Resident and Fellow Corner
Topical Anesthesia for Common Pediatric Procedures
By Shobhit Jain, MD
Children in the hospital are faced with many challenges. Pain control has recently taken center stage, but a lot remains to be done to accomplish a pain-free hospital stay. Studies have highlighted the fact that pain assessment and management practices are commonly deficient in hospital and emergency room settings [1,2].
The reasons for inadequate pain management include the myth that children do not experience pain, fear of over sedation and the use of inappropriate tools to assess the child for fear and pain . Additionally, many providers consider “common” procedures to be “minor” or “quick” and not requiring pain management.
However, it is becoming increasingly clear that untreated pain has tremendous impact on a child throughout their lives. Pain experienced early in life can impact lifetime pain perception . Local and topical anesthetics are very helpful in alleviating procedural pain. Additionally, non-pharmacologic measures can be quite useful when initiated pre-procedure. These measures may be applied with the help of a Child Life Specialist.
Useful topical agents for common procedures (further descriptions below)
EMLA (Eutectic Mixture of Local Anesthetics): Topical anesthetic cream containing lidocaine (2.5%) and prilocaine (2.5%). To ensure full effect of this topical anesthetic it must be applied 30 to 60 minutes prior to venipuncture procedures. Barriers to use include delay in time to effect, vasoconstriction of superficial vessels leading to difficulty in venipuncture and uneven topical application, leading to variable efficacy of the drug [5,6]. EMLA has occasionally caused methemoglobinemia.
Iontophoresis: This technique uses a small electric charge from external electrodes for transdermal administration of lidocaine. It has limited use in clinical practice due to significant barriers, including discomfort, demand on provider time, and significant local skin reactions.
J-Tip- Needle Free Jet injection of Lidocaine Device (NJILD): A carbon dioxide-driven, needleless system that delivers 0.2mg of buffered 1% lidocaine via transdermal administration. This syringe device has rapid onset; it has been shown to work in approximately 3 to 5 minutes. Jimenez et al compared J-tip to EMLA for pediatric IV placement and concluded that the J-Tip provided better pain control for venipuncture than EMLA .
LMX4 (previously ELA-max), similar products including Anecream: Lidocaine cream (4%) with a liposomal formulation that enhances skin penetration. Recommended application time is 30-60 min, making it more feasible than EMLA for use in the ED / ICU or other time-sensitive settings.
Pain-ease - Vapocoolant spray: 1,1,1,3,3-Pentafluoropropane and 1,1,1,2-Tetrafluoroethane
Pain Ease is a topical aerosol anesthetic skin refrigerant. The coldness decreases the nerve conduction velocity of C and A-delta fibers, which in turn interrupts the nociceptive inputs to the spinal cord. However, it has been shown to be less effective than other options like J-tip.
Synera: Eutectic mixture of lidocaine 70 mg and tetracaine 70 mg. This patch is a disposable, oxygen-activated system that uses heat to enhance drug absorption through the stratum corneum. Application is recommended for 20 to 30 minutes prior to venous cannulation. Synera patches should not be applied to broken or inflamed skin.
Zingo: Lidocaine hydrochloride monohydrate powder intradermal needle-free injection system. This device delivers lidocaine into the skin via a helium-powered delivery system, numbing the site in one to three minutes. Zingo can be bulkier and is priced higher than J-tip. It can be used on intact skin prior to venipuncture in children 3-18 years of age.
Pershad et al compared the cost effectiveness of several options for IV placement in an ED setting and concluded that NJILD was the most preferred alternative .
Topical anesthesia for common procedures needs to be used more widely. Several options are available and the choice of product may be narrowed down to patient and provider preference, time sensitivity, ease of administration, or cost. Topical lidocaine application is recommended for urethral and nasogastric tube placement. For venipunctures, the J-tip for its rapid action and cost effective profile. LMX4 may be used when time is not a barrier, and Pain-Ease may be considered for older children. J-tip may also be used as an adjunct for regional anesthesia and lumbar punctures along with LMX4 and local infiltration. Synera is useful when vasodilation is preferred.
- MacLean S, Obispo J, Young K. The gap between pediatric emergency department procedural pain management treatments available and actual practice. Pediatr. Emerg. Care. 23 (2007) 87–93. doi:10.1097/PEC.0b013e31803.
- Young K. Pediatric procedural pain. Ann. Emerg. Med. 45 (2005) 160–171. doi:10.1016/j.annemergmed.2004.09.019.
- Zempsky W, Cravero J. Relief of pain and anxiety in pediatric patients in emergency medical systems. Pediatrics. 114 (2004) 1348–56. doi:10.1542/peds.2004-1752.
- Kennedy R, Luhmann J, Zempsky W. Clinical implications of unmanaged needle-insertion pain and distress in children. Pediatrics. 122 Suppl (2008) S130–S133. doi:10.1542/peds.2008-1055e.
- Moureau N, Zonderman A. Does it always have to hurt? Premedications for adults and children for use with intravenous therapy. J. Intraven. Nurs. 23 (n.d.) 213–9. http://www.ncbi.nlm.nih.gov/pubmed/11847760.
- Zempsky W. Pharmacologic approaches for reducing venous access pain in children. Pediatrics. 122 Suppl (2008) S140–53. doi:10.1542/peds.2008-1055g.
- Jimenez N, Bradford N, Seidel K, et al. A comparison of a needle-free injection system for local anesthesia versus EMLA for intravenous catheter insertion in the pediatric patient. Anesth. Analg. 102 (2006) 411–4. doi:10.1213/01.ane.0000194293.10549.62.
- Pershad J, Steinberg S, Waters T. Cost-effectiveness analysis of anesthetic agents during peripheral intravenous cannulation in the pediatric emergency department. Arch. Pediatr. Adolesc. Med. 162 (2008) 952–961. doi:10.1001/archpedi.162.10.952.