Mixture Of Local Anesthetic Cream Research Articles

Effectiveness of the Eutectic Mixture of Local Anaesthetics Cream in the Management of Arteriovenous Fistula Needle Insertion Pain in Patients Undergoing Haemodialysis.

This review aimed to assess the effectiveness of the eutectic mixture of local anaesthetics (EMLA) cream in the management of arteriovenous fistula (AVF) needle insertion pain in adult patients undergoing haemodialysis (HD) compared with other alternative interventions. The main search was conducted in November 2020 and updated in December 2021. In the search strategy, keywords and synonyms were used and multiple databases were searched with no date limitation to ensure a comprehensive search that would yield all studies relevant to the review and minimise location bias. A total of 209 studies were found in this search and filtered. After filtering through these studies, only five studies were finally included in the review. EMLA-cream was found to be effective in reducing AVF needle insertion pain among adult patients undergoing HD. Despite EMLA cream's effectiveness in reducing HD needle insertion pain and its fewer side effects, the findings of the included studies should be interpreted with caution, as there are some limitations, and further research is required.

Analgesia for Infant Circumcision: Eutectic Mixture of Local Anesthetic (EMLA) Cream versus Dorsal Penile Nerve Block using Bupivacaine

Context: Circumcision is a painful procedure; thus, analgesia for neonatal circumcision is advocated for every male infant, and its use is considered essential by the American Academy of Pediatrics. Aim: This study aimed to compare the analgesic, hemodynamic effects, and complications of an eutectic mixture of a local anesthetic cream versus dorsal penile nerve block using bupivacaine for infants coming for circumcision. Materials and Methods: This was a prospective randomized interventional study involving 64 infants scheduled for circumcision at the Jos University Teaching Hospital. Infants were randomized into one of two groups through allocation concealment technique. Group I received dorsal penile nerve block with plain bupivacaine 0.5 mL/kg of 0.25%, while group II received 1 g of an eutectic mixture of a local anesthetic cream (EMLA). Circumcision started 5 minutes after penile block for group I and 1 hour after EMLA cream application for group II. Pain levels using CRIES scale, hemodynamic parameters, duration of surgery, and postoperative complications were noted and documented. Data were analyzed using SPSS version 23. A P value of less the 0.05 was considered statistically significant. Results: The study groups were comparable in demographic characteristics (P = 0.054). Less infants had CRIES scores of >4 in the DPNB group up to 2 hours postoperative period. Hemodynamic parameters were within normal ranges but higher in the EMLA group. No complication was noted in both study groups. Conclusion: Dorsal penile nerve block with bupivacaine provided better analgesia in infants undergoing circumcision than EMLA.

Efficacy of Eutectic Mixture of Local Anesthetic Cream and Vibrator Device in Pain Reduction during Peripheral Venous Cannulation in a Tertiary Care Center of Central Nepal

Background Venous cannulation is a commonly performed procedure which often leads to patient anxiety. Application of a vibrator device and or prior use of topical anesthetics are proven methods to decrease associated pain.
 Objective To compare the clinical efficacy of prior use of Eutectic Mixture of Local Anesthetic (EMLA) cream and vibrator device in pain reduction during peripheral venous cannulation.
 Method A true experimental study was conducted in November 2019 among 78 patients aged 20-60 years receiving peripheral cannulation at operation theatre. They were included using consecutive sampling and sorted to interventional and noninterventional group using simple random sampling lottery method. Participants in the non-interventional group received peripheral cannulation using routine technique whereas participants in the interventional group received topical Eutectic Mixture of Local Anesthetic cream or vibrator device prior to cannulation. Perceived post cannulation pain intensity was measured using numerical pain rating scale. Kruskal-Wallis test was used for data comparison.
 Result The mean age of the participants was 40.57 ± 12.5 years. The median pain score of Eutectic Mixture of Local Anesthetic cream, vibrator and no intervention was 3, 3 and 6 respectively. The reduction in median pain intensity was significantly greater with topical anesthetic cream and vibrator device when compared to the noninterventional group (p < 0.05).
 Conclusion Prior interventions with Eutectic Mixture of Local Anesthetic or vibrator device are useful in reducing pain intensity during peripheral venous cannulation. Routine use of these in day to day practice could be a part of standard nursing care practice.

Local anesthetics versus systemic analgesics for reducing pain during Extracorporeal Shock Wave Lithotripsy (ESWL): A systematic review and meta-analysis.

