Numbing cream for peds IV's?

rghbsn, BSN, RN · Oct 31, 2009

The cream you are thinking about is called EMLA...it is lidocaine based, and there are a few different versions. There are some at my facility that use it on the Peds floor, but not nearly everyone uses it. In the ED, it is available, but almost never used, for a few reasons.

1: It takes time...you're looking at leaving it in place for around 30 min or so to get a somewhat effective result, not always practical.

2: It doesn't always work...lidocaine works, but it's not as effective transdermally.

3: It can make IV's harder...the lidocaine constricts blood vessels, and will sometimes make a viable site more difficult to access.

I don't think it's brutal to not use it, kids learn what the cream is, then they wait for 30 mins in anticipation of an IV stick anyway...I think the stress and anxiety of waiting would be worse, personally. Not to mention, it can decrease the chance of success...leading to multiple sticks. That's worse, too.

My recommendation is, if you're going to use it, is to find several sites, apply the EMLA to more than one site. If you are unable to access one site, you won't have to wait another 30 mins to try again.

By the way, EMTALA is the Emergency Medical Treatment and Active Labor Act, or anti-dumping law. There are EMTALA forms that are filled out to transfer pt.s between facilities, etc. to prevent hospitals from transferring pt.s to other facilities just to get them out of their facility, etc. Just thought I'd share.

allnurses Guide · Oct 31, 2009

The cream you are thinking about is called EMLA...it is lidocaine based, and there are a few different versions. There are some at my facility that use it on the Peds floor, but not nearly everyone uses it. In the ED, it is available, but almost never used, for a few reasons.
1: It takes time...you're looking at leaving it in place for around 30 min or so to get a somewhat effective result, not always practical.
2: It doesn't always work...lidocaine works, but it's not as effective transdermally.
3: It can make IV's harder...the lidocaine constricts blood vessels, and will sometimes make a viable site more difficult to access.

Lidocaine w/o epi does not constrict blood vessels. There are only two local anesthetics that have vasoconstriction properties cocaine (which is considered a local anesthetic and is most often used by ENT) and ropivicaine. Lidocaine does sometimes obstruct your view/placement if you are giving it subdermal. Adding bicarb to lidocaine is probably the most effective way to make IV starts as painless as possible, but just as a reminder most kids aren't really responding to the pain so much as just the anxiety of getting stuck.

rghbsn, BSN, RN · Oct 31, 2009

I stand corrected on the vaso-constriction.

It's still not as effective on peds patients as some like to think. And it's almost never left in place long enough.

Editorial Team / Moderator · Oct 31, 2009

We rarely use it -- it's more effective in the kids' minds than on their skin, I think. But I've found that the 30 minutes it takes for EMLA to work allows these kids to work themselves up into a lather about having an IV, numbing cream or not.

Sarah Hay · Oct 31, 2009

When I did my rotation on a Pediatric floor, the RN used sweeties on a little infant while doing his IV.

Trauma Columnist · Oct 31, 2009

When we use EMLA in the ER, we apply it at triage - which gives it time to work. If the child is acutely ill and can't wait the 30 minutes, then we just hold them down, do what needs to be done and let parents comfort them.

RedCell · Oct 31, 2009

My recommendation is, if you're going to use it, is to find several sites, apply the EMLA to more than one site. If you are unable to access one site, you won't have to wait another 30 mins to try again.

Eutectic Mixture of Local Anesthetics (EMLA cream) is not just lidocaine based, it contains prilocaine as well. I would think twice before slathering up Little Johnnie's arms and legs with EMLA. Prilocaine does some bad things to hemoglobin as in it changes hemoglobin from a ferrous state (Fe2+) to a ferric state (Fe3+) in excessive doses. Methemoglobinemia is not a risk I would be willing to accept just to start an IV.

SC lidocaine with bicarb works EXTREMEMLY well, however in a peds patient (depending on age), the anxiety and fear of the unknown are still going to be a factor. Since PO midazolam is out of the question in most ERs, brutane is usually the final answer.

Lacie, BSN, RN · Oct 31, 2009

We routinely use it in dialysis units. I get young people moving from peds to adult dialysis units and they wouldnt let you stick without it even for venipuncture over cannulation. I've used it in ER/ICU on peds but like others have pointed out the ancipation is horrible for kids. Now on the other hand if you have peds that are accustomed to being repeatedly stuck over a period of time it's a great med. Just be sure to put it on a good 1/8" thick and wrap it securely in plastic wrap for a minimum of 30-40 min. If applied properly it can be of great use. In adult dialysis pt's it works wonders when your cannulating with #14g stainless steel needles twice 3x's a week.

EmergencyNrse · Oct 31, 2009

EMLA 2% is a wonderful medication that works well before IV starts. There is an over-the-counter version called LMX too. With either medicine you really need to use an occlusive dressing over the cream for it to work better.

An ER that's really on top of their game can and will apply this in triage (it takes almost no additional time to do it.) If you identify a patient, infant or toddler that will have blood drawn or receive IV therapy you just apply it right there. It works while they wait for MD exam and is ready by the time lab arrives or you go to start the IV.

In Hematology/Oncology kids that have ports, parents will apply it to the port sites in anticipation before they even come to the hospital.

Lastly, the cold sprays help desensitize the skin as well. I was skeptical as to how effective it was until seeing it used in a Pediatric ER. Works great and there is no waiting.

dcampbell · Oct 31, 2009

I had the "cold spray" myself. I needed a steroid injection in the shoulder, and when I saw that large needle coming at me I was a little concerned:) But I must say, the spray really worked well. Maybe some of you all know the name of it. I wonder if it could be/is used for IV starts or blood draws?

rghbsn, BSN, RN · Oct 31, 2009

Eutectic Mixture of Local Anesthetics (EMLA cream) is not just lidocaine based, it contains prilocaine as well. I would think twice before slathering up Little Johnnie's arms and legs with EMLA. Prilocaine does some bad things to hemoglobin as in it changes hemoglobin from a ferrous state (Fe2+) to a ferric state (Fe3+) in excessive doses. Methemoglobinemia is not a risk I would be willing to accept just to start an IV.
SC lidocaine with bicarb works EXTREMEMLY well, however in a peds patient (depending on age), the anxiety and fear of the unknown are still going to be a factor. Since PO midazolam is out of the question in most ERs, brutane is usually the final answer.

Sorry, let me clarify...I would recommend identifying multiple areas, and putting EMLA over the 2 best sites in your mind. Not slathering up Johnnie's arms and legs, lol. That's quite a mental picture, though...Little Johnnie with white, puffy arms and legs, wrapped in seran wrap, too. Would be quite funny if not for the methemoglobinemia. Also know that younger children and infants have a higher risk of methemoglobinemia and would not be a candidate for multiple EMLA sites.

The spray does work awesome...I had an ingrown toenail repair, and the podiatrist sprayed my toe before placing the block. Didn't feel a thing.