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Pharmacological Methods for Relieving Procedural Pain

This information is intended for informational purposes only and are not intended to replace a healthcare provider's judgment. This document is meant to offer choices to the treating providers. Each patient's treatment course should be considered in light of his or her particular clinical circumstances.

1) Sucrose
Sucrose is available as a 12% solution. For term infants the sequence is as follows: slowly give 1.5 to 2 cc PO over 2 minutes, wait 2 minutes before starting the procedure, may give remaining 0.5 cc of sucrose on a pacifier or on gloved finger. Both the sucrose and the act of sucking provide an analgesic effect. Analgesia should persist for up to eight minutes. The dose may be repeated once. Sucrose works best for neonates, but may be tried in infants up to three months.

2) EMLA Cream and Anesthetic Disc
EMLA Cream is an emulsion of lidocaine 2.5% and prilocaine 2.5%. The cream is applied to the skin in a thick layer and then covered with an occlusive dressing. Adequate anesthesia is achieved in one hour, although the anesthetic effect will increase until three hours have passed if the cream is left in place. For injections the cream should be optimally left on for over two hours (except as indicated in table). Once the cream has been removed the anesthesia will persist for one to two hours. Vasoconstriction is an occasional problem with EMLA use. This may be reversed by applying a warm pack to the site before the procedure. EMLA should only be applied to intact skin. EMLA may be used in infants thirty-two weeks of age and older. One risk of EMLA is methemoglobinemia. Infants, especially those being treated with other methemoglobin inducing agents (sulfa drugs) or with G6PD deficiency, are more likely to have this complication.

EMLA Dosing per 24 Hour Period

* only appropriate for infants over 32 weeks gestation

3) Numby Stuff
Numby Stuff is a device that delivers an anesthetic through the skin using iontophoresis. The solution used is Iontocaine which contains lidocaine 2% and epinephrine 1:100,000. If Iontocaine is not available, stock lidocaine 2% with epinephrine 1:100,000 may also be used. The dose is always 1 cc. The time to anesthetic effect depends upon what current is used on the machine. The range is ten to twenty minutes. Anesthesia lasts for one hour after placement. Further instructions are available in the BMC Policy & Procedure. The grounding/dispersive electrode often causes transient discomfort to the child. The following interventions may be helpful: remove all metal/jewelry, place the grounding/dispersive electrode on another adult and maintain skin to skin contact, apply pressure to both the grounding/dispersive and medication electrodes, distract the patient, and run the machine at the lowest setting (2.0 mA/min). Numby Stuff should only be applied to intact skin. It should not be placed on any body parts that are supplied by end arteries: fingers, toes, ears, penis. Persons with a pacemaker should not have either electrode placed on them. Numby Stuff may be used after one year of age, but patients under five years should have an adult to act as ground. Persistent discomfort, despite the abovementioned interventions, is reason to halt the procedure. Discomfort and local irritations may be more common in patients with light colored skin.

4) Vapocoolant spray
Vapocoolant sprays cause a transient freezing of the skin surface. The anesthetic effect begins immediately after application, but lasts less than one minute. It may be applied by direct spraying or by the application of a saturated cotton ball. Vapocoolant should only be applied to intact skin. If using the spray technique hold the spray can 3 to 9 inches away from the site. Spray to desired area for up to ten seconds, or until a white frost is immediately noted. Avoid getting the spray into the face. Immediately swab with alcohol and perform the procedure. If using a cotton ball, place a cotton ball in the medicine cup. Spray into the cup for ten seconds. Apply the cotton ball to the desired area using forceps and hold for fifteen seconds. Perform the procedure immediately afterwards.

5) Local Infiltration
Alkalinizing lidocaine before infiltration will reduce pain. Mix one part of sodium bicarbonate with nine parts lidocaine 2% (1:10 ratio). Inject the solution with a small (27 or 30 gauge) needle. When injecting multiple times, try and inject through previously anesthetized parts. Buffered lidocaine may be better tolerated when the superficial tissues have been previously anesthetized using EMLA, Numby Stuff or vapocoolant. If marcaine is used it should not be buffered because it will precipitate out.

6) LET
LET consists of lidocaine 4%, epinephrine 0.1% and tetracaine 0.5%. It is suitable to use before laceration repair in children over six months of age. Onset of action is 15 to 30 minutes, duration of anesthesia is 45-60 minutes. First, apply LET with a cotton swab to the edges of the wound. Then, place a cotton ball saturated with LET into the wound, and secure this with tape. If necessary, have the parent/guardian hold it in place while wearing a glove. LET may not be used on fingers, toes, earlobes, or the glans of the penis.

7) ELA-max
ELA-max is a 4% lidocaine cream. It is applied for 30-60 minutes before the painful procedure. It does not contain prilocaine, so methemoglobinemia is not a concern. Use of an occlusive dressing is not necessary, but may help to hold the cream in place.

8) Conscious sedation
For further management see the BMC Pediatric Conscious Sedation Policy.

9) Anesthesia
General anesthetics may be appropriate for some patients depending upon the amount of anticipated pain and the anxiety level. These agents may only be given by anesthesiologists in controlled settings.

10) Oral and parenteral medications
When premedicating a patient it is essential to consider that medication's time to onset. Harriet Lane and the PDR are two good references for medication dosing, contraindications and timing.

For more information:
PainFree Pediatrics
Boston Medical Center
91 East Concord Street
Maternity Building, 6th Floor
Boston, MA 02118
617-414-7899 (phone)