Extracorporeal Shock Wave Lithotripsy (ESWL) is one of the treatment options for patients with renal and ureteral calculi. Even though the procedure is less invasive compared to others, pain caused by the procedure is a major concern. Several studies recommended the use of either local or systemic analgesia with varying results. We aimed to compare the use of local anesthetics and systemic analgesics from randomized controlled trials evaluating pain management during ESWL. A systematic search adhering to the Preferred Reporting Items for Systematic Review and Meta-Analysis protocol was performed in theMedline, ScienceDirect, and Cochrane library databases. The bias was evaluated using the Cochrane risk of bias tool. Mean difference (MD) was used to analyze continuous outcomes. A total of seven studies were obtained. The topical anesthesia used was eutectic mixture of local anesthetic cream and xylocaine gel. In contrast, the local injection anesthesia used was subcutaneous prilocaine and intracutaneous sterile water injection. The systemic analgesics used were intramuscular and oral forms of sodium diclofenac. There is no significant difference between the visual analogue scale results between the local and systemic groups (P> .05). The differences in ESWL frequency were also insignificant (P > .05). Additional analgesics supplementation (MD 8.44, 95% CI 2.28-14.61, P¼ .007) and the duration of the procedure (MD 1.39, 95% CI 0.21-2.56, P¼ .02) were significantly lower in the local group. Local anesthesia in ESWL shows a similar degree of pain and frequency but has a shorter duration and fewer analgesics supplementation than systemic analgesics.

Comparison of the Effectiveness between 5% Eutectic Mixture of Local Anesthetic Cream and Ethyl Chloride Spray Applied on the Skin Prior to Intravenous Cannulation

Background: Since the patients scheduled for an endoscopic procedure had been unhappy with pain during intravenous cannulation. Objective: To compare the effectiveness between 5% eutectic mixture of local anesthetic cream and ethyl chloride spray applied on the skin prior to the procedure. Materials and Methods: One hundred eighty-six patients were randomized equally into three groups, A: 5% eutectic mixture of local anesthetic cream, B: ethyl chloride spray, and C: placebo. Then a nurse used a 22-gauge (22G) needle catheter to administer a cannula. Five minutes after the intravenous cannulation, a co-researcher assessed the patient’s pain perception and satisfaction as well as the nurse’s difficulty in performance by means of a numeric rating scale. Results: One hundred seventy-six patients completed the present study. Participants having the anesthetic cream and spray application as well as the placebo expressed their pain scores as 1.7±1.3, 1.6±1.2, and 2.2±1.3, respectively. Therefore, patients applied with local anesthetics had significantly less pain perception than those with the placebo (p=0.039); however, scores were not different between the anesthetic cream and the spray groups. Conclusion: Patients scheduled for an endoscopic procedure did not showed significant pain relief with either the 5% eutectic mixture of local anesthetic cream or the ethyl chloride spray. Keywords: 5% eutectic mixture of local anesthetic cream, Ethyl chloride spray, Endoscopic surgery, Intravenous cannulation, Pain

Methemoglobinemia Secondary to Herbal Products.

