Burns 24 (1998) 259-263

in grafting of full thickness burns under local anaesthesia with

EMLA@ cream
TomaZ F. Jane%
Department of Plastic Surgery mzd Burns, Chical Centre, Ljubljma, Slovenia

Accepted 2 October 1997

Abstract

Two elderly patients with 6 and 4 per cent total body surface area (TBSA) full thicknessburnswere entirely skin grafted solely
under topical ,anaesthesia with EMLA cream. Both patients had several concurrent illnesses.The risk of general or regional
anaesthesiafor their generalcondition wasmuch greater than the risk of unhealedburn woundswhich substantiallyimpaired the
patients’ quality of life. The surgicalprocedureswere painlessto both patients. The taking of the skin grafts and the healing of
the donor siteswere uneventful. It seemsthat the late skin grafting of full thicknessburns up to loper cent TBSA may be
accomplishedsolely under the topical anaesthesiawith EMLA cream and thus avoiding the general or spinal anaesthesiain a
high risk ErouL of thermally injured patients. 0 1998Elsevier ScienceLtd for ISBI. All rights reserved.

1. Pntroductilon ated with venepuncture, intravenous or arterial cannu-

lation in children and adults [l-4], lumbar puncture in
Eutectic iidocaine-prilocaine cream 5 per cent children [5], cannulation in haemodialysis [6], curettage
(EMLAO, ASTRA@, S(iderGilje, Sweden) is a eutectic of molluscum contagiosum in children [7], laser treat-
mixture of the local anaesthetics (lidocaine 25 mg/g, ment of port wine stains [8], infiltration of local anaes-
prilocaine 25 mgig) that provides dermal analgesia tlhetic [9], cautery of genital warts [lo], extracorporeal
following topical application. The use of EMLA cream shock wave lithotripsy treatment of urinary calculi [ll],
has been mainly studied in management of pain associ- vasectomy [12], separation of preputial adhesions [13],
Table 3 vulva1 biopsy [14], incision and drainage of breast
Classification of physical status according to the American Society of abscesses [la minor procedures on tympanic
Anesthesiologists [29] membrane [16], retrobulbar injections [17], removal of
arch bars [18], electromyography [19], and percuta-
Category Description
neous renal biopsy [20].
1 Healthy patient It does not appear that the skin grafting of full thick-
II Mild systemic disease - no functional limitation ness burns under local anaesthesial with EMLA cream
III Severe systemic disease - definite functional limitation hlas been reported. There have been several studies
IV Severe systemic disease that is a constant threat to life published about the use of EMLA cream in split skin
V Moribund patient unlikely to survive 24 h with or
graft harvesting [21-231 where EMLA cream was used
without operation
on intact skin. Howeve;, EMLA cream has been also
Table 2
Case 1: surgical procedures performed

Days postburn Burn wounds and their size Size of the skin Amount of EMLA
grafts (cm’) cream used (g)
-
28 Left thigh, right knee (3 per cent TBSA) 220 65
39 Abdomen (2 per cent TBSA) 140 45
51 Right elbow, forearm, left breast (1 per cent TBSA) 80 35
Total 6 per cent TBSA 440 145

0305-4179/98/$19.00 + 0.00 0 1998 Elsevier Science Ltd for ISBI. All rights reserved
PZZ: SO305-4179(97)00118-6
260 ?: E Jmu5XJBurns 24 (1998) 259-263

used as a local anaesthetic for cleansing venous leg
ulcers [24-261. that is, the cream was applied to the
wounds. The recommended dose of EMLA cream is
15-30 g per lCl0 cm2 when used on intact skin and the
recommended time of application is 2-5 h [21,22]. The
application time of the cream on the wounds is shorter
with an anaesthetic effect being achieved after 30 min
[25]. Th e only adverse reactions of EMLA cream
published to ciate have been local reactions such as
paleness, redness and edema [21-231. The use of
EMLA cream is contraindicated in infants younger
than 3 months due to possible methaemoglobinaemia
[27,28].
The use of E:MLA cream in surgical management of
full thickness burns in two high risk patients is
described. They sustained 6 and 4 per cent total body
surface area (TBSA) full thickness burns, respectively,
which were skin grafted entirely under local anaes-
thesia with EMLA cream.
2. Case reports
2.1. Case1
An 81-year-old housewife was admitted to the burns
unit on the day of injury. She sustained an 8 per cent
body surface area burn to her right elbow and forearm,
abdomen and right breast, right knee and left thigh
when several litres of boiling water had been split over
her. Full thickness burns involved 6 per cent TBSA.
She was in group IV of the A.S.A. classification of

(a)

Fig. 1. Patient