries of the impact pattern over diverse materials used as transducers was performed, analyzing the footprint of the RAW waves in an agarose gel. The results obtained were then checked and fine-tuned using human skin samples instead of agarose. Furthermore, ex vivo experiments were carried out to characterize the effect of the RAWs in the cutaneous delivery of diclofenac (DIC) and lidocaine (LID) administered in the form of gels. The application of RAWs resulted in an increased delivery of DIC and LID to the skin, whose intensity was dependent on the composition of the formulation. In fact, the maximum observed for DIC and LID in short-time experiments (39.1 ± 11.1 and 153 ± 16 µg/cm², respectively) was comparable to those observed using ablation-assisted drug delivery under the same conditions. In conclusion, the combination of RAWs with specific formulation strategies is a feasible alternative for the cutaneous delivery of drug candidates when short onset of action is required.

Comparison of the pain-reducing effects of EMLA cream and of lidocaine tape during arteriovenous fistula puncture in patients undergoing hemodialysis: A multi-center, open-label, randomized crossover trial

Arteriovenous fistula puncture pain is a serious problem for patients undergoing dialysis and a good indication for topical anesthetics. No previous study has compared lidocaine/prilocaine cream (EMLA) with lidocaine tape for pain relief during arteriovenous fistula puncture in patients undergoing maintenance hemodialysis. To this end, we conducted a multicenter randomized crossover study including 66 patients (mean age, 65.8 years; males, 57.6%) undergoing maintenance hemodialysis thrice/week. Subjects were assigned to Sequence EL (EMLA administration followed by lidocaine, with 1-week wash-out) or Sequence LE (reverse administration, first lidocaine then EMLA). All subjects completed the study. At each puncture site, 1 g EMLA (25 mg lidocaine + 25 mg prilocaine) or one sheet of lidocaine tape (18 mg lidocaine) was applied 1 h or 30 min prior to arteriovenous fistula puncture, respectively. The primary endpoint was puncture pain relief, which was measured using a 100-mm visual analog scale. The secondary endpoints included quality of life, which was measured by SF-36, and safety. EMLA produced a 10.1-mm greater visual analog scale improvement than lidocaine tape (P = 0.00001). However, there was no statistically significant difference in the quality of life between the two groups, and no significant carryover/period effect was observed in any analysis. Further, no drug-related adverse events were observed. Taken together, these results suggest that EMLA cream is superior to lidocaine tape for the relief of arteriovenous fistula puncture pain in patients undergoing maintenance hemodialysis. Trial registration: University Hospital Medical Information Network Clinical Trials Registry (UMIN000027885).

Lidocaine as treatment for neonatal seizures: Evaluation of previously developed population pharmacokinetic models and dosing regimen

AIMS

Lidocaine is used to treat neonatal seizures refractory to other anticonvulsants. It is effective, but also associated with cardiac toxicity. Previous studies have reported on the pharmacokinetics of lidocaine in preterm and term neonates and proposed a dosing regimen for effective and safe lidocaine use. The objective of this study was to evaluate the previously developed pharmacokinetic models and dosing regimen. As a secondary objective, lidocaine effectiveness and safety were assessed.

METHODS

Data from preterm neonates and (near-)term neonates with and without therapeutic hypothermia receiving lidocaine were included. Pharmacokinetic analyses were performed using non-linear mixed effects modelling. Simulations were performed to evaluate the proposed dosing regimen. Lidocaine was considered effective if no additional anticonvulsant was required and safe if no cardiac adverse events occurred.

RESULTS

Data were available for 159 neonates; 50 (31.4%) preterm and 109 term neonates, of whom 49 (30.8%) were treated with therapeutic hypothermia. Lidocaine clearance increased with postmenstrual age by 0.69%/day (95% confidence interval 0.54-0.84%). During therapeutic hypothermia (33.5°C), lidocaine clearance was reduced by 21.8% (7.26%/°C, 95% confidence interval 1.63-11.2%) compared to normothermia (36.5°C). Simulations demonstrated that the proposed dosing regimen leads to adequate average lidocaine plasma concentrations. Effectiveness and safety were assessed in 92 neonates. Overall effectiveness was 53.3% (49/92) and 56.5% (13/23) for neonates receiving the proposed dosing regimen. No cardiac toxicity was observed.

CONCLUSION

Lidocaine pharmacokinetics was adequately described across the entire neonatal age range. With the proposed dosing regimen, lidocaine can provide effective and safe treatment for neonatal seizures.