Dear Editor, We read with interest the recent article by Al-Qahtani et al. regarding methemoglobinemia in a young boy.[1] We would like to discuss few other essential points that we believe to be important for Saudi J Med Med Sci readers to have a comprehensive understanding of this topic.[23] While there seems to be a good temporal correlation between Ferula asafoetida ingestion and the development of methemoglobinemia in the case reported, we still strongly recommend that in such cases, a comprehensive workup should be performed to rule out congenital methemoglobinemia. In young patients, we should be very cautious and always consider congenital methemoglobinemia before labeling them as a case of acquired methemoglobinemia. We recommend genetic testing for cytochrome b5 reductase deficiency and hemoglobin (Hb) M to ensure that in such cases, the child is free from any genetic perturbations that can put him/her at risk for the recurrence of methemoglobinemia in future.[4] Hb M is a special variant in which heme iron can undergo auto-oxidation, resulting in methemoglobinemia. The common Hb M variants are Hb M-Boston, Hb M-Iwate, Hb Auckland, Hb Chile, Hb M-Saskatoon and Hb M-Milwaukee. Food products such as frozen items may have high nitrate content, and there have been reports of clusters of cases with many family members developing methemoglobinemia because of frozen food consumption.[5] In addition, it should be noted that rarely used topical agents such as eutectic mixture of local anesthetic cream, e-cigarettes, contaminated water and other herbal medicines such as choy sum can lead to methemoglobinemia.[6] In the case reported by Al-Qahtani et al., it is unclear why the patient had anemia of 10.4 g/dl and leukocytosis of 24,000/mm. Did the authors look for hemolysis in this case and what was the likely explanation of the high white blood cell count? Getting a serum lactate dehydrogenase and other hemolytic panel such as serum haptoglobin, direct antiglobulin test and peripheral blood smear would be beneficial to rule out concomitant hemolysis that can be associated with methemoglobinemia.[7] The family history is very relevant in this case, as rightly explained by Al-Qahtani et al.[1] As per the history provided, both the brothers of the infant had glucose-6-phosphate dehydrogenase (G6PD) deficiency. However, we recommend that the parents should also be checked for this deficiency. In case of a male boy, there is a 50% chance of having a G6PD deficiency if the mother is a carrier. Therefore, genetic testing of parents is mandatory to predict the likelihood of transmitting the condition to children. Methylene blue (MB) is the drug of choice in the management of methemoglobinemia. In the case reported by Al-Qahtani et al., MB was not given for the fear that he may be positive for G6PD deficiency given the strong family history. This patient was critically sick and mechanically ventilated. We are not sure about the logistic resources at the author’s medical center, but a rapid fluorescent spot test for G6PD deficiency is now readily available, which can confirm G6PD deficiency in as early as a few minutes.[8] This patient was not given either MB or vitamin C and instead was successfully treated with hyperoxic ventilation. This is a great learning case, but we wish to reinforce the fact to the readers that MB should be the first choice and all efforts should be made to check the G6PD status so that patients are not denied the standard of care. It should also be noted that in addition to MB and ascorbic acid, other drugs such as riboflavin and cimetidine can be used to treat methemoglobinemia with variable outcomes.[3] Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

EMLA cream vs 10% lidocaine cream for attenuating venous cannulation pain – a clinical trial

Background: Venous cannulation is a painful procedure that is associated with anxiety, distress and discomfort. But pain is frequently overlooked in adults.Aims and Objective: We compared the efficacy of 5% EMLA cream and 10% lidocaine cream in attenuating pain associated with peripheral venous cannulation.Methods: This prospective, randomized, placebo-controlled trial was conducted in 102 ASA I and II adults scheduled for elective surgery. They were randomly allocated by blind balloting to one of three groups: group E had 1.5 mL of EMLA cream, group L 1.5 mL of 10% lidocaine cream, and group P 1.5 mL KY gel. All cream was applied over a visible vein for 60 min with occlusive dressing. Pain was evaluated using visual analogue scale (VAS) and verbal rating scale (VRS).Results: The mean VAS score was significantly lower with either EMLA cream (2.62±1.76 cm) or 10% lidocaine cream (1.85±1.58 cm) than with placebo (4.78 ±1.88 cm), p<0.001. Most patients who received EMLA cream (76.5%) or 10% lidocaine cream (70.6%) compared with placebo (55.9%) had mild pain during cannulation using VRS.Conclusion: The eutectic mixture of local anesthetic cream and lidocaine cream attenuated pain associated with peripheral venous cannulation to varying degrees.Keywords: Venous cannulation pain, 10% lidocaine, EMLA, VAS, VRS, Side effects

Comparison between Vapocoolant Spray and Eutectic Mixture of Local Anesthetics Cream in Reducing Pain during Spinal Injections.

Background Eutectic mixture of local anesthetics (EMLA) cream is often used for local anesthesia during spinal injections. However, this agent has delayed onset of action while vapocoolant spray serves more advantages. The vapocoolant spray containing ethyl chloride has fast onset and is safe, low cost, and widely available. This study aimed at comparing the effectiveness of vapocoolant spray and EMLA cream in reducing pain for spinal injections. Methods This was an experimental study on 94 subjects with 47 subjects treated with EMLA cream and 47 subjects treated with vapocoolant spray. The effectiveness of anesthesia was assessed by using Numeric Pain Rating Scale (NPRS) and patient movement during the surgery. Results This study found that the pain scale was NPRS 0 (0–3) for the EMLA group and NPRS 0 (0–4) for the vapocoolant spray group. There was no significant difference between two groups for pain scale according to the Mann–Whitney U test. For patient movement, the movement was reported only in one (2.1%) patient in the EMLA group and one (2.1%) patient in the vapocoolant spray group. Based on Fisher's test, there was no significant difference between the two groups for patient movement. Conclusions Both EMLA cream and vapocoolant spray were equally effective in reducing pain during spinal injection. There was no difference in degree of pain reduction and patient movement between the EMLA cream group and the vapocoolant spray group during spinal injection.

