Issues in Comprehensive Pediatric Nursing, 32:65–76, 2009Copyright © Informa Healthcare USA, Inc.ISSN: 0146-0862 print / 1521-043X onlineDOI: 10.1080/01460860902737418

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UCPN0146-08621521-043XIssues in Comprehensive Pediatric Nursing, Vol. 32, No. 2, April 2009: pp. 1–29Issues in Comprehensive Pediatric Nursing

ATRAUMATIC CARE: EMLA CREAM AND APPLICATION OF HEAT TO FACILITATE PERIPHERAL VENOUS CANNULATION IN CHILDREN

Venipuncture in ChildrenL. Huff et al. Lori Huff, BSN, RN, CCRNAnnette Hamlin, BSN, RN

Diane Wolski, BSN, RNTracy McClure, BSN, RN

Aris Beoglos Eliades, PhD, RN

Akron Children’s Hospital, Akron, Ohio

Laurie Weaver, BSN, RN

Wooster Community Hospital, Wooster, Ohio

Deb Shelestak, PhD, RN

Kent State University, Stark Campusm, North Canton, Ohio

The purpose of this study was to investigate whether the application ofheat placed to a child’s potential intravenous (IV) site after the applica-tion of EMLA Cream™ decreases vasoconstriction, therefore promotingatraumatic care in the hospitalized pediatric patient.

Venipuncture in children is a painful and frequently performed proce-dure. While use of EMLA Cream™ to reduce pain on insertion is a commonpractice with pediatric patients, no studies had measured venous size inrelation to EMLA Cream™ and heat application. A descriptive quantitativedesign was used to examine the use of EMLA Cream™ and application

Received 24 October 2008; accepted 9 January 2009.Partial funding provided by Akron Children’s Hospital, Pediatric Nursing Research Grant. We

thank Kristine Gill, PhD, RN, Emeritus Faculty, College of Nursing, The University of Akron, Ohiofor assistance with manuscript preparation.

Address correspondence to Lori Huff, 6200 Education Coordinator, Akron Children’s Hospital,One Perkins Sq., Akron, Ohio, 44308. E-mail: lhuff@chmca.org

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of heat to facilitate venipuncture for peripheral venous cannulation.A convenience sample of 30 hospitalized Caucasian children, eight totwelve years old, participated. Vascular ultrasound directly measuredthe vein prior to and 1 hour after EMLA Cream™ application, as well as2 minutes after heat application.

Mean vein measurements were 0.243 cm prior to EMLA Cream™,0.205 cm after EMLA Cream™ applied for 1 hour, and 0.253 cm aftertwo minutes of heat. There was a significant increase in vein visualiza-tion from pre-application of heat to post application of heat with asuccess rate of 80% with the first time attempt of IV insertion. Therefore,application of heat counteracts the adverse effect of vasoconstriction thatoccurs with EMLA Cream™ application, potentially increasing periph-eral venous cannulation success rates.

Keywords: Atraumatic care, Venipuncture, Emla Cream, Heat application, Children,Pediatrics

Venipuncture in children is recognized by nursing and child-life specialists tobe one of the most painful and frequently performed invasive proceduresinstituted by nurses. In an era when atraumatic care is of great concern, theapplication of Eutectic Mixture of Local Anesthetic (EMLA) Cream™ to thevenipuncture site is a common practice in pediatric hospitals and clinics.EMLA Cream™ is known to cause initial blanching and vasoconstriction,which may hinder successful intravenous catheterization (Arildsson,Nilsson, & Stromberg, 2000). At the study hospital, nurses noticed that whenthey used EMLA Cream™ there was a “white cloud” that would form at thesite, making it difficult to visualize the vein. Instead of one venipuncture, itoften would take multiple attempts to successfully insert an IV. Thus, whatwas supposed to be an atraumatic procedure became a traumatic one.

THEORETICAL FRAMEWORK

The framework used for this research study was Donna Wong’s ConceptualModel of Atraumatic Care. Atraumatic care is the provision of therapeuticcare utilized in healthcare settings that eliminates or minimizes thepsychological and physical distress experienced by children and families(Hockenberry & Wilson, 2007). Wong identified three principles thatprovide the framework for atraumatic care. The first is to prevent or mini-mize the child’s separation from the family. The second is to promote asense of control, and the third is to prevent or minimize bodily injury andpain (Hockenberry & Wilson, 2007). The application of EMLA Cream™does “prevent or minimize” the pain caused by intravenous (IV) insertion.The goal of this research was to minimize the “bodily injury” and pain by

Venipuncture in Children 67

counteracting the vasoconstriction from the EMLA Cream™, therebydecreasing the number of venipuncture attempts.

