Eutectic Mixture Of Local Anesthetics Application Research Articles

Anaphylactic shock secondary to topical EMLA

Abstract The eutectic mixture of local anesthetics (EMLAs) is an anesthetic cream frequently used by dermatologists for various aesthetic procedures on a daily basis. Although side effects of EMLA are usually mild local skin reactions, rare complications such as methemoglobinemia, central nervous system toxicity, and cardiotoxicity can occur. Herein, we are reporting a case of anaphylactic shock to topical application of EMLA.

Efficacy of Emla (Eutectic Mixture of Local Anaesthetics) and Let (Lidocaine, Epinephrine, Tetracaine) for Topical Use in Wound Management for Children: A Systematic Review and Meta-Analysis.

Lacerations are common injuries managed by emergency department practitioners and are mostly witnessed in children. These lacerations usually require wound closure, which may result in one of the most unpleasant and painful childhood experiences. The pain can be minimized through topical anesthesia, such as a combination of lidocaine, epinephrine, and tetracaine (LET) and a eutectic mixture of local anesthetics (EMLA). The current study was carried out to demonstrate the efficacy of EMLA and LET in pediatric wound management. A thorough literature search was carried out without any time limitation on five electronic databases, including PubMed, Medline, Web of Science, Embase, and Google Scholar. Relevant studies from these databases and their references were scoured for additional studies. Study quality appraisal and data analysis were conducted using Review Manager software (RevMan 5.4.1). The literature search yielded 1651 articles of which only eight were eligible for inclusion in the present study. A meta-analysis of results from 3 studies showed that LET had a significant pain reduction than the control interventions (SMD: -0.46; 95% CI: -0.69, -0.23: p<0.0001). However, the pooled effect size of data from 3 studies showed EMLA had an insignificant difference with the control interventions (SMD: -0.79; 95% CI: -1.82, -0.24: p = 0.13). Similarly, no significant difference in the number of adverse reactions was reported in either EMLA (OR: 2.31; 95% CI: 0.67, 7.93; p = 0.18) or LET (OR: 0.99; 95% CI: 0.15, 6.50; p = 0.99) Our study suggests that the topical application of EMLA and LET effectively offers pain-free wound management among pediatric patients. However, the interventions are subject to adverse reactions that should be considered when managing the wounds.

A Review of Current Literature of Interest to the Office-Based Anesthesiologist.

A Review of Current Literature of Interest to the Office-Based Anesthesiologist.

A comparison of the impact of time on the analgesic efficacy of emla cream application in children undergoing venipuncture: A randomized controlled trial

BackgroundIntravenous catheterization (venipuncture) is a common and relatively painful procedure carried out routinely in healthcare facilities. Topical Eutectic Mixture of Local Anesthetics (EMLA) has been advocated to reduce the pain associated with venipuncture in children. However, it is not precisely understood how long EMLA should be applied prior to the procedure. Some studies recommend the use of EMLA at least 60 min prior to the procedure. This study was performed to evaluate the effectiveness of EMLA when used with a shorter preparation time prior to the procedure. MethodsIn this double-blinded clinical trial, 231 patients aged 2 to 6 years were enrolled and randomly allocated into three groups. Group 1 received EMLA cream 20 min before venipuncture, group 2 received EMLA cream 60 min before venipuncture, and group C received vitamin A ointment as a control group. Pain intensity was recorded in groups based on the FLACC score. Study participants, nurses, and evaluators were blinded to the treatment group. ResultsPain severity was lower in groups 1 (mean score = 1.96) and 2 (mean score = 1.56) compared to the controls (mean score = 8.7; P<0.001). There was no difference in pain severity between groups 1 and 2 (P = 0.134). ConclusionEMLA cream significantly reduces the pain associated with venipuncture in children. Also, the application of topical EMLA 20 min before venipuncture is as practical as using it 60 min before this procedure.