Does the Application of Heat Gel Pack After Eutectic Mixture of Local Anesthetic Cream Improve Venipuncture or Intravenous Cannulation Success Rate in Children? A Randomized Control Trial

Needle-related procedures are the most common sources of pain for children in the hospital setting. The most used topical anesthetic, eutectic mixture of local anesthetic (EMLA) cream, may cause transient vasoconstriction. It has been postulated that this vasoconstriction may decrease vein visualization. The application of heat gel pack after removal of EMLA cream in the site of venipuncture counteracts the vasoconstriction, improving vein visualization. We assessed using a prospective randomized controlled trial whether the application of heat gel pack increases the needle procedure success rate. The primary study outcome was procedural success rate at the first attempt. The study enrolled 400 children, 200 of whom applied heat gel pack after removing EMLA (treatment group) and 200 did not (control group). Procedural success rate at the first attempt, vein perception before procedure, procedural pain, and adverse events were recorded in both groups. Eighty-eight percent of the procedures were successful at the first attempt in the treatment group and 89% in the control group (P = 0.876). Vein perception was not significantly different in the 2 groups (P = 0.081). Pain score after the procedure was similar in the 2 groups. This study shows that the application of heat gel pack after removal of EMLA cream does not improve venipuncture or intravenous cannulation success rate.

Transdermal Ketoprofen Patch in Comparison to Eutectic Mixture of Local Anesthetic Cream and Subcutaneous Lidocaine to Control Pain Due to Venous Cannulation.

Background:This study was established to compare the analgesic and side effects between transdermal ketoprofen patch 30 mg and eutectic mixture of local anesthetic (EMLA) cream applied to the peripheral venous cannulation site and lidocaine injection before cannulation.Patients and Methods:One hundred and five adult patients who had been scheduled for elective general surgery with patients' physical status American Society of Anesthesiologists classes I and II were randomly divided into three groups: Group I (EMLA group) received EMLA cream, Group II (lidocaine group) received subcutaneous infiltration of 1 ml of 2% lidocaine HCl 10 min before cannulation, and Group III (ketoprofen group) received a transdermal ketoprofen patch 30 mg. Groups I and III received their cream or patch 60 min before cannulation. The pain resulting from cannulation by an 18G cannula was assessed by a visual analog scale (VAS) at the time of cannulation and every 2 h for another 6 h for all groups. Signs of inflammation at the site of cannulation (erythema, induration, edema, and blanching) were observed at the site of cannulation for 24 h.Results:Ketoprofen patch, EMLA cream, and lidocaine injection were found to be equal in controlling pain caused by venous cannulation with no significant difference in VAS. Signs of inflammation at the site of cannulation (blanching, erythema, and induration) were very evident in Group I (EMLA) which showed significant difference than in other two groups.Conclusions:EMLA cream, ketoprofen patch, and lidocaine injection have equal ability to alleviate pain due to cannulation when applied before the procedure, but ketoprofen patch is more superior as it had less local inflammatory effect in comparison to EMLA cream and without double puncture as with lidocaine injection.

Local anaesthetic systemic toxicity

Access the CPD MCQs for this issue online here ### Key points Well-placed local anaesthetics (LAs) can yield great clinical benefits. But systemic toxicity related to their use can be devastating. The highly publicized case in 2004 of Mayra Cabrera, a theatre nurse who died shortly after delivery of her baby boy when her epidural infusion of bupivacaine was mistakenly connected to her i.v. line, reminds us to be vigilant and to learn from such rare events. While prevention is clearly the most important element in avoiding morbidity and mortality associated with local anaesthetic systemic toxicity (LAST), such cases still occur despite best practice. Knowing how to manage these uncommon events is vital. In this review, we cover LA toxicity, its incidence, clinical features, risk factors, prevention, and management and examine i.v. lipid emulsion (ILE) therapy in more detail. LAST has been recognized for more than a hundred years, but the precise incidence is currently unknown. In 1928, the American Medical Association reported 40 deaths attributable to LAs.1 Cocaine was responsible for half of these deaths, but procaine was also implicated. These findings prompted the search for less toxic agents. Lidocaine, first synthesized in 1944, was the first amide LA to be used clinically. However, in 1979, the potentially fatal toxicity of amide LAs was highlighted by Albright.2 More recently, studies from 1993 …

