(Eutectic Mixture Of Local Anesthetics - lidocaine 2.5% & prilocaine 2.5%)
Explain to child that EMLA is like a "magic cream that takes hurt away." Tap or lightly scratch site of procedure to show child that "skin is now awake."
Apply the "peel and stick" anesthetic disc or a thick layer (dollop) of EMLA cream over normal intact skin to anesthesize site (about one-half of 5 gram tube; can use 1/3 of tube if puncture site is localized and superficial, e.g., intradermal injection or heel/finger puncture).
For venous access, apply to 2 sites; place enough cream on antecubital fossa to cover medial and lateral veins. Do not rub the cream.
If using the cream, place transparent adhesive dressing (i.e.,Tegaderm) over EMLA. Make sure cream remains in a dollop or mound. A piece of plastic film (i.e., Saran Wrap) with tape to seal the edges can be used. Use only as much adhesive as needed to prevent leakage.
To make the dressing less accessible, cover it loosely with a self-adhering Ace-type bandage, such as Coban, or an IV protector, such as IV House*. Label the dressing with "EMLA applied," the date, and the time to distinguish it from other types of dressings. Instruct older children not to disturb the dressing. (Covering the dressing with an opaque material may reduce the attraction and discourage "fingering.") Supervise younger or cognitively-compromised children throughout the application time.
Leave EMLA on skin for at least 60 minutes for superficial puncture and 2 to 3 hours for deep penetration, i.e., IM injection, biopsy. EMLA may be applied at home and may need to be kept on longer in persons with dark and/or thicker skin. Anesthesia may last up to 4 hours after EMLA is removed.
Remove disc or dressing before procedure and wipe cream from skin. With transparent adhesive, grasp opposite sides, and while holding dressing parallel to skin, pull sides away from each other to stretch and loosen dressing. An adhesive remover may be used.
Observe skin reaction, either blanched or reddened. If there is no obvious skin reaction, EMLA may not have penetrated adequately; test skin sensitivity and if needed, reapply.
Repeat tapping or lightly scratching skin to show child that "skin is asleep" so that it cannot feel a needle either.
After procedure, assess behavioral response. If child was upset, use pain scale, e.g., FACES, to help child distinguish between pain and fear. (See a FACES pain rating scale.)
In the United States, EMLA is approved for use in infants 37 weeks of gestational age and older.** It should not be used in those rare patients with congenital or idiopathic methemoglobinemia and in infants under the age of 12 months who are receiving treatment with methemoglobin-inducing agents, e.g., sulfonamides, phenytoin (Dilantin), phenobarbital, and acetaminophen (Tylenol). Methemoglobin, a.dysfunctional form of hemoglobin, reduces the blood's oxygen-carrying capacity, causing cyanosis and hypoxemia. The use of intravenous methylene blue promptly eliminates the methemoglobinemia. EMLA is contraindicated in anyone with a known history of sensitivity or allergy to amide-type local anesthetics (lidocaine, prilocaine, mepivacaine, bupivacaine, etidocaine) or to any other component of the product.
Note: Although the package insert lists under "Warnings" that patients taking drugs associated with drug-induced methemoglobinemia, such as acetaminophen, are at greater risk for developing methemoglobinemia, there have been no reported cases of this complication occurring in children taking acetaminophen and using EMLA.
Follow the manufacturer's guidelines for MAXIMUM RECOMMENDED APPLICATION AREA TO INTACT SKIN FOR INFANTS AND CHILDREN
| Age and Body
Weight Requirements |
Maximum Total Dose of EMLA |
Maximum Application Area |
Maximum
Application Time |
| 1 to 3 months or < 5 kg | 1 g | 10 cm2 (1.25 × 1.25 in) | 1 hour |
| 4 to 12 months and > 5 kg | 2 g | 20 cm2 (1.75 × 1.75 in) | 4 hours |
| 1 to 6 years and > 10 kg | 10 g | 100 cm2(4 × 4 in) | 4 hours |
| 7 to 12 years and > 20 kg | 20 g | 200 cm2 (5.5 × 5.5 in) | 4 hours |
| Please note: If a patient greater than 3 months old does not meet the minimum weight requirement, the maximum total dose of EMLA should be restricted to that which corresponds to the patient's weight. | |||
* For more information, contact I.V. House, 7400 Foxmont Dr., Hazelwood, MO 63042-2198, USA; 800-530-0400; Fax: 314-831-3683; Email: ivhouse@ivhouse.com. www.ivhouse.com
** In other countries, check their package insert for specific age guidelines.
Guidelines For Pain Management During Newborn Circumcision
Guidelines For Atraumatic Skin/Vessel Punctures
JCAHO Pain Standards and Hot Line
March 15, 2002
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