Issues in Comprehensive Pediatric Nursing, 32:6576, 2009

Copyright Informa Healthcare USA, Inc.

ISSN: 0146-0862 print / 1521-043X online
DOI: 10.1080/01460860902737418
ATRAUMATIC CARE: EMLA CREAM AND APPLICATION
OF HEAT TO FACILITATE PERIPHERAL VENOUS
CANNULATION IN CHILDREN
Lori Huff, BSN, RN, CCRN
Annette Hamlin, BSN, RN
Diane Wolski, BSN, RN
Tracy McClure, BSN, RN
Aris Beoglos Eliades, PhD, RN
Akron Childrens Hospital, Akron, Ohio
Laurie Weaver, BSN, RN
Wooster Community Hospital, Wooster, Ohio
Deb Shelestak, PhD, RN
Kent State University, Stark Campusm, North Canton, Ohio
65
The purpose of this study was to investigate whether the application of
heat placed to a childs potential intravenous (IV) site after the applica-
tion of EMLA Cream decreases vasoconstriction, therefore promoting
atraumatic 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 common
practice with pediatric patients, no studies had measured venous size in
relation to EMLA Cream and heat application. A descriptive quantitative
design was used to examine the use of EMLA Cream and application
Received 24 October 2008; accepted 9 January 2009.
Partial funding provided by Akron Childrens Hospital, Pediatric Nursing Research
Grant. We
thank Kristine Gill, PhD, RN, Emeritus Faculty, College of Nursing, The Universi
ty of Akron, Ohio
for assistance with manuscript preparation.
Address correspondence to Lori Huff, 6200 Education Coordinator, Akron Childrens
Hospital,
One Perkins Sq., Akron, Ohio, 44308. E-mail: lhuff@chmca.org
L. Huff et al.
of heat to facilitate venipuncture for peripheral venous cannulation.
A convenience sample of 30 hospitalized Caucasian children, eight to
twelve years old, participated. Vascular ultrasound directly measured
the vein prior to and 1 hour after EMLA Cream application, as well as
2 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 after
two minutes of heat. There was a significant increase in vein visualization
from pre-application of heat to post application of heat with a
success rate of 80% with the first time attempt of IV insertion. Therefore,
application of heat counteracts the adverse effect of vasoconstriction that
occurs with EMLA Cream application, potentially increasing peripheral
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 to
be one of the most painful and frequently performed invasive procedures
instituted by nurses. In an era when atraumatic care is of great concern, the
application of Eutectic Mixture of Local Anesthetic (EMLA) Cream to the
venipuncture 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 when
they used EMLA Cream there was a white cloud that would form at the
site, making it difficult to visualize the vein. Instead of one venipuncture, it

often would take multiple attempts to successfully insert an IV. Thus, what
was supposed to be an atraumatic procedure became a traumatic one.
THEORETICAL FRAMEWORK
The framework used for this research study was Donna Wongs Conceptual
Model of Atraumatic Care. Atraumatic care is the provision of therapeutic
care utilized in healthcare settings that eliminates or minimizes the
psychological and physical distress experienced by children and families
(Hockenberry & Wilson, 2007). Wong identified three principles that
provide the framework for atraumatic care. The first is to prevent or minimize
the childs separation from the family. The second is to promote a
sense of control, and the third is to prevent or minimize bodily injury and
pain (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
counteracting the vasoconstriction from the EMLA Cream, thereby
decreasing 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 hospital
procedures. In this study, 165 patients ranging in age from 20 to 100 years
old were asked to rate the pain of sixteen common hospital procedures.
Venipuncture ranked fourth of sixteen procedures listed; only drawing an
arterial blood gas, inserting a nasogastric tube, or placing a central line
exceeded intravenous insertion. Kleiber et al. (2007) stated that children
reported significant pain during peripheral intravenous cannulation despite
the use of topical anesthetic. In addition, other studies acknowledged placement

of IV catheters as a painful and stressful procedure for children (Jimenez,
Bradford, Seidel, Sousa, & Lynn, 2006; Tak & van Bon, 2006). Since venipuncture
has been recognized as a painful procedure, interventions that
lessen the pain, such as EMLA Cream, have been used clinically.
The effectiveness of EMLA Cream and other topical anesthetic
creams has been validated in several research studies performed on children
receiving venipuncture. For example, Koh, Fanurik, Stoner, Schmitz, and
VonLanthen (1999) reported that parental application of EMLA Cream
at home appeared to be as effective as clinician application in reducing
childrens pain and distress associated with IV insertion. Kleiber and associates
(2002) compared EMLA Cream and ELA Max application for
venipuncture in children and found no significant difference in pain ratings
and difficulty in vein cannulation, with both reducing pain for successful IV
insertion. Tak and van Bon (2006) compared the effect of EMLA Cream
and a placebo cream on the reported pain and observed distress associated
with venipuncture in children. Their results concluded that EMLA
Cream reduced pain from venipuncture (Rogers & Ostrow, 2004).