Effect of lidocaine-prilocaine eutectic mixture of local anaesthetic cream compared with oral sucrose or both in alleviating pain in neonatal circumcision procedure

Neonatal circumcision is one of the oldest and most frequently performed surgical procedures on males. Newborns demonstrate strong endogenous reaction to pain and therefore modalities are being explored for optimum pain relief during circumcision. Pediatric nurses have a vital role for the use of these modalities and minimising the pain response during the neonatal minor procedures. The aim of this study was to assess the effectiveness of eutectic mixture of local anaesthetic (EMLA) cream compared with oral sucrose and both in alleviating pain in neonatal circumcision. This study was conducted in the Day Care Surgery Department of Maternity and Children Hospital, Dammam City, KSA. 90 full-term newborn males who underwent circumcision were divided randomly into three groups (30 each). Each group was assigned to receive a different type of analgesics such as EMLA cream (Group A), oral sucrose (Group B) or combination of EMLA cream and oral sucrose (Group C). Neonatal pain agitation and sedation scale (N-PASS) was used 5 min before, during and 5 min after the circumcision procedure to assess the neonatal response to pain. N-PASS scores were significantly lower in Group C (median Group C = 5.2, Group A = 5.8, Group B = 8.5; P< 0.001). The endogenous response to pain in terms of escalation of heart rate and reduction in O 2 saturation were minimal among Group C (P < 0.0001). Duration of crying was comparable among all the groups. The combination of sucrose and EMLA cream revealed a higher analgesic effect and minimal adverse response to pain than either EMLA cream or sucrose alone during neonatal circumcision.

The effectiveness of diclofenac gel and eutectic mixture of local anesthetic cream on vein puncture pain severity with vein catheter in patient undergoing cesarean section: A randomized, double-blind, placebo-controlled trial.

Aim:This study was aimed to explore the effect of applying diclofenac gel and a eutectic mixture of local anesthetic (EMLA) cream on vein puncture pain severity with vein catheter in the patients undergoing cesarean section.Materials and Methods:The sample comprised 90 women undergoing elective cesarean section that referred to Imam Ali Hospital's maternity section in Amol city (Northern Iran). Data collection tools included visual analog scale for pain severity and a checklist for short term possible side-effects of diclofenac gel, EMLA cream and Vaseline ointment as placebo.Results:The pain of vein puncture with diclofenac gel and EMLA cream was significantly lower than that with the Vaseline ointment (P = 0.001). Similarly, there was a significant difference between using diclofenac gel and EMLA cream in catheter insertion pain severity (P = 0.006). In addition, there was no short term possible side-effect with using diclofenac gel and Vaseline ointment, but a short term side-effect (blanching) was detected in 20% of subjects with EMLA cream.Conclusion:Compared to Vaseline cream, EMLA cream and diclofenac gel application significantly reduces the pain severity associated with vein catheter insertion. Use of diclofenac gel is preferred compared with EMLA cream, because of economics, more efficiency purpose, and no side-effects.

Loss of anatomical landmarks with eutectic mixture of local anesthetic cream for neonatal male circumcision

We report two cases of newborns who developed marked local edema after application of a eutectic mixture of local anesthetic (EMLA) topical anesthetic cream for neonatal male circumcision (NMC). Although local edema and erythema are known potential side effects of EMLA cream, a common anesthetic used for NMC, the loss of landmarks precluding safe NMC has not previously been reported, and is described here. Although we cannot recommend an alternate local anesthetic for neonates with this reaction to EMLA, based on a review of the published data we think that serious systemic adverse events related to EMLA are extremely rare.