BACKGROUND

The literature indicates that studies such as those conducted by Morrison,et al. (1998) validated venipuncture as one of the most traumatic hospitalprocedures. In this study, 165 patients ranging in age from 20 to 100 yearsold were asked to rate the pain of sixteen common hospital procedures.Venipuncture ranked fourth of sixteen procedures listed; only drawing anarterial blood gas, inserting a nasogastric tube, or placing a central lineexceeded intravenous insertion. Kleiber et al. (2007) stated that childrenreported significant pain during peripheral intravenous cannulation despitethe use of topical anesthetic. In addition, other studies acknowledged place-ment of IV catheters as a painful and stressful procedure for children (Jimenez,Bradford, Seidel, Sousa, & Lynn, 2006; Tak & van Bon, 2006). Since veni-puncture has been recognized as a painful procedure, interventions thatlessen the pain, such as EMLA Cream™, have been used clinically.

The effectiveness of EMLA Cream™ and other topical anestheticcreams has been validated in several research studies performed on childrenreceiving venipuncture. For example, Koh, Fanurik, Stoner, Schmitz, andVonLanthen (1999) reported that parental application of EMLA Cream™at home appeared to be as effective as clinician application in reducingchildren’s pain and distress associated with IV insertion. Kleiber and asso-ciates (2002) compared EMLA Cream™ and ELA –Max application forvenipuncture in children and found no significant difference in pain ratingsand difficulty in vein cannulation, with both reducing pain for successful IVinsertion. Tak and van Bon (2006) compared the effect of EMLA Cream™and a placebo cream on the reported pain and observed distress associatedwith venipuncture in children. Their results concluded that EMLACream™ reduced pain from venipuncture (Rogers & Ostrow, 2004).

A disadvantage of EMLA Cream™ has been the resulting blanching ofthe skin, causing decreased vein visualization (Liu, Kirchner, & Petrack,2003). Bjerring, Anderson, and Arendt-Nielsen (1989) reported that EMLACream™ caused initial blanching and vasoconstriction maximally after1.5 hours of application in adults. Arildsson, Asker, Salerud, and Stromberg(2000) performed a study using 12 subjects to assess the changes in theappearance of superficial skin capillaries and skin microvascular perfusion.In their comparison of different lengths of time of EMLA Cream™application, they found that longer application prolonged hyperemia. In addi-tion, Lenhardt, Seybold, Kimberger, Stoiser, and Sessler (2002) discoveredthat by locally warming the venipucture site prior to insertion, the time and

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number of venipuncture attempts was reduced. Haggblad, Larsson,Arildsson, Stromberg, and Salerud (2001) investigated the effect of heatapplication on vessel size. The study assessed the effects of heat onanalgesized skin in 12 Caucasian males and females, ages 21–32 years.It was determined that increased blood flow occurred in the deeper lying skinvessels, but not the capillaries, when heat was applied. None of these studiesexamined the vessel size with heat in combination with EMLA Cream™.

Liu et al. (2003) explored the use of EMLA Cream™ application andheat for a time frame of 60 minutes. This randomized, double-blindedclinical trial used healthy adult subjects to compare the degree of pain ofintravenous catheterization at 20 and 60 minutes after application ofEMLA Cream™ with heat, EMLA Cream™ without heat, or placebowithout heat (Liu et al., 2003). The goal of this study was to determinewhether the addition of heat to EMLA Cream™ shortened time of onsetfor effective analgesia. The researchers found that applying EMLACream™ for 20 minutes with heat provided moderate analgesia,measured by a 100mm visual analog scale, and that the manufacturer’srecommended time of 60 minutes remained superior for sufficient analge-sia. (Liu et al. 2003).

No studies using adults or children have examined the combinedeffectiveness of heat after EMLA Cream™ application on vein size, veinvisibility, the child’s pain level, or rate of first-attempt venipuncture. Thepurpose of this study was to investigate whether the application of heatplaced to a child’s potential intravenous site after the application ofEMLA Cream™ decreases vasoconstriction, therefore promoting atrau-matic care in the hospitalized pediatric patient.

DESIGN AND METHOD

Design

A descriptive, quantitative design was used to explore the use of EMLACream™ and application of heat to facilitate peripheral venous cannulation.

