EMLA Cream vs 10% Lidocaine Cream for Attenuating Venous Cannulation Pain – A Clinical Trial

Abstract

Background: Venous cannulation is a painful procedure
that is associated with anxiety, distress and discomfort.
But pain is frequently overlooked in adults. Aims and
Objective: We compared the efficacy of 5% EMLA cream
and 10% lidocaine cream in attenuating pain associated with
peripheral venous cannulation. Methods: This prospective,
randomized, placebo-controlled trial was conducted in
102 ASA I and II adults scheduled for elective surgery.
They were randomly allocated by blind balloting to one
of three groups: group E had 1.5 mL of EMLA cream,
group L 1.5 mL of 10% lidocaine cream, and group P 1.5
mL KY gel. All cream was applied over a visible vein for
60 min with occlusive dressing. Pain was evaluated using
visual analogue scale (VAS) and verbal rating scale (VRS).
Results: The mean VAS score was significantly lower with
either EMLA cream (2.62±1.76 cm) or 10% lidocaine cream
(1.85±1.58 cm) than with placebo (4.78 ±1.88 cm), p

Full text

The ANNALS of AFRICAN SURGERY January 2019 Volume 16 Issue 1
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EMLA Cream vs 10% Lidocaine Cream for Attenuating Venous
Cannulation Pain – A Clinical Trial
Oluwayemisi Bamidele Oluwadun,1 Oyebola Olubodun Adekola,2 Olufemi I.O. Dada,2 Simeon O. Olanipekun,1
Adebayo Sulaimon Adetunji,3 John Olutola Olatosi,2 Olushola Temitayo Kushimo2
1 Department of Anaesthesia, EKO Hospital, Lagos, Nigeria
2 Department of Anaesthesia, University of Lagos & Lagos University Teaching Hospital, Nigeria
3 Department of Anaesthesia, Lagos State University Teaching Hospital, Nigeria
Correspondence to: Dr OB Ogundun, Department of Anaesthesia, Eko Hospital, Ikeja, Lagos, Nigeria; email: gyogundun@yahoo.co.uk
Abstract
Background: Venous cannulation is a painful procedure
that is associated with anxiety, distress and discomfort.
But pain is frequently overlooked in adults. Aims and
Objective: We compared the ecacy of 5% EMLA cream
and 10% lidocaine cream in attenuating pain associated with
peripheral venous cannulation. Methods: This prospective,
randomized, placebo-controlled trial was conducted in
102 ASA I and II adults scheduled for elective surgery.
They were randomly allocated by blind balloting to one
of three groups: group E had 1.5 mL of EMLA cream,
group L 1.5 mL of 10% lidocaine cream, and group P 1.5
mL KY gel. All cream was applied over a visible vein for
60 min with occlusive dressing. Pain was evaluated using
visual analogue scale (VAS) and verbal rating scale (VRS).
Results: The mean VAS score was signicantly lower with
either EMLA cream (2.62±1.76 cm) or 10% lidocaine cream
(1.85±1.58 cm) than with placebo (4.78 ±1.88 cm), p<0.001.
Most patients who received EMLA cream (76.5%) or 10%
lidocaine cream (70.6%) compared with placebo (55.9%)
had mild pain during cannulation using VRS. Conclusion:
The eutectic mixture of local anesthetic cream and lidocaine
cream attenuated pain associated with peripheral venous
cannulation to varying degrees.
Key words: Venous cannulation pain, 10% lidocaine,
EMLA, VAS, VRS, Side eects
Ann Afr Surg. 2019; 16(1):4–10
DOI: http://dx.doi.org/10.4314/aas.v16i1.2
Conicts of Interest: None
Funding: None
© 2019 Author. This work is licensed under the Creative
Commons Attribution 4.0 International License.