Lidocaine‐Propitocain Cream, a Eutectic Mixture of Local Anesthetics, Effectively Relieves Pain Associated With Vascular Access Intervention Therapy in Patients Undergoing Hemodialysis: A Placebo‐Controlled, Double‐Blind, Crossover Study

Vascular access intervention therapy (VAIVT) is necessary to maintain vascular access in patients undergoing hemodialysis. VAIVT-associated vasodilatation is painful. However, few reports have focused on effective pain relief at the time of VAIVT. The present study was performed to determine whether lidocaine-propitocain cream, a eutectic mixture of local anesthetics (EMLA), effectively reduces VAIVT-associated pain in patients undergoing hemodialysis. This placebo-controlled, double-blind, crossover study was conducted in a single center. Among 210 patients who underwent a total of 437 VAIVT procedures from August 2017 to June 2018, 30 patients were randomly allocated to either the EMLA-placebo arm or placebo-EMLA arm at the time of VAIVT. EMLA application significantly reduced the visual analog scale score compared with placebo (47.0 ± 21.1 vs. 68.6 ± 20.7 mm, respectively; P < 0.05). EMLA is a safe and effective treatment for relief of VAIVT-associated pain in patients undergoing hemodialysis.

Effects of Extracorporeal Shock Wave-Mediated Transdermal Local Anesthetic Drug Delivery on Rat Caudal Nerves

Cavitation plays a substantial role in the clinical effects of extracorporeal shock wave therapy (ESWT). It is also generally accepted as a major mechanism in sonophoresis. To identify the enhancing effect of extracorporeal shock wave-mediated transdermal drug delivery, 24 Wistar rats were randomly assigned to four groups: (i) topical application of a eutectic mixture of local anesthetics (EMLA); (ii) 1-MHz ultrasound; (iii) ESWT pre-treatment combined with EMLA application; (iv) ESWT concurrent with EMLA application on rat tails. The degree of anesthesia was assessed using the amplitude and latency of sensory nerve action potentials within 5 min after a 60-min EMLA application. The results indicated that ESWT pre-treatment and concurrent ESWT accelerated the anesthetic effects of the EMLA cream on the tail nerve (p < 0.05). This finding might indicate that shock wave-mediated transdermal drug delivery is possible during the ESWT period.

Randomized controlled trial of topical EMLA and vapocoolant spray for reducing pain during wDPT vaccination.

Intramuscular vaccination is among the most common source of iatrogenic pain in infants. Vapocoolant sprays are rapid-acting alternative to topical anesthetics. They provide transient anesthesia via evaporation induced skin cooling, and reduce pain due to vaccine injection in children and adults. The objective was to compare the synergistic analgesic effect of eutectic mixture of local anesthetics (EMLA) with breastfeeding (EB group) and vapocoolant spay with breastfeeding (VB group) to that of only breastfeeding (BO group) during whole cell diptheria, pertussis and tetanus (wDPT) vaccination. A double blind randomized controlled trial was done to include infants up to 3 months of age who came for their first wDPT vaccination. The primary outcome variable was the duration of cry after vaccination. Secondary outcome variables were Modified Facial Coding Score, Neonatal Infant Pain Scale and latency of onset of cry. Of the 201 eligible participants, 111 babies were excluded and remaining 90 babies were randomized into three groups of thirty each. The groups did not differ significantly in baseline characteristics. Median (interquartile range, IQR) of duration of cry was lesser [35.86 (21.07-107.75) seconds] in babies receiving EMLA cream with breast feeding (EB group) and in babies receiving vapocoolant spray with breast feeding (VB group) [32.58 (21.25-106.21) seconds] as compared to babies receiving only breast feeding (BO group) [67.5 (27.6-180) seconds] (P=0.147). Difference in median (IQR) of latency of cry was not statistically significant. Modified Facial Coding Score and Neonatal Infant Pain Scale at 1 minute and 3 minutes was significantly lower in the EB and VB group, as compared to the BO group (P<0.05). Addition of topical EMLA application or vapocoolant spray to breastfeeding during wDPT vaccination does not reduce duration of cry in infants up to 3 months of age. However, they are able to show reduction in pain score and further studies are warranted to assess their efficacy as pain relief measures in infants and children.