Setting/Sample

The study was conducted at a 250-bed pediatric hospital that providescare of children from birth through teenage years, and serves a populationof 2.5 million in northeastern Ohio. The convenience sample consistedof 30 Caucasian children ranging in age from 8 to 12 years, with medicalor surgical diagnoses requiring IV insertion and who were hospitalized onthe school-age unit at a children’s hospital. The sample was limited toCaucasian children to decrease variation in visibility of the vein that may

Venipuncture in Children 69

result from skin color. Children with mental disability were excluded dueto the challenge of trying to obtain consent/assent, and the inability of thechild to communicate the pain scale. In addition, children with dehydra-tion, and those receiving vasoactive medications were excluded becauseof the potential alteration in vein size.

Protection of Human Subjects

Approval of the proposed study was received prior to project implementa-tion from the Institutional Review Board (IRB) at the pediatric hospitalserving as the study site. Confidentiality and protection of identifyinginformation for individual subjects occurred by assigning a study identifiernumber and aggregating data for reporting purposes. Primary investigatorsinvolved in the research study completed the National Institutes of HealthOffice of Extramural Research Protecting Human Research ParticipantsProgram prior to initiation of the study. Informed consent was obtainedfrom the parent/legal guardian for all subjects. In addition, assent wassought from subjects aged 10 through 12 years as required by the IRB.

Intervention

The DeRoyal infant heel warmer is a FDA-approved product, which, whenactivated and allowed to warm (approximately 45 seconds), maintains amaximum temperature of 104 degrees for ten minutes (DeRoyal productmanual, 2006). Some fluctuation of temperature may occur due to ambienttemperatures in the area where the product is activated. The researchersfollowed the manufacturer’s guidelines for use to activate the warmingmechanism.

EMLA Cream™ is FDA approved to provide dermal and epidermalanalgesia from the release of Lidocaine and Prilocaine. It acts directly onthe dermal and epidermal pain receptors and nerve endings, promotinganalgesia to the affected area (AstraZeneca, 2005). Dosage was directedby physician’s order. EMLA Cream™ was applied to intact skin under anocclusive dressing.

Instruments

The Wong-Baker FACES Pain Rating Scale is a self-reporting pain levelinstrument designed to be used with children over the age of 3. The scaleis comprised of 6 faces depicting levels of pain resulting in a score from0–10. The child is asked to point to the face that best reflects his or herpain (Hockenberry, & Wilson, 2007). Reliability, validity, and preferenceof the FACES Pain Scale is well documented and frequently used in

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pediatric settings (Keck, Gerkensmeyer, Joyce, & Schade, 1996; Luffy &Grove, 2003; West et al., 1994; Wong & Baker, 1996).

The SonoSite iLook 25 was used to measure vein size. The SonoSite iLook25 is a FDA approved personal imaging vascular ultrasound (SonoSite iLook25, product manual, 2004). It is used in direct visualization of veins to assistwith the insertion of intravenous catheters into vessels which are difficult tovisualize. Interrater reliability for vein measurement was established throughthe examination of six veins by the three research nurses. The intraclass corre-lation was strong, at .962, indicating consistency in vein measurement.

The investigators created a Vein Visibility Scale which was utilized toassess the difficulty of vein visualization (1 = easily visible, 2 = some-what visible, and 3 = not visible). Vein visibility was assessed prior toEMLA Cream™ application, one hour after EMLA Cream™, and twominutes after heat application.

The participant’s age, along with pain score measures, vein measure-ments, and nursing assessment of vein visibility was recorded on theProcedure Assessment Data Tracking Tool created by the researchers.

Participant Enrollment

The child-life specialist and unit clinical coordinators contacted the researcherswhen a child on the school-age unit required an IV insertion. The researchersdetermined if the child met inclusion criteria, and the primary care nurse wasinformed. The researchers provided a study enrollment packet and explainedthe study to the patient and the patient’s legal guardian. The researchers beganthe enrollment process by obtaining consent for the child to participate in thestudy. Once consent was obtained from the legal guardian and the child’sassent, when appropriate, a study number was assigned to each participant.

Venipuncture Protocal

Registered nurses who demonstrated competence in performing veni-puncture on the school-age child and were identified by their peers asdemonstrating excellence in this skill performed the venipuncture proce-dure. Five registered nurses were selected and educated about the researchprotocol prior to the initiation of the study to maintain consistency indata collection. The venipuncture procedure was performed according tohospital standards and policy. The researchers implemented the studyprotocol during the venipuncture procedure.