A disadvantage of EMLA Cream has been the resulting blanching of
the skin, causing decreased vein visualization (Liu, Kirchner, & Petrack,
2003). Bjerring, Anderson, and Arendt-Nielsen (1989) reported that EMLA
Cream caused initial blanching and vasoconstriction maximally after
1.5 hours of application in adults. Arildsson, Asker, Salerud, and Stromberg
(2000) performed a study using 12 subjects to assess the changes in the
appearance 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 addition
,
Lenhardt, Seybold, Kimberger, Stoiser, and Sessler (2002) discovered
that by locally warming the venipucture site prior to insertion, the time and
L. Huff et al.
number of venipuncture attempts was reduced. Haggblad, Larsson,
Arildsson, Stromberg, and Salerud (2001) investigated the effect of heat
application on vessel size. The study assessed the effects of heat on
analgesized skin in 12 Caucasian males and females, ages 2132 years.
It was determined that increased blood flow occurred in the deeper lying skin
vessels, but not the capillaries, when heat was applied. None of these studies
examined the vessel size with heat in combination with EMLA Cream.
Liu et al. (2003) explored the use of EMLA Cream application and
heat for a time frame of 60 minutes. This randomized, double-blinded
clinical trial used healthy adult subjects to compare the degree of pain of
intravenous catheterization at 20 and 60 minutes after application of
EMLA Cream with heat, EMLA Cream without heat, or placebo
without heat (Liu et al., 2003). The goal of this study was to determine
whether the addition of heat to EMLA Cream shortened time of onset
for effective analgesia. The researchers found that applying EMLA
Cream for 20 minutes with heat provided moderate analgesia,
measured by a 100mm visual analog scale, and that the manufacturers
recommended time of 60 minutes remained superior for sufficient analgesia.
(Liu et al. 2003).
No studies using adults or children have examined the combined
effectiveness of heat after EMLA Cream application on vein size, vein
visibility, the childs pain level, or rate of first-attempt venipuncture. The
purpose of this study was to investigate whether the application of heat
placed to a childs potential intravenous site after the application of
EMLA Cream decreases vasoconstriction, therefore promoting atraumatic
care in the hospitalized pediatric patient.
DESIGN AND METHOD
Design
A descriptive, quantitative design was used to explore the use of EMLA
Cream and application of heat to facilitate peripheral venous cannulation.
Setting/Sample
The study was conducted at a 250-bed pediatric hospital that provides
care of children from birth through teenage years, and serves a population
of 2.5 million in northeastern Ohio. The convenience sample consisted
of 30 Caucasian children ranging in age from 8 to 12 years, with medical
or surgical diagnoses requiring IV insertion and who were hospitalized on
the school-age unit at a childrens hospital. The sample was limited to
Caucasian children to decrease variation in visibility of the vein that may
Venipuncture in Children
result from skin color. Children with mental disability were excluded due
to the challenge of trying to obtain consent/assent, and the inability of the
child to communicate the pain scale. In addition, children with dehydration,
and those receiving vasoactive medications were excluded because
of the potential alteration in vein size.
Protection of Human Subjects
Approval of the proposed study was received prior to project implementation
from the Institutional Review Board (IRB) at the pediatric hospital
serving as the study site. Confidentiality and protection of identifying
information for individual subjects occurred by assigning a study identifier
number and aggregating data for reporting purposes. Primary investigators
involved in the research study completed the National Institutes of Health
Office of Extramural Research Protecting Human Research Participants
Program prior to initiation of the study. Informed consent was obtained
from the parent/legal guardian for all subjects. In addition, assent was
sought from subjects aged 10 through 12 years as required by the IRB.
Intervention
The DeRoyal infant heel warmer is a FDA-approved product, which, when
activated and allowed to warm (approximately 45 seconds), maintains a
maximum temperature of 104 degrees for ten minutes (DeRoyal product
manual, 2006). Some fluctuation of temperature may occur due to ambient
temperatures in the area where the product is activated. The researchers
followed the manufacturers guidelines for use to activate the warming
mechanism.
EMLA Cream is FDA approved to provide dermal and epidermal
analgesia from the release of Lidocaine and Prilocaine. It acts directly on
the dermal and epidermal pain receptors and nerve endings, promoting
analgesia to the affected area (AstraZeneca, 2005). Dosage was directed
by physicians order. EMLA Cream was applied to intact skin under an
occlusive dressing.