Effects of EMLA Cream Application on Pain Perception and Pain Response of Children with Cancer During Implanted Venous Access Port Needle Insertion

Purpose: The purpose of this study was to identify effects of EMLA (Eutectic Mixture of Local Anesthetics) cream application on pain perception and pain response during insertion of implanted venous access port needle in children with cancer. Methods: From December 2010 to August 2011, at U university hospital, 20 patients scheduled for implanted venous access port needle insertion were recruited, and randomly assigned to receive either EMLA or a placebo cream 1 hour before the implanted venous access port needle insertion. While conducting needle insertion, changes in pulse and oxygen saturation on the pulse oxymeter monitor were measured and pain behavior reaction was also measured during needle insertion in the treatment room. After conducting needle insertion, self-reported pain reaction, and mothers’ perception of the children’s pain reaction were measured. Collected data were statistically processed using SPSS version 17.0 for Windows, and analyzed using descriptive statistics, t-test. Results: Children’s self-reported degree of pain, degree of pain as perceived by mothers and pain behavior reaction decreased significantly in the EMLA application group compared with the placebo group. Conclusion: Findings indicate that application of EMLA cream is effective in relieving pain in these children during implanted venous access port needle insertion.

Lidocaine-Prilocaine Cream as Analgesia for IUD Insertion: A Prospective, Randomized, Controlled, Triple Blinded Study.

Introduction:Copper IUD is a long term and reversible contraception which equals tubal ligation in terms of sterilization. One of the barriers to using this contraception method is the fear and the pain associated with its insertion. Eutectic mixture of local anesthetics (EMLA) 5% is a local anesthetic that contains 25 mg lidocaine and 25 mg of prilocaine per gram. Application of topical analgesic cream to the cervix for laser surgery, hysteroscopy and hysterosalpingography is knownAims:this study aimed to determine the effect of EMLA on IUD insertion pain.Methods:This triple blind clinical trial was conducted on 92 women in a clinic in Hamedan in 2012. After applying the cream on the cervix, pain in three steps, after using Tenaculum, after inserting hystrometr and after inserting IUD and removing IUD insertion tube were assessed with visual analog scale and were compared in EMLA group and placebo groupStatistical analysis used to determine and compare the pain of independent t tests, Mann-Whitney U test and repeated measures analysis of variance and chi-square tests to determine the homogeneity of variables and Fisher’s exact test was usedResults:Insertion hystrometr was determined as the most painful IUD insertion. The mean pain at step 2 (inserting hystrometr) was (3/11±2/53) in EMLA group, (5/23±2/31) in placebo group. EMLA cream significantly reduced the pain after using tenaculum (P<0/001), pain inserting Hystrometr (P< 0/001) and pain at IUD insertion and removing insertion tube (P< 0/001)Conclusions:Topical Application of EMLA 5% cream as a topical anesthetic on the cervix before insertion IUD reduced the pain during this procedure.

EMLA Application Exceeding Two Hours Improves Pediatric Emergency Department Venipuncture Success

The purpose of this study was to determine whether placing Eutectic Mixture of Local Anesthetics (EMLA) at emergency department (ED) triage improves venipuncture success. Emergency department triage nurses prospectively identified patients aged 0-18 years assessed to have 50% or greater chance of needing venipuncture while in the emergency department. Identified patients received EMLA or no intervention according to randomized 24-h blocks. Data were collected on need for venipuncture, venipuncture success (defined as obtaining access in one attempt), and duration and success of EMLA application (defined as EMLA occluded between 1 and 5 h). Parents' satisfaction and perception of pain were assessed with a 5-item scale. Consent was obtained from 267 out of 287 patients, in whom 111 of 154 venipunctures were successful (72%). EMLA (n = 100) and no-intervention (n = 167) groups did not differ by age or dehydration-related illnesses. Nurses flagged patients more often on days when EMLA was not applied (χ(2) = 37.8, df2, p < 0.0001), but with lower specificity of needing venipuncture (48.5% no-intervention venipuncture rate vs. 73% venipuncture rate with EMLA (χ(2) = 14.4, df2, p = 0.0001). Of the 73 EMLA patients undergoing venipuncture, 2 removed EMLA at unknown times; 2 had application duration longer than 5 h, and nurses chose non-EMLA venipuncture sites for 8. Punctures through EMLA sites with appropriate duration were successful in 51/61 (84%) versus 58/89 (65%) in untreated skin (p = 0.01, odds ratio (OR) = 2.8; 95% confidence interval (CI) [1.3, 6.2]). Success in intention-to-treat groups did not differ (OR = 1.8, 95% CI [0.87, 3.7]). Improved venipuncture success was seen linearly with increased application duration (p = 0.018). Parents perceived less pain with punctures through EMLA sites (p = 0.006). Venipuncture through an EMLA site reduced pain and improved success. Rates improved with increasing application duration. Barriers to triage EMLA placement should be evaluated. Application longer than 2 h should be studied further as a means to improve success. EMLA was supplied as a part of the Investigator-sponsored study program of AstraZeneca.