Introduction
Crile Washington invented the cannula and used intravenous
therapy for the management of shock; this management
popularized venous cannulation (1). Peripheral venous
cannulation is a routine procedure during the delivery of
anesthesia, which many adults nd painful. Inadequate
pain relief is not only unpleasant for patients but may cause
anxiety about further treatment, deter patients from seeking
medical care in the future (2), and result in increase in
heart rate and blood pressure (3). The increase in heart rate
and blood pressure leads to increased myocardial oxygen
consumption and increased risk of myocardial infarction
in patients at risk, especially those with hypertension and
coronary artery disease (4). The use of topical anesthetic
agents for venous cannulation is on the increase (5). In
our institution, analgesia for cannulation is oered only
to children. We compared the ecacy of topical 5%
EMLA cream and 10% lidocaine cream in attenuating pain
associated with peripheral venous cannulation in adults.
Methods
This prospective, randomized, placebo-controlled study
was conducted between April 2013 and March 2014 after
institutional approval and informed consent were obtained
from all patients. Adult patients aged 18–60 years, with
the American Society of Anesthesiology (ASA) physical
status score I or II, scheduled for elective procedures under
anesthesia were studied. Criteria for exclusion were: refusal
to participate, past history of hypertension, arrhythmias,
chronic pain, and local skin infection, those on antiarrhytmic
agents such as calcium channel blockers and beta blockers,
analgesic use 24 hours before venous cannulation, allergy
or sensitivity to amide local anesthetic and glycerine, and
more than one attempt at cannulation. Power was analysed
for independent t test to determine an appropriate sample
size; the dierence in mean of the visual analogue scale
during venepuncture from a previous study was 13.3 (6). To
achieve a power of 80% and α = 0.05, a minimum sample
size of 34 was considered appropriate.
Original article

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AttenuAting venous cAnulAtion pAin—A clinicAl triAl
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Study protocol
Routine preoperative anesthetic was review the day before
surgery. The study protocol was explained to the patients
and they were educated on the use of the visual analogue
scale (VAS) and verbal rating scale (VRS) that were used
to assess pain. The primary outcome compared the eects
of 10% lidocaine cream and of EMLA cream on VAS and
VRS. The secondary outcome compared the eects of 10%
lidocaine cream and of EMLA cream on the heart rate, blood
pressure and cutaneous skin manifestation.
In the operating theatre, the researcher randomly placed the
patients into three groups; each patient picked a prewritten
card from a bag. Group E treatment consisted of EMLA
cream, Group L 10% lidocaine cream and Group P used KY
gel; the placebo cream (KY gel) is reported not to have an
analgesic eect (7). The patients and research assistant were
blinded to the cream used. A multiparameter monitor was
attached to the patient to measure heart rate, non-invasive
blood pressure and oxygen saturation before and during
cannulation. The proposed cannulation site was cleaned
with alcohol swab, and the research assistant applied 1.5 mL
of the appropriate cream over the dorsum of the patient’s
hand. Next, an improvised occlusive dressing made of 4 by
4 gauze was applied and held in place with plaster for 60
min. The gauze was removed after 60 min and the researcher
assessed skin sensations such as itching, burning, tingling
and cold, after which the cream was removed gently using
a methylated spirit swab.
For uniformity, the researcher performed venous cannulation
using an 18G cannula on all patients, and the cannula was
secured with transparent plaster. Each patient’s reaction
during cannulation was noted by a second research assistant
and reported as expressionless, grimacing, hand withdrawal,
shouting or crying. Each patient was observed for features
of vaso-vagal reaction such as dizziness, light headedness,
sweating, or nausea.
Each patient was then asked to grade the cannulation pain
on the VAS, a 10-cm line marked 0 at one end and 10 at the
other (0 = no pain; 10 = worst pain imaginable). Assessments
of pain on the linear scale were measured to the nearest
centimeter. Each patient also assessed pain using the VRS
as none, mild, moderate, and severe.
Each patient’s immediate post-cannulation heart rate and
blood pressure were measured once the cannula was secured
with transparent plaster, then at every 1-minute interval for
10 minutes: before cannulation (baseline)-TB, immediate
post cannulation (T0), 1 min after cannulation (T1), 2 min
after cannulation (T2), 3 min after cannulation (T3), 4 min
after cannulation (T4), 5 min after cannulation (T5), 6 min
after cannulation (T6), 7 min after cannulation (T7), 8 min
after cannulation (T8), 9 min after cannulation (T9), and 10
min after cannulation (T10).