Instruments
The Wong-Baker FACES Pain Rating Scale is a self-reporting pain level
instrument designed to be used with children over the age of 3. The scale
is comprised of 6 faces depicting levels of pain resulting in a score from
010. The child is asked to point to the face that best reflects his or her
pain (Hockenberry, & Wilson, 2007). Reliability, validity, and preference
of the FACES Pain Scale is well documented and frequently used in
L. Huff et al.
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 iLook
25 is a FDA approved personal imaging vascular ultrasound (SonoSite iLook
25, product manual, 2004). It is used in direct visualization of veins to assist

with the insertion of intravenous catheters into vessels which are difficult to
visualize. Interrater reliability for vein measurement was established through
the examination of six veins by the three research nurses. The intraclass correl
ation
was strong, at .962, indicating consistency in vein measurement.
The investigators created a Vein Visibility Scale which was utilized to
assess the difficulty of vein visualization (1 = easily visible, 2 = somewhat
visible, and 3 = not visible). Vein visibility was assessed prior to
EMLA Cream application, one hour after EMLA Cream, and two
minutes after heat application.
The participants age, along with pain score measures, vein measurements,
and nursing assessment of vein visibility was recorded on the
Procedure Assessment Data Tracking Tool created by the researchers.
Participant Enrollment
The child-life specialist and unit clinical coordinators contacted the researche
rs
when a child on the school-age unit required an IV insertion. The researchers
determined if the child met inclusion criteria, and the primary care nurse was
informed. The researchers provided a study enrollment packet and explained
the study to the patient and the patients legal guardian. The researchers began
the enrollment process by obtaining consent for the child to participate in the
study. Once consent was obtained from the legal guardian and the childs
assent, when appropriate, a study number was assigned to each participant.
Venipuncture Protocal
Registered nurses who demonstrated competence in performing venipuncture
on the school-age child and were identified by their peers as
demonstrating excellence in this skill performed the venipuncture procedure.
Five registered nurses were selected and educated about the research
protocol prior to the initiation of the study to maintain consistency in
data collection. The venipuncture procedure was performed according to
hospital standards and policy. The researchers implemented the study
protocol during the venipuncture procedure.
Immediately prior to the initiation of the venipuncture procedure, the
researcher obtained a baseline pain score using the Wong-Baker FACES
Pain Rating Scale. Next, the RN performing the venipuncture identified
the childs vein to be accessed. The researcher, using vascular ultrasound,
Venipuncture in Children
directly visualized and measured the vein (measurement #1) and assessed
vein visibility using the Vein Visibility Scale, then EMLA Cream was
applied to the site for one hour to provide dermal and epidermal analgesia.
After removal of the EMLA Cream, the researcher obtained another
measurement (#2) of the vein size and visibility. The researcher then
applied heat for two minutes using a DeRoyal infant heel warmer, after
which the researcher obtained a third measurement (#3) of vein size and
visibility. 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 Procedure
Assessment Data Tracking Tool by the researcher.
DATA ANALYSIS
To evaluate the effectiveness of heat on view size and visibility after
EMLA Cream, a one way repeated measures ANOVA was used for the
two outcome variables. Thirty school-aged children were tested under three
conditions: 1) before application of EMLA Cream and heat; 2) after
EMLA Cream but before heat was applied; and 3) after both EMLA
Cream and heat. A p value < .05 was considered statistically significant.
Mauchleys test (W) was performed to assess possible violation of the sphericity
assumption; this was not significant for both vein measurement and
visualization 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, GreenhouseGeiser e values of .945 and .858 suggests that
both sample variance covariance matrices did not depart substantially from
sphericity. Because the GreenhouseGeiser e
values were close to 1.00, no
correction was made to the degrees of freedom used to evaluate the significance
of the F ratio. The Statistical Package for the Social Sciences (SPSS
Version 15) for Windows was used for descriptive and multivariate data
analysis. All results are reported in aggregate form.
RESULTS
The study sample included school aged children whose age ranged from
8 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 the
three times was statistically significant: F(2.58) = 30.4, p = .000; the
L. Huff et al.
Table 1. Means and (standard deviations) of vein measurement
and visualization
(1) Before EMLA (2) After EMLA (3) After EMLA
and heat n = 30 before heat n = 30 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 -1.58
VM2 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.