Immediately prior to the initiation of the venipuncture procedure, theresearcher obtained a baseline pain score using the Wong-Baker FACESPain Rating Scale. Next, the RN performing the venipuncture identifiedthe child’s vein to be accessed. The researcher, using vascular ultrasound,

Venipuncture in Children 71

directly visualized and measured the vein (measurement #1) and assessedvein visibility using the Vein Visibility Scale, then EMLA Cream™ wasapplied to the site for one hour to provide dermal and epidermal analgesia.After removal of the EMLA Cream™, the researcher obtained anothermeasurement (#2) of the vein size and visibility. The researcher thenapplied heat for two minutes using a DeRoyal infant heel warmer, afterwhich the researcher obtained a third measurement (#3) of vein size andvisibility. Once the final measure of vein size and visibility was obtained,the RN attempted the venipuncture. After the venipuncture was performed,the researchers, using the Wong-Baker FACES Pain Rating Scale,obtained a second pain score. Data were recorded on the ProcedureAssessment Data Tracking Tool by the researcher.

DATA ANALYSIS

To evaluate the effectiveness of heat on view size and visibility afterEMLA Cream™, a one way repeated measures ANOVA was used for thetwo outcome variables. Thirty school-aged children were tested under threeconditions: 1) before application of EMLA Cream™ and heat; 2) afterEMLA Cream™ but before heat was applied; and 3) after both EMLACream™ and heat. A p value < .05 was considered statistically significant.Mauchley’s test (W) was performed to assess possible violation of the sphe-ricity assumption; this was not significant for both vein measurement andvisualization of the vein (Vein measurement: W = .942, c2 = 1.684, df = 2,p = .431; Vein Visualization: W = .835, c2 = 5.058, df = 2, p = .080).Additionally, Greenhouse–Geiser e values of .945 and .858 suggests thatboth sample variance covariance matrices did not depart substantially fromsphericity. Because the Greenhouse–Geiser e values were close to 1.00, nocorrection was made to the degrees of freedom used to evaluate the signifi-cance of the F ratio. The Statistical Package for the Social Sciences (SPSSVersion 15) for Windows was used for descriptive and multivariate dataanalysis. All results are reported in aggregate form.

RESULTS

The study sample included school aged children whose age ranged from8 to 12 years (mean = 10.0, SD = 1.46), 16 females and 14 males.

Vein Measurement

Table 1 describes the average vein size over the three time periods.The overall F for differences in average vein measurement across thethree times was statistically significant: F(2.58) = 30.4, p = .000; the

72 L. Huff et al.

corresponding effect size was a partial h2 = .512, demonstrating that, allother conditions being stable, approximately 51% of the variance in veinmeasurement could be attributed to the application of EMLA Cream™and/or heat. Post hoc analysis revealed a significant difference in veinsize between the baseline (VM1) and after application of EMLA Cream™(VM2). There was a corresponding difference between vein size afterEMLA (VM2) and after application of heat (VM3). There was a statisticaldifference between the baseline vein size (VM1) and vein measurementafter application of EMLA Cream™ and heat (VM3). See Table 2 for thepost hoc t values. Figure 1 illustrates the finding that the average veinmeasurement of .253 cm after the application of heat was larger whencompared to the average vein measurement of .205 cm after EMLA andthe baseline measurement of .243 cm.

Vein Visualization

Table 1 and Figure 2 describe vein visualization over the three time periods.The overall F for differences in average visualization across the three timeswas statistically significant (F (2.58) = 40.02, p = .000). The correspondingeffect size was a partial h2 = .58, denoting that all other conditions beingstable, approximately 58% of the variance in visualization can be attributed to

Table 1. Means and (standard deviations) of vein measurementand visualization

(1) Before EMLA and heat n = 30

(2) After EMLA before heat n = 30

(3) After EMLA and heat n = 30

Vein Measurement .243 (.08) .205 (.08) .253 (.07)Vein Visualization 1.37 (.7) 2.33 (.7) 1.67 (.8)

Table 2. Post hoc analysis of vein measurement and vein visualization

t

VM1 to VM 2 5.28*

VM1 to VM3 −1.58VM2 to VM3 −8.16*Visual 1 to Visual 2 −7.37*Visual 2 to Visual 3 −3.07*Visual 1 to Visual 3 6.68*

*p < .05.VM = Vein Measurement.Visual = Vein Visualization.