Efficacy of two oral premedicants: midazolam or a low‐dose combination of midazolam–ketamine for reducing stress during intravenous cannulation in children undergoing CT imaging

Pain, anxiety and fear of needles make intravenous cannulation extremely difficult in children. We assessed the efficacy and safety of oral midazolam and a low-dose combination of midazolam and ketamine to reduce the stress and anxiety during intravenous cannulation in children undergoing computed tomography (CT) imaging when compared to placebo. Ninety-two ASA I or II children (1-5 years) scheduled for CT imaging under sedation were studied. Children were randomized to one of the three groups. Group M received 0.5 mg x kg(-1) midazolam in 5 ml of honey, group MK received 0.25 mg x kg(-1) midazolam mixed with 1 mg x kg(-1) ketamine in 5-ml honey and group P received 5-ml honey alone, orally. In 20-30 min after premedication, venipuncture was attempted at the site of eutectic mixture of local anesthetics cream. Sedation scores and venipuncture scores were recorded. Primary outcome of the study was incidence of children crying at venipuncture (venipuncture score of 4). Significantly more children cried during venipuncture in placebo group compared to the other two groups (19/32 (59%) in group P vs 1 each in groups M and MK, (P < 0.001) (RR 2.37, 95% CI 1.55-3.63). In 20-30 min after premedication, group P had more children in sedation score 1 or 2 (crying or anxious) compared to the other two groups (P < 0.05). At this time, group MK showed more children in calm and awake compared to group M (P = 0.02). At venipuncture, group P had more children in venipuncture score 3 or 4 (crying or withdrawing) compared to group M or MK (P < 0.05), while groups M and MK were comparable. A low-dose combination of oral midazolam and ketamine or oral midazolam alone effectively reduces the stress during intravenous cannulation in children undergoing CT imaging without any adverse effects. However, the combination provides more children in calm and quiet state when compared to midazolam alone at venipuncture.

Comparison of Three Analgesic Treatment Protocols for Pain Management during Extracorporeal Shock Wave Lithotripsy

Introduction: In this prospective and randomized study, we aimed to compare the efficacy of a eutectic mixture of local anesthetics (EMLA) cream, diclofenac sodium (DS) and EMLA in combination with DS (EMLA+DS) for pain management during extracorporeal shock wave lithotripsy (ESWL). Patients and Methods: 120 patients who had undergone ESWL for renal stones were included in the study. The patients were randomized into three groups: the first group was treated with a eutectic mixture of local anesthetics cream (EMLA), while intramuscular DS was applied to the second group and EMLA+DS was applied to the third group. Pain during ESWL was assessed with the 10-score linear and visual analogue pain scale and was compared between groups. Results: Mean age was 44.4 ± 1.9 years. There was no statistically significant difference between groups regarding patients’ mean age, weight, stone size, shock waves, duration of ESWL and energy level values (p > 0.05). The mean pain score during ESWL was 3.90 ± 0.16 in the EMLA group, 3.28 ± 0.18 in the DS group and 3.05 ± 0.18 in EMLA+DS group (p = 0023). Conclusion: DS appears to be more efficient than EMLA in reducing pain during ESWL. Using EMLA+DS has no superiority in relieving pain compared to DS-only treatment.

Topical Anesthesia With EMLA does Not Decrease Pain During Vasectomy

Previous studies show conflicting results of the ability of EMLA (eutectic mixture of local anesthetics) to decrease pain during vasectomy. We examined the effectiveness of EMLA cream to decrease pain in patients undergoing bilateral percutaneous no-scalpel vasectomy. A prospective study was performed in which 316 patients used EMLA cream (178) or no topical anesthesia (138) before vasectomy. EMLA cream was applied by patients 1 hour before the scheduled time of surgery. Bilateral percutaneous no-scalpel vasectomy was then performed in the 2 groups with local infiltration of 1% lidocaine into the scrotal wall and vasal sheath. Following the procedure patients were asked to rate their associated pain using a visual analog scale. Statistical analysis was performed using the 2-sided Student t test. Mean patient age was similar in the groups with and without EMLA (39.1 and 39.0 years, respectively). No significant difference in mean visual analog pain scores were noted between the EMLA and control groups (21.5 vs 21.0, p = 0.8). Topical anesthesia with EMLA did not significantly decrease the pain associated with percutaneous vasectomy.

The endoscopic application of eutetic mixture of local anaesthetics cream

The endoscopic application of eutetic mixture of local anaesthetics cream

Pain in Infants Who Are Younger Than 2 Months During Suprapubic Aspiration and Transurethral Bladder Catheterization: A Randomized, Controlled Study