The cannulation site was continuously observed for local skin
reactions such as blanching, erythema, localized induration,
edema and urticaria hourly for the rst 2 hours and then at
6 hours, 12 hours, and 24 hours post cannulation. Allergic
reactions, if any, were noted and treated with standard rescue
measures.
Statistical analysis
Demographic, blood pressure, heart rate and visual analogue
scores were analyzed using analysis of variance, while
clinical data and VRS were analyzed with test of proportions
and Chi-square test; p <0.05 was considered statistically
signicant. Data obtained were analyzed using the Statistical
Package for Social Sciences (SPSS) Version 21 (SPSS Inc.,
Chicago, IL, USA).
Results
A total of 102 adult surgical patients were recruited. The
mean age, weight, height and BMI were comparable between
the 3 groups (Table 1).
Table 1: Demographic and clinical characteristics of patients
(n = 34 for each group)
Treatment groups
Variable EMLA Lidocaine Placebo p value
Age/years
(mean±SD)32.4±10.0 35.9± 9.2 35.4±9.3 0.27
Weight/kg
(mean±SD) 75.1±9.67 73.5±14.6 74±13.6 0.88
Height (m) 1.7±0.77 1.65±0.07 1.6±0.03 0.79
BMI (kg/m2) 27.8±3.4 27.1±6.2 27.6±5.1 0.83
Gender ratio
(M:F) 13:21 20:14 8:26 0.26
ASA (ratio
I:II) 19:15 20:14 24:10 0.23
Pain scores
The median VAS score at venous cannulation diered
signicantly between the three groups: group E 2 (0–8),
group L 2 (0–5) and group P 5 (1–8), p <0.001. VAS score
between groups E and L was similar, p = 0.45. On distribution
of pain between the group using VRS, more patients with
pain were in group P (34) than in groups E (32) and L (26),
p <0.001; pain distribution was similar between groups E
and L, p = 0.45.

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Reactions during cannulation
Table 2 shows the frequency distribution of patients with
dierent reactions to cannulation. In group E, 13(38.2%)
patients were expressionless during cannulation while
19(55.9%) grimaced. In group L, more than half of the
patients 18(52.9%) were expressionless while 14(41.2%)
grimaced. In group P, 6(17.6%) of the patients were
expressionless and 16(47.1%) grimaced. The dierence
in reactions during cannulation across the 3 groups was
statistically signicant, p=0.003.
Table 2: Mean visual analogue scale scores in the three groups
(n = 34 for each group)
EMLA Lidocaine Placebo p value
Mean±SD 2.6±1.8 1.9±1.5 4.8±1.9 0.001*
Median 2.0 2.0 5.0
* statistically signicant
Heart rate
Figure 1 shows the mean heart rates against time in the
dierent groups. The mean heart
rate in group E rose from baseline
value at T0. The mean heart rate
at T3 min fell below baseline and
remained steady below baseline
value throughout the study period.
In group L, mean heart rate fell
below baseline value immediate
post cannulation (T0) and remained
below baseline value till the end of
the study. The lowest value in heart
rate in group L was at T4. The mean
heart rate in the placebo group rose
above baseline value and remained
above baseline value throughout the
study period.
Figure 2 shows percentage changes
in mean heart rates from baseline
values with time. In groups E and
P, a rise of 1.78% and 7.17% was
observed when baseline values were
compared with immediate post-
cannulation values (T0). Group
L demonstrated a fall of –0.72%
from baseline values at (T0). The
placebo group demonstrated the
highest change with a 7.17% rise
from baseline values. Signicant
differences were observed in
percentage changes in mean HR from baseline values
between the groups during the study except at T8, p=0.10.