Venipuncture in Children 73

the application of EMLA Cream™ and/or heat. Post hoc analysis revealedsignificant differences between all three time periods. See Table 2 for thepost hoc t values.

Perceptions of Pain

Self reported pain levels were measured prior to venipuncture and imme-diately after cannula insertion using the Wong-Baker FACES pain scale.

Figure 1. Vein Measurements before and after EMLA and heat.

0.2530.243

0.205

0.1

0.14

0.18

0.22

0.26

0.3

Measurement#1 No Heat or

Emla

Measurement#2 EMLA no

Heat

Measurement#3 EMLA and

Heat

Mean Vein Measurement

Mea

sure

men

t in

cm

Figure 2. Vein Visualization rating before and after EMLA and heat.

1.67

1.37

2.33

1

1.5

2

2.5

3

Measurement#1 No Heat or

Emla

Measurement#2 EMLA no

Heat

Measurement#3 EMLA and

Heat

Mean Visualization1 = Easily visible2 = Somewhat visible3 = Not visible

74 L. Huff et al.

There was a significant difference between the pre-procedure level ofpain (M = 2.9, SD = 3.0) and post-procedure pain levels (M = 6.9,SD = 2.7), t(29) = 6.520, p = .000.

LIMITATIONS AND AREAS OF FURTHER STUDY

Limitations of the study design and associated areas for future researchinclude: a small, age-limited, convenience sample; and lack of benchmarkdata on first-attempt IV insertion success rate. As the sample size waslimited to 30 children ranging in ages 8–12, future studies including alarger population and age range are indicated. In addition, as the popula-tion was limited to Caucasian children, future studies with other racialgroups are warranted to explore the impact of skin color on vein visual-ization. Another limitation was a lack of benchmark data to provide acomparison for the first-attempt success rates for each of the five RNsperforming the venipuncture procedure. Past experience and anecdotalreports indicated at least 2–3 attempts were required for successfulcatheter insertion due to blanching associated with EMLA Cream™, butdata on first-attempt success rates is not available in the literature and wasnot acquired prior to the start of the study. This study found a success rateof 80% with the first time attempt of IV insertion with heat after EMLACream™ application, providing a comparison point for future studies.

Limitations of the study instrumentation and associated areas forfuture research include: lack of pre- and post-IV insertion benchmarkpain score data and use of the Wong-Baker FACES Pain Rating Scale asthe selected measurement for atraumatic care. The study results suggestthat anticipatory anxiety with venipuncture may influence the child’sreport of pain as measured on the Wong-Baker FACES Pain RatingScale. For example, two different cystic fibrosis patients each verbalizeda pain scale of 8 prior to initiating the procedure. So, the question iswhether the increase in the post-insertion pain score was due to perceivedpain, anticipatory pain, or experiential anxiety from previous venipunc-ture attempts. Future studies that provide data on pre–post-IV insertionpain scores with and without use of EMLA Cream™ and studies thatexplore and differentiate the concepts of perceived or anticipatory painand anxiety would be beneficial.

CONCLUSION

There have been no prior pediatric and/or adult studies completed that aresimilar in nature to this study; no other studies have measured venous sizeor vein visibility in relation to EMLA Cream™ and heat application. Liuet al. (2003) reviewed heat and EMLA Cream™ only in relation to length

Venipuncture in Children 75

of onset for anesthesia. Lenhardt et al. (2002) only studied how heat withEMLA Cream™ facilitated venous cannulation in results to the numberof attempts and the time required.

The data from this study of school-age children suggest that the appli-cation of heat may counteract the adverse effect of vasoconstriction whichoccurs as a result of EMLA Cream™ application. The vein measurementresults provide evidence of vasoconstriction with the application ofEMLA Cream™. The baseline mean vein size of .243 cm decreased to amean vein size of .205 cm after application EMLA Cream™. The meanvein size measurement increased beyond the baseline .253 cm after heatwas applied. The increase in vein size with heat application correspondsto a reported increase in visibility during IV insertion.

There was a significant increase in vein visualization from pre-applicationof heat to post-application of heat. Therefore, application of heat counter-acts the adverse effect of vasoconstriction that occurs with EMLACream™ application, potentially increasing peripheral venous cannulationsuccess rates. Atraumatic care was promoted for these children throughsuccessful facilitation of venous cannulation with an 80% first-attemptsuccess rate. In the study hospital, use of heat application after the use ofEMLA Cream™ application to counteract the adverse effect of vasocon-striction has been implemented.

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