Effect of Oral Administration of Acetaminophen and Topical Application of EMLA on Pain during Transrectal Ultrasound-Guided Prostate Biopsy

PurposeTransrectal ultrasound-guided prostate biopsy is the procedure of choice for diagnosing prostate cancer. We compared with pain-relieving effect of acetaminophen, a known drug for enhancing the pain-relieving effect of tramadol, and eutectic mixture of local anesthetics (EMLA), a local anesthetic agent, with that of the conventional periprostatic nerve block method.Materials and MethodsThis was a prospective, randomized, single-blinded study. A total of 430 patients were randomly assigned to three groups. Group 1 received a periprostatic nerve block with 1% lidocaine, group 2 received acetaminophen 650 mg, and group 3 received EMLA cream for pain control. All patients were given 50 mg of tramadol intravenously 30 minutes before the procedure. At 3 hours after completion of the procedure, the patients were asked to grade their pain on a horizontal visual analogue scale (VAS). The patients were also asked whether they were willing to undergo future biopsy if required.ResultsThere were no significant differences between the three groups in terms of age, prostate-specific antigen, prostate size, or numbers of biopsy cores. The pain scores for groups 2 and group 3, which were 3.47±1.92 and 3.50±1.36, respectively, were similar and were significantly lower than that of group 1, which was 5.24±2.07.ConclusionsAcetaminophen and EMLA cream with intravenous injection of tramadol are safe, easy, and effective methods of controlling pain during the procedure. These methods were more effective for pain relief than was the conventional periprostatic nerve block method.

Vapocoolant Spray vs Lidocaine/Prilocaine Cream for Reducing the Pain of Venipuncture in Hemodialysis Patients: A Randomized, Placebo-Controlled, Crossover Study

Patients undergoing hemodialysis are repeatedly exposed to stress and pain from approximately 300 punctures per year to their arteriovenous fistula. This study was designed to measure pain associated with venepuncture during AVF cannulation and to compare the effectiveness of ethyl chloride vapocoolant spray, topical eutectic mixture of local anesthetics (EMLA) cream and placebo in controlling pain caused by venepuncture of arteriovenous fistula patients undergoing chronic hemodialysis. This randomized, placebo-controlled, crossover study, included 41 patients undergoing conventional hemodialysis three times a week. First intervention was conducted as baseline pain assessment (control). In the three consecutive dialysis sessions, every patient randomly received 1) ethyl chloride vapocoolant spray, 2) EMLA, or 3) placebo cream before venepuncture. Pain perception was recorded by patients immediately after cannulation on a 0-100 mm visual analogue scale (VAS). p<0.05 was considered as significant. VAS scores presented a marked inter-individual variation during venepuncture. EMLA application resulted in significantly lower total pain scores compared to control and all other interventions (p<0.05). No patient experienced severe pain with EMLA or vapocoolant. The patients reported less moderate and severe pain with EMLA, and vapocoolant spray compared to control and placebo interventions. Moderate and severe pain scores were similar between EMLA and vapocoolant spray (p>0.05). Venipuncture for AVF cannulation causes mild to moderate pain in hemodialysis patients. Although local application of EMLA is more effective than in preventing venepuncture pain, ethyl chloride vapocoolant is as effective as EMLA for preventing mild to moderate puncture pain in patients undergoing hemodialysis.