Mean arterial pressure
Figure 3 shows the mean arterial pressure (MAP) against
time. MAP decreased in all the groups at T3 with that of the
treatment groups dropping below baseline values. Figure 4
shows the mean percentage change in mean arterial pressure
from baseline values over the study period. MAP increased
in all the 3 groups immediate post cannulation (T0). The
increases from baseline values were 2.92%, 2.10% and
6.01% in groups E, L and P respectively. These changes
were not statistically signicant, p=0.39. Throughout the
study period there was no statistical dierence between the
3 groups when considering percentage change in MAP from
baseline values.
Mean rate pressure product
Figure 5 shows the mean rate pressure product over the
study period. Statistical dierence was observed only at T3,
olAwudAn et Al.
Figure 1: Mean heart rate (bpm) at different time points
TB
0
–2
–4
2
4
6
8
T0 T1 T2 T3 T4
Time in minutes
EMLA
LIDOCAINE
PLACEBO
% change from baseline
T5 T6 T7 T8 T9 T10
TB
74
76
78
80
82
84
86
88
90
94
92
T0 T1 T2 T3 T4
Time in minutes
EMLA
LIDOCAINE
PLACEBO
Mean heart rate (mmHg beats/minute)
T5 T6 T7 T8 T9 T10
TB
85
87
89
91
93
95
97
99
101
T0 T1 T2 T3 T4
Time in minutes
EMLA
LIDOCAINE
PLACEBO
Mean MAP (mmHg)
T5 T6 T7 T8 T9 T10
Figure 2: Percentage change in mean heart rate from baseline
TB
0
–2
–4
2
4
6
8
T0 T1 T2 T3 T4
Time in minutes
EMLA
LIDOCAINE
PLACEBO
% change from baseline
T5 T6 T7 T8 T9 T10
TB
74
76
78
80
82
84
86
88
90
94
92
T0 T1 T2 T3 T4
Time in minutes
EMLA
LIDOCAINE
PLACEBO
Mean heart rate (mmHg beats/minute)
T5 T6 T7 T8 T9 T10
TB
85
87
89
91
93
95
97
99
101
T0 T1 T2 T3 T4
Time in minutes
EMLA
LIDOCAINE
PLACEBO
Mean MAP (mmHg)
T5 T6 T7 T8 T9 T10

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p=0.01. Group P showed the highest rise of 12,365 mmHg.
beat.min–1 in the immediate post cannulation period while
the least rise was in the EMLA group at 5,997.1 mmHg.
beat.min–1 at T7 post cannulation.
Side effects
In group E, 1 patient (2.9%) had burning skin sensation; in
group L, 2 patients (5.9%) had burning skin sensation and
1 patient (2.9%) tingling sensation. In assessing local skin
reactions in all 3 groups, 1 patient (2.9%) in each group
was observed to have blanching
of the skin when treatment
creams ceased. Blanching was
no longer observed 1 hour post
cannulation.
Discussion
We have demonstrated
that VAS was lower after
application of EMLA and
10% lidocaine cream 60 min
before venous cannulation than
after application of KY gel.
However, VAS was comparable
with EMLA and 10% lidocaine
cream. A similar observation
with EMLA and lidocaine
creams was reported earlier;
however, a comparison was
not made with the placebo
(8). The observation in the
two studies may suggest that
lidocaine and EMLA creams
have equipotent analgesic
effect during venepuncture,
while KY gel had inferior
analgesic property. Miller et al.
compared the analgesic eect
of SC 1% lidocaine (0.3–0.5
mL), 2.5 g EMLA cream and
1 mL Iontocaine (a mixture of
2% lidocaine and 1:100,000
epinephrine) on pain at
application of agent and during
venous cannulation in adults
scheduled for ambulatory
surgery (5). The authors
observed that at application
of topical anesthetic agent,
patients who received SC
1% lidocaine had a higher
VAS (15.6±9.4) mm than
those receiving either EMLA
cream (VAS 0.2 ±0.4) mm or
Figure 5: Mean rate pressure product at different time points
SVC
RPA
SVC
RPA
IVC
Soft
IVC
Loss of conciousness
Frequency
Clinical presentation
012345678
Quadriplegia
Abasia
Gait disturbances
Overt neck wound
Bleeding from the ear
Quadriparesis
Aphasia
Urine stool incontinence
Otorrhea
TB
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
T0 T1 T2 T3 T4
Time (minutes)
EMLA
LIDOCAINE
PLACEBO
Mean RPP change (mmHg.beats/min)
T5 T6 T7 T8 T9 T10
TB
0
–2
–4
–5
2
4
6
8
10
T0 T1 T2 T3 T4
Time (minutes)
EMLA
LIDOCAINE
PLACEBO
% change from baseline
T5 T6 T7 T8 T9 T10
Figure 4: Percentage change in mean BP from baseline
Figure 3: Mean arterial blood pressure at different time points
TB
0
–2
–4
2
4
6
8
T0 T1 T2 T3 T4
Time in minutes
EMLA
LIDOCAINE
PLACEBO
% change from baseline
T5 T6 T7 T8 T9 T10
TB
74
76
78
80
82
84
86
88
90
94
92
T0 T1 T2 T3 T4
Time in minutes
EMLA
LIDOCAINE
PLACEBO
Mean heart rate (mmHg beats/minute)
T5 T6 T7 T8 T9 T10
TB
85
87
89
91
93
95
97
99
101
T0 T1 T2 T3 T4
Time in minutes
EMLA
LIDOCAINE
PLACEBO
Mean MAP (mmHg)
T5 T6 T7 T8 T9 T10

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Iontocaine (VAS 2.5 ±4) mm. During venous cannulation,
patients who received EMLA cream had a higher VAS
(22.3±20.1) mm than those who had either SC 1% lidocaine
(VAS 6.4±8.5) mm or Iontocaine (VAS 4.2±7.2) mm. The
authors concluded that Iontocaine (Numby Stu system
using ionotophoresis) had superior analgesic eect during
application and at venous cannulation. This is because
ionotophoresis uses a mild electrical current to deliver the
ions of medication and drive medication through the skin,
hence ensuring that the block is localized and dense. The
limitation of Miller et al.’s study was the relatively small size
of 10 individuals per group; future studies are encouraged
with larger sample sizes (5).
In another study among adult volunteers, either EMLA or 4%
lidocaine cream was shown to be eective in reducing pain
associated with pinprick when compared with placebo (9).
However, the anesthetic ecacy of 4% lidocaine cream and
EMLA cream was comparable, though the use of occlusive
lidocaine had a faster onset of action than EMLA cream.
Similarly, no adverse events were seen (9). The authors
concluded that a topical preparation with 4% lidocaine is an
eective and safe treatment option for supercial anesthesia,
with faster onset of action.
Selby and Bowles (10) compared the analgesic eect of three
agents. Patients were randomly allocated to 4 groups before
venous cannulation: SC lidocaine, ethyl chloride spray,
EMLA cream applied for 5 min, and control (no analgesia).
Pain during venepuncture was assessed using a VAS of 100
mm. They observed that lidocaine and ethyl chloride were
very eective in removing venepuncture pain (95% CI for
the dierence between the control and spray groups was
7.0–23 mm, and between the control and lignocaine groups
10–25 mm). EMLA cream had a limited, but insignicant,
eect (95% CI for dierence between control and EMLA
groups was 2–15 mm). They concluded that the analgesic
eect of lignocaine and ethyl chloride was better than that of
EMLA cream applied for 5 min before venous cannulation
(10). This is contrary to our observation with lidocaine and
EMLA creams; the dierence may be because EMLA was
applied 60 min before venepuncture in our study.
In another study (11), the VRS in patients who received
EMLA cream 60 min before cannulation was lower than
VRS with lidocaine iontophoresis (20 mA) during venous
cannulation with a large bore catheter (18G). However, the
onset of analgesia was short with iontophoresis; similarly,
erythema and paraesthesia were transient and common (11).
The authors concluded that EMLA provided a dense and
superior analgesia than ionotophoresis. This was contrary
to the observation made by Miller et al. (5). The former
researchers attributed their observations to the use of a low
iontophoretic dose. The variation in these observations may
reect a dierent patient group, dierent iontophoretic dose
and a smaller stimulus (5, 11).
The dierence in mean pain score in studies on pain during
venous cannulation has been attributed to dierences in size
of cannula, site of venous cannulation, dosage and duration
of application of topical agent, use of premedication, and
gender (2, 9, 10, 12).
Hemodynamic parameters
We observed a signicant increase in heart rate immediate
post cannulation (T0) from baseline values in groups E and
P but a decrease in heart rate in group L.
Similarly, a 1.5% decrease in heart rate in patients treated
with lidocaine injection prior to cannulation was reported
earlier (4), despite the dierence in the route of administration
and concentration of lidocaine in the two studies. While this
study used 4% lidocaine cream, the latter study administered
0.25 mL of 1% lidocaine directly in the subcutaneous layer
(4).
A prospective, randomized clinical trial assessed the
efficacy and side effects of commonly used topical
anesthesia methods in adults receiving peripheral venous
cannulation. The study was double-blinded to the degree
that the methodologies allowed. One hundred and fty
healthy adults undergoing elective surgery were randomly
allocated to ve groups: EMLA cream, ethylchloride spray,
intracutaneous inltration with 2% lidocaine, placebo cream,
and no treatment. Venepuncture was performed with a 18G
cannula on the dorsal side of the hand. Puncture pain and
pain caused by the topical treatment itself were measured
using VAS (range: 0–100 mm). Hemodynamic response,
diculties in performing the puncture and side-eects were
recorded. All analgesic techniques were well tolerated.
Hemodynamic response and degree of puncture diculty
showed no dierences between the groups. Puncture pain
(median mm VAS) following inltration (1.0) and EMLA
(10.0) was signicantly lower than in no treatment (30.0)
or in placebo (30.0). The benet of local inltration was
altered by injection pain (11.5). Spray did not signicantly
lower puncture pain (26.5) and, in addition, was associated
with discomfort (10.5). In adults, EMLA cream signicantly
reduces puncture pain and represents an acceptable alternate
method for topical anesthesia in venous cannulation. Local
lidocaine inltration is impaired by applicational pain,
whereas spraying the puncture site with ethylchloride has
no analgesic benet.
The percentage change in mean heart rate at cannulation in
olAwudAn et Al.

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9
group P (7.17%) is comparable with that in the placebo group
(7.25%) in the latter study (3). However, the percentage
increase in mean HR was sustained for 10 min in our
study but for 3 min in another study (4). We attributed our
observation to lack of premedication while some researchers
premedicated all their patients with 20 mg temazepam one
hour before venepuncture (4). On the contrary, a decrease
in heart rate 15 min post cannulation following the use of
EMLA cream before cannulation was reported in another
study (13). The observed decrease was recorded 15 min
post cannulation, which may not be a good representation
of what occurred immediate post cannulation.
We reported a sudden increase in MAP at the 10th min
(T10) only in group E patients. The percentage change
from baseline value in MAP at this time (T10) was also
increased. This increase may be due to reduced analgesic
eect with early manifestation in the MAP. It is possible
that other hemodynamic parameters may also have shown
an increase had the duration of study been extended. In this
study, 10% lidocaine cream provided a consistent protective
eect against signicant increase in heart rate and MAP
accompanying venous cannulation. These eects may not
be unrelated to the degree of pain attenuation that lidocaine
delivers. 10% lidocaine gave the lowest pain scores and also
the lowest level of alteration in hemodynamic variables.
Langham et al. (4) observed a 10–15% increase in MAP
in the placebo group. In this study, MAP rose by 6.01%
in group P. This disparity may be due to the dierent sites
of blood pressure measurement. Langham et al. measured
blood pressure on the finger using the finapres (4),
while we measured at the upper arm using an electronic
sphygmomanometer. The napres technique has been shown
to have low precision for systolic and MAP measurements,
and is thus not permitted for absolute blood pressure
measurements in individual patients (14). Finger arteries
are aected by contraction and dilatation in response to
psychological and physical stress and these in turn aect the
readings from the napres (14). An awake patient must be
relaxed for accurate readings to be obtained from the napres
(14). An electronic sphygmomanometer with an appropriate
size cu applied to the upper arm is more likely to give
readings close to those obtained were invasive monitoring
used (14). Therefore, the napres might have given an
exaggerated MAP in the placebo group.
The rate–pressure product (RPP: a product of systolic blood
pressure and heart rate) is a good index of myocardial oxygen
consumption, and the maximum recommended range is
12,000 to 23,000 mmHg.beat.mm–1 (14). Values above this
are commonly associated with myocardial ischemia and
angina. In our study, the mean RPP throughout in the placebo
group was 10, 970 mmHg.beat.mm–1, in the EMLA group
10,328 mmHg.beat.mm–1, and in the lidocaine group 11,881
mmHg.beat.mm–1. None of the groups had RPP range that
fell within the maximum range expected; as such, there
may not be signicant increase in oxygen consumption in
normotensive patients following venous cannulation.
In the perioperative period, Rao et al. (15) recommend not
greater than 20% uctuation in heart rate and systolic blood
pressure in patients with cardiac morbidity going for non-
cardiac surgery. The increase in baseline values observed
of 7.17% for heart rate and 6.01% for MAP in the placebo
group in response to venous cannulation were lower than
the allowable uctuation. These values were further reduced
in the two treatment groups E (HR, 1.78%; MAP, 2.92%)
and L (HR, 0.72%; MAP, 2.10%). This implies that with
the attenuation of venous cannulation pain, hemodynamic
uctuations can be minimized. Therefore, in patients with
cardiac morbidity (those with hypertension and coronary
artery disease) who may show exaggerated hemodynamic
response to pain, it is imperative that these uctuations are
avoided by attenuating cannulation pain.
Side effects
We observed minimal side eects on application of treatment
creams. During cream application 1 patient in the EMLA
group and 2 patients in the lidocaine group complained of
burning. Tingling sensation was also reported by 1 patient
in the lidocaine group. Other authors, however, did not
have similar experience with lidocaine application (4). The
sensations reported by these patients subsided once the
creams were removed. Browne et al. (6) reported mild
pruritus following the use of amethocaine.
Blanching of the skin after removal of treatment creams
was observed in 1 patient in each group. A higher incidence
had been reported earlier in a similar study; in the EMLA
cream group, 3 patients (8.8%) had blanching of skin while
10 patients (29.8%) had erythema (16). EMLA cream is
known to cause initial local vasoconstriction, leading to
blanching; this is followed by vasodilatation, resulting in
erythema and induration (17). We reported no erythema and
only 1 patient blanched, this we attributed to the dark skin
of our studied population unlike other studies with light-
skinned patients. Kano et al. (18) noticed local erythema
in 8 out of 24 patients treated with lidocaine for venous
cannulation pain. Browne et al. (6) compared EMLA with
topical Amethocaine for cannulation and observed that
blanching occurred more with the EMLA group (23 patients
out of 32 patients) while erythema was observed more in the

The ANNALS of AFRICAN SURGERY January 2019 Volume 16 Issue 1
10
Amethocaine group (11 patients out of 32). The cutaneous
manifestation observed resolved within an hour. Sakamoto et
al. (16) observed a reduction in the number of patients with
local reaction 30 min after cream removal (blanching from
8.8% to 2.9%, erythema from 29.4% to 8.8%), suggesting
that these cutaneous manifestations are local and transient.
This study is limited by the paucity of literature on 10%
lidocaine for comparison and critical analysis with our study.
Nevertheless, we have demonstrated that EMLA and 10%
lidocaine creams attenuated pain and the associated pressor
response to venous cannulation to varying degrees. Lidocaine
cream gave lower pain score and better cardiovascular
stability during cannulation than EMLA cream. Both were
associated with transient, localized cutaneous manifestations.
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