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EMLA cream for peripheral IV starts

I am exploring the idea of implementing a standardized policy for the use of topical anesthetic cream for peripheral IV starts in adults. Currently, a standing order for its use does not exist for the adult population (although it does for pediatrics). I am looking for both relevant literature to help in proposing this change and also real-world experiences and/or policies from others who have incorporated EMLA into adult IV practice. Can you help me?


The downside to this

The downside to this practice will be planning the venipuncture. EMLA requires about 60 minutes to be effective, I think, but you should check their literature. Do you always have that amount of time to wait before beginning an IV? There are technologies that are faster.  


Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257


Office Phone 770-358-7861

Karen Day
Karen Day's picture
I agree with Lynn, time can

I agree with Lynn, time can be an issue with this practice.  there are other products such as the Synera patch and a new one called Zingo(not a patch, but a burst of topical lidocaine), I am not real familiar with the latter, but I bet your peds department will be.  Also, could you consider a small injection of lidocaine sub-Q near the prospective insertion site (this is what our anesthesia department does and we as the picc team can do for the apprehensive patient as long as no allergies to caines).  With the patches and Zingo, what if you are not successful in achieving the PIV at the site you have prepared?  You would have to repeat the process with another patch and wait time.  Just a few suggestions, hope they help.



paul f halvachs
In the Amer. J of Critical

In the Amer. J of Critical Care, May 2008 Vol 17 No 3 is an excellent article by M. Halm.

She did an meta analysis of 15 articles on the use of buffered lidocaine and NS with Benzyl Alcohol (perservative)  Her conclusion was that the use of buffered lido as compared to straight lido was a Class 1 Recommendation.  In critical care speak that means found to be "acceptable safe effective and considered Standard of Care".  Now this is only the authors opinion but a review of multiple studies is good.  The use of perservative saline is Class 2a ie supported by good evidence but not exceelent evidence

Paul Halvachs CCRN

IV Team

Thank you Paul for your

Thank you Paul for your literature reference. I will review it.

Jennifer Houlihan RN, MSN


Do you have a small facility

Do you have a small facility so that this would be feasible for you?  What kinds of patients/procedures?  Do you also use injectable, so that topical would be only one option? One area topical might work well is in outpatient clinics for implanted ports.  Patients can even place the anesthetic at home before clinic.  

We rarely use topical for adults.  We use Lidocaine 1% ID, or Lidocaine 2% ID, buffered.  We're a 500 bed facility - trying to coordinate topical anesthesia with our restarts, especially with the number emergent calls we get, would be a nightmare.

We often use topical lido on peds, and planning is a major part of the process.  Most of us IV RNs request that no one other than us place the topical anesthetic if we'll be the cannulator.  Our vascular assessment and palpation skills are much more developed than a non-IV RN, and others often place the anesthetic in an area we would not have chosen.  I've preferred other sites than other IV RNs chose as well.  Then you have to put more anesthetic on, and wait again.

The Halm article has been useful to us.


Mari Cordes, BS RN 

Nurse Educator IV Therapy
Fletcher Allen Health Care, Burlington VT
Educator, Bard Access Systems 

Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center

Mari,  Thank you for your


 Thank you for your feedback. Our hospital is a 300-bed facility and feasibility of such a policy that incorporated topical anesthetic into adult IV therapy does seem challenging.  The logistics of getting it in place (whether by doing that ourselves or having a non-IV therapy RN do so) seem cumbersome. We use SQ lido for PICC lines/ultrasound guided sticks but I feel that method can complicate the cannulator's ability to palpate the vein in more superficial sites.

This has become a point of interest for me because I do hear more and more patients asking for it ( I  believe it is used in local same-day surgery centers) and since IV sticks are arguably one of the most universally identified 'unpleasantries' of hospitalization, I would like to see if there is more we can do to minimize the pain besides having a dedicated IV therapy team available for those 'hard sticks'.

 Thanks again for you insight,

Jennifer Houlihan RN, MSN



mary ann ferrannini
 We have a standardized

 We have a standardized procedure allowing those certified to select either a lidocaine cream or SQ lidocaine. We have found the lidocaine cream use in the adult population to be impractical d/t to the length of time needed for it to work. Another issue for us is that others will try to place the cream at selected sites and then I get there and disagree on their site selection. If I am going to use it, I will select the vein and select a back-up location and then place the cream on two sites. Another thing to consider is the trend to have certain therapies (ie.antibiotics) started within short time frames. I am sure your goal is to reduce the pain of venipuncture. A good option is the SQ lidocaine. In my opinion,a better option is a well trained IV team with excellent assessment,knowledge and venipuncture skills.




mary ann ferrannini
Jennifer I can e-mail you a
Jennifer I can e-mail you a copy of the standardized procedure. can consider training a selected group of nurses that have good to excellent skill levels.
Mary Ann,  I would

Mary Ann,

 I would appreciate a copy of your procedure. I agree that to roll out such a policy we will definitely be engaging our core IV team nurses first. My work email is [email protected]


mary ann ferrannini
Jennifer I will get that
Jennifer I will get that standardized procedure to ASAP. I am off for e few days and did not see your post until now.
kathy mohn-las vegas In our

kathy mohn-las vegas In our community here in the Far West-we must have a physician

order to use Emla-it is easy to get because most facilities have pre-printed orders. The

discouraging part is that it takes so long for the EMLA to work.  There was a very

promising technology by BBraun a few years ago called the Lido-Site.  That thing was

wonderful-and it worked in 10 minutes.  We saw it at a network meeting and it was

so-o-o-o impressive.  Anyone know why they pulled it and when if ever it will come back?

kathy mohn-las vegas

Beverly Sharpe
We are exploring the use of

We are exploring the use of Zingo and are hoping to get some feedback from anyone who has trialed or is currently using in pediatrics.  Would like to know some true hands on data, does is work in 1-3 minutes and comparing to LMX how do you rate its effectiveness.  

Gwen Irwin
LMX4 doesn't take as long as

LMX4 doesn't take as long as EMLA.  The pediatric PICC/IV team uses this for PICC insertions, since it doesn't take as long.  EMLA in their experience takes about 1 12 - 2 hours.  LMX4 takes abpit 30-45 minutes to be effective for PICC insertions.  They have used it for about 2 years.

Gwen Irwin

Austin, Texas

LMX4 is on our formulary. 

LMX4 is on our formulary.  I use it prior to PICCs.  We have found that applying a heat pack (heel warmer) over the LMX4 is helpful, and Child LIfe has read that massaging the LMX4 helps make it work better/faster. 

We are also looking into adding Zingo, and hope to trial it soon. 



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