The effect of 50% glycolic acid on the percutaneous absorption of eutectic mixture of local anesthetics (EMLA): a study of the electrofulguration-induced pain

EMLA has a slow onset due to its limited percutaneous absorption into an intact skin, while Glycolic acid (GA) has been known to have the capability of disrupting the skin barrier function. To the best of our knowledge, the effect of 50% GA on the percutaneous absorption of EMLA has not been studied previously. The study used a two-step randomized double blind controlled trial involving 20 healthy subjects each. The first step compared the pain intensity upon applying GA and placebo for 4 minutes prior to EMLA occlusive application over time. Based on findings made in the first step, second step observation focused on the effect of occlusion on EMLA percutaneous absorption after GA application in minute 30 and 45. A second of 20 mA electrofulguration induced the pain, while modified Verbal Rating Scale (VRS) measured the pain intensity. Significant VRS difference (P < 0.05) between GA and placebo group was found in minute 15, 20, 30 and 45. However, no significant VRS difference was found after minute 60 (P = 0.420). Adequate cutaneous analgesia was achieved in minute 30 in the treatment (GA) group and in minute 45 in the placebo. There was no significant VRS difference between the occlusive and non-occlusive group in minute 30 (P = 0.214) and minute 45 (P = 0.309). Administering 50% GA prior to EMLA application enhances percutaneous absorption of EMLA, which accelerates the onset of adequate cutaneous analgesia, even without using an occlusive dressing.

Transdermal Xenobiotics in Newborn Skin.

Newborn infants are regularly exposed to a wide variety of topical agents, including treatments for rashes, antimicrobial agents, solvents, and skin barriers or moisturizers. Premature and hospitalized infants are also exposed to topical iodine for antisepsis and to topical analgesic agents. The fact that most of these agents have not been specifically evaluated for use in infants has recently been recognized as a major public health concern. The epidermis of preterm infants is not fully developed, constituting an incomplete barrier to systemic absorption of topical agents. Thus, substances applied to the skin can have adverse systemic effects. Povidone-iodine and steroid creams have been associated with thyroid and hypothalamic-pituitary axis suppression, respectively, in premature infants. Application of topical EMLA (Eutectic Mixture of Local Anesthetics) for analgesia has been implicated in methemoglobinemia in premature infants. Exposure to natural latex in gloves and medical equipment may sensitize infants, leading to the development of airway hyperreactivity and other allergic manifestations. Therefore, it is advisable to limit skin exposure of premature infants to xenobiotics. Further work is required to define safe doses of common agents. In addition, transdermal administration of systemic medications, including methylxanthines, may be practical in premature infants.

Safety and pharmacokinetics of EMLA in the treatment of postburn pruritus in pediatric patients: a pilot study.

The purpose of this study was to determine the safety and pharmacokinetics of a eutectic mixture of local anesthetics (EMLA) used to ameliorate postburn pruritus after application onto newly formed, intact skin in children. EMLA was applied once to an itchy site where healed skin had formed. Serial blood samples were collected to measure lidocaine, prilocaine, o-toluidine, and methemoglobin. Maximal plasma concentration, minimal plasma concentration, time to achieve the maximal plasma concentration, elimination half-life, and area under the concentration-time curve were calculated. Vital signs, oxygen saturation, clinical signs of hypoxia, and itch intensity were measured. Five children had 15.7 +/- 2.54 g (+/- SD) of EMLA applied to a skin surface area of 93.0 +/- 37.0 cm2. Lidocaine and prilocaine concentrations were below toxic levels; o-toluidine was not detected. Methemoglobin remained between 1 and 3%; patients did not exhibit any clinical signs of hypoxia. Mean oxygen saturation was 98.9 +/- 0.01%. The mean number of pruritic episodes and antihistamine breakthrough doses were greater in the 2 prestudy control days compared with study day 3 (P = 0.01 and P = 0.03, respectively). Skin at the site of EMLA application remained anesthetized for 12 to 13 hours. In this small pilot study, EMLA seems to be a safe, novel treatment for postburn pruritus in burned children when applied to newly healed, intact skin.

A blinded, randomized, paired, placebo-controlled trial of 20-minute EMLA cream to reduce the pain of peripheral IV cannulation in the ED

A eutectic mixture of local anesthetics (EMLA) in cream from has been used as a topical anesthetic to reduce the pain of procedures penetrating the skin. It is generally applied for 45 to 60 minutes before the painful procedure. The purpose of this study was to determine whether a 20-minute application of EMLA is useful in reducing the pain of routine peripheral intravenous cannulation in the emergency department (ED). A blinded, randomized, placebo-controlled, paired trial compared the pain of intravenous cannulation in both hands of study subjects: one hand was treated with 20-minute EMLA cream and the other hand was treated with 20-minute placebo cream. Forty subjects identified the more painful hand and scored pain measurements of each hand using a 10-cm visual analog scale. These data failed to demonstrate any significant benefit of EMLA compared with placebo. EMLA is not useful for intravenous cannulation when used for 20-minute application times. There may be more effective and less costly ways of reducing the pain of intravenous cannulation that patients would prefer.

Use of a Eutectic Mixture of Local Anesthetics for Prolonged Subcutaneous Drug Administration

The efficacy of a eutectic mixture of local anesthetics (EMLA) in alleviating the pain associated with subcutaneous needle insertion for infusion of the iron-chelating agent, deferoxamine, was examined in 12 patients with homozygous beta-thalassemia. As reported by the patient using a 100-mm visual analogue scale, the pain of insertion was rated as significantly less after application of EMLA (mean +/- SD, 1.5 +/- 2.2 mm) than the pain associated with needle insertion without EMLA (34.8 +/- 33.5 mm, P = .005). Subsequently, in a double-blind randomized trial of 10 beta-thalassemia patients, EMLA was significantly better (5.7 +/- 8.2 mm) than placebo (27.0 +/- 22.8 mm, P = .01) in reducing the pain of needle insertion for deferoxamine infusion. No adverse effects were reported with the use of EMLA cream. These results suggest that EMLA may be effective in reducing the pain associated with needle insertion for subcutaneous deferoxamine infusion in beta-thalassemia patients, which may lead to improved compliance with this irritating, prolonged therapy. The safety of EMLA use in these patients, and others receiving regular parenteral therapy, should now be examined.

Laser-Induced Pain for Evaluation of Local Analgesia

High-energy lasers are suitable for experimental pain stimulation because they selectively activate the polymodal nociceptors. Argon laser light penetrates deep into the skin and makes this laser type preferable for simulating pain arising from surgical skin incisions. Short argon laser pulses were applied to the skin and three parameters were quantified before and during analgesia; sensory threshold, pain threshold, and the pain-related cortical response (latency and amplitude). Determination of sensory and pain thresholds made it possible to distinguish between two levels of analgesia; the pain block, where no pain was felt but other sensations were still perceived; and total sensory block, where the laser stimulus elicited no sensations of any type. The analgetic effects of cutaneous injections of lidocaine and topical application of EMLA (eutectic mixture of local anesthetics) cream were evaluated and compared by means of the introduced parameters. Lidocaine produced total sensory block almost immediately after injection, which was associated with the absence of cortical response to cutaneous laser stimulation. When the EMLA cream was applied for 15 minutes, both sensory and pain thresholds increased. During the next 30 minutes after removal of the cream, the thresholds increased further. The increase in analgetic effect after removal of the cream was studied using different times (15, 30, 60, 80, 100, and 120 minutes) for topical EMLA cream application. Total sensory block was reached 20 minutes after removal of application for 80 minutes or immediately after removal of the cream after it was applied for 100 or 120 minutes.(ABSTRACT TRUNCATED AT 250 WORDS)