The Decision to Use Topical Anesthetic for Intravenous Insertion in the Pediatric Emergency Department

Abstract

Topical anesthetic creams to reduce the pain of intravenous (IV) placement may be more effectively used in the emergency setting if they are applied by nurses in the triage area of the emergency department or soon after the patient is placed into a room. This strategy requires accurate prediction of which patients will require IV placement. The objective of this study was to compare triage nurse judgment regarding IV placement in pediatric patients with a triage prediction rule using chief complaint, referral status, and high-risk medical history. A secondary objective was to evaluate whether the presence of the anesthetic cream placed in triage influenced the subsequent decision to place an IV and thus invalidate the prediction strategy. Triage nurses were randomly assigned to a prediction score group (PRD), classifying patients as "IV likely" if the prediction score was > or =2, or an "own judgment" (RN JDGMT) group, classifying any patient that he or she considered to have a > or =50% risk of receiving an IV. The rate of actual IV placement in the emergency department treatment rooms was compared between the triage prediction strategies. To assess the influence of the presence of lidocaine 2.5% and prilocaine 2.5% (EMLA cream) on the judgment to place an IV, only 75% of the "IV likely" patients had EMLA applied in triage; the IV placement rate was compared between "IV likely" patients who did or did not have EMLA applied. The authors enrolled 3,790 of 5,025 (75.4%) of eligible patients. The RN JDGMT group predicted 165 of 250 (66%; 95% confidence interval = 59% to 72%) of IVs placed, compared with 127 of 305 (41%; 95% CI = 36% to 47%) in the PRD group (p < 0.0001). Positive predictive values were 59% and 53% for the RN JDGMNT and PRD groups, respectively. There was no difference in IV placement rates in the "IV likely" patients who did and did not have EMLA applied. Triage nurse judgment to predict eventual IV placement had greater sensitivity and similar predictive value compared with a prediction model based on medical history and chief complaint. The triage placement of topical anesthetic in pediatric patients did not change the eventual rate of IV placement.