Proper diagnosis of urinary tract infections depends on obtaining an uncontaminated urine sample for culture. Suprapubic aspiration and transurethral catheterization are the 2 recommended procedures for obtaining specimens for urine culture from young infants. The objective of the current study was to compare the pain that is experienced during these 2 procedures when performed in young infants. A prospective, single-blind, randomized, controlled study was conducted at a university-affiliated hospital in Israel. Institutional Research Ethics Board approved the study. Infants who were 0 to 2 months of age and presented to the emergency department with fever and therefore required urine collection for culture were randomly assigned evenly into 2 sample collection groups: suprapubic aspiration or transurethral catheterization. Patients were excluded when they were born prematurely or had had a previous sepsis workup or other painful procedures or an anomaly of the urogenital system or abdominal wall. Eutectic mixture of local anesthetic cream that contained lidocaine and prilocaine was applied 1 hour before the procedure. The urethra was catheterized using a 5-Fr latex-free feeding tube that was lubricated with sterile water-soluble jelly that contained 2% lidocaine hydrochloride. Pediatric residents who were experienced with the procedures performed both suprapubic aspiration and transurethral catheterization. The parents were instructed to use any comfort strategies that they wished, including verbal or physical comforting and pacifiers. Pain during collection was assessed on a 100-mm visual analog scale by a nurse and a parent. In addition, the infant's upper part of the body was videotaped during the procedure. An investigator, who was blinded to the procedure, assigned a point score according to the Douleur Aigue du Nouveaune neonatal acute pain scale. For ensuring a successful blinding process, the following steps were taken. First, camera recording started 30 seconds before the procedure to prevent the possibility of distinguishing between the procedures on the basis of their duration. Second, the physician and the nurse were asked not to speak during the procedure to avoid revealing the nature of the procedure. Third, the person who videotaped the procedure watched the tape before it was analyzed to ensure the impossibility of identifying the procedure from the tape. The Student's t test was used to compare the groups. The primary outcome was the mean Douleur Aigue du Nouveaune score. Secondary outcomes were the mean visual analogue scale for pain as estimated by the parents and by the nurse. We estimated that 25 patients would be needed in each group to detect a difference in the mean Douleur Aigue du Nouveaune score of at least 2 points with a power of 80% and alpha of .05. The study was conducted between April 1, 2004, and April 30, 2005. Fifty-eight infants were recruited; 29 were randomly assigned to suprapubic aspiration, and 29 were randomly assigned to transurethral catheterization. Seven infants were excluded because of consent withdrawal (3 patients), because of technical difficulties during videotaping (3 patients), or because the child voided during the procedure (1 patient). Twenty-seven infants in the suprapubic aspiration group and 24 in the transurethral catheterization group completed the study. All male infants were circumcised. An adequate urine sample was obtained in 18 (66%) of 27 patients in the suprapubic aspiration group and in 20 (83.3%) of 24 in the transurethral catheterization group. The mean Douleur Aigue du Nouveaune score was significantly higher in patients who were randomly assigned to suprapubic aspiration compared with patients who were randomly assigned to transurethral catheterization (7 and 4.5, respectively). The differences in Douleur Aigue du Nouveaune score also were significant in a subgroup analysis of boys and girls. Mean visual analogue scale scores by parents was higher in the suprapubic aspiration group compared with transurethral catheterization (63 +/- 27 mm vs 46 +/- 26, respectively). Similarly, mean visual analogue scale scores by nurses was higher in the suprapubic aspiration group compared with transurethral catheterization (3 +/- 18 mm vs 43 +/- 25 mm, respectively). In infants who are younger 2 months, suprapubic aspiration is more painful than transurethral catheterization. Health professionals should consider these differences when choosing a method for obtaining a urine sample from young infants.

Purpura after Application of EMLA Cream in Two Children

The eutectic mixture of local anesthetic cream, a 1 : 1 mixture of prilocaine and lidocaine, 2.5% each, is frequently used in pediatric and dermatologic practice to obtain local anesthesia. Side effects include transient skin blanching, erythema, urticaria, allergic contact dermatitis, irritant contact dermatitis, hyperpigmentation, and purpura. We report two children with a purpuric reaction after application of this mixture cream. Purpura after application of this anesthetic cream is a rare nonallergic reaction and only 17 occurrences have been reported, to our knowledge, in the literature. Patch tests could not be performed in our two patients because of lack of parental consent but we suggest that the purpuric reactions were most probably of toxic origin. The pathogenesis of purpura after application of eutectic mixture of local anesthetics cream, which resolves within 2 weeks without dermatologic sequelae and without any specific therapy, is complex. The lesions are probably caused by the direct effect of the cream components on the vessels but many other factors, such as atopic dermatitis, prematurity, subjective predisposition to purpura, trauma, and thrombocytopenia may play important pathogenetic roles.