corresponding effect size was a partial h2 = .512, demonstrating that, all
other conditions being stable, approximately 51% of the variance in vein
measurement could be attributed to the application of EMLA Cream
and/or heat. Post hoc analysis revealed a significant difference in vein
size between the baseline (VM1) and after application of EMLA Cream
(VM2). There was a corresponding difference between vein size after
EMLA (VM2) and after application of heat (VM3). There was a statistical
difference between the baseline vein size (VM1) and vein measurement
after application of EMLA Cream and heat (VM3). See Table 2 for the
post hoc t values. Figure 1 illustrates the finding that the average vein
measurement of .253 cm after the application of heat was larger when
compared to the average vein measurement of .205 cm after EMLA and
the 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 times
was statistically significant (F (2.58) = 40.02, p = .000). The corresponding
effect size was a partial h2 = .58, denoting that all other conditions being
stable, approximately 58% of the variance in visualization can be attributed to
Venipuncture in Children
Measurement in cm
0.3
0.26
0.22
Mean Vein Measurement
0.18
0.14
0.1
0.243
0.205
0.253
Measurement Measurement Measurement
#1 No Heat or #2 EMLA no #3 EMLA and
Emla Heat Heat
Figure 1. Vein Measurements before and after EMLA and heat.
3
2.5
1 = Easily visible
2 = Somewhat visible 2
1.37
2.33
1.67
Mean Visualization
3 = Not visible
1.5
1
Measurement Measurement Measurement
#1 No Heat or #2 EMLA no #3 EMLA and
Emla Heat Heat
Figure 2. Vein Visualization rating before and after EMLA and heat.
the application of EMLA Cream and/or heat. Post hoc analysis revealed
significant differences between all three time periods. See Table 2 for the
post hoc t values.
Perceptions of Pain
Self reported pain levels were measured prior to venipuncture and immediately
after cannula insertion using the Wong-Baker FACES pain scale.
L. Huff et al.
There was a significant difference between the pre-procedure level of
pain (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 research
include: a small, age-limited, convenience sample; and lack of benchmark
data on first-attempt IV insertion success rate. As the sample size was
limited to 30 children ranging in ages 812, future studies including a
larger population and age range are indicated. In addition, as the population
was limited to Caucasian children, future studies with other racial
groups are warranted to explore the impact of skin color on vein visualization.
Another limitation was a lack of benchmark data to provide a
comparison for the first-attempt success rates for each of the five RNs
performing the venipuncture procedure. Past experience and anecdotal
reports indicated at least 23 attempts were required for successful
catheter insertion due to blanching associated with EMLA Cream, but
data on first-attempt success rates is not available in the literature and was
not acquired prior to the start of the study. This study found a success rate
of 80% with the first time attempt of IV insertion with heat after EMLA
Cream application, providing a comparison point for future studies.
Limitations of the study instrumentation and associated areas for
future research include: lack of pre- and post-IV insertion benchmark
pain score data and use of the Wong-Baker FACES Pain Rating Scale as
the selected measurement for atraumatic care. The study results suggest
that anticipatory anxiety with venipuncture may influence the childs
report of pain as measured on the Wong-Baker FACES Pain Rating
Scale. For example, two different cystic fibrosis patients each verbalized
a pain scale of 8 prior to initiating the procedure. So, the question is
whether the increase in the post-insertion pain score was due to perceived
pain, anticipatory pain, or experiential anxiety from previous venipuncture
attempts. Future studies that provide data on prepost-IV insertion
pain scores with and without use of EMLA Cream and studies that
explore and differentiate the concepts of perceived or anticipatory pain
and anxiety would be beneficial.
CONCLUSION
There have been no prior pediatric and/or adult studies completed that are
similar in nature to this study; no other studies have measured venous size
or vein visibility in relation to EMLA Cream and heat application. Liu
et al. (2003) reviewed heat and EMLA Cream only in relation to length
Venipuncture in Children
of onset for anesthesia. Lenhardt et al. (2002) only studied how heat with
EMLA Cream facilitated venous cannulation in results to the number
of attempts and the time required.
The data from this study of school-age children suggest that the application
of heat may counteract the adverse effect of vasoconstriction which
occurs as a result of EMLA Cream application. The vein measurement
results provide evidence of vasoconstriction with the application of
EMLA Cream. The baseline mean vein size of .243 cm decreased to a
mean vein size of .205 cm after application EMLA Cream. The mean
vein size measurement increased beyond the baseline .253 cm after heat
was applied. The increase in vein size with heat application corresponds
to a reported increase in visibility during IV insertion.
There was a significant increase in vein visualization from pre-application
of heat to post-application of heat. Therefore, application of heat counteracts
the adverse effect of vasoconstriction that occurs with EMLA
Cream application, potentially increasing peripheral venous cannulation
success rates. Atraumatic care was promoted for these children through
successful facilitation of venous cannulation with an 80% first-attempt
success rate. In the study hospital, use of heat application after the use of
EMLA Cream application to counteract the adverse effect of vasoconstriction
has been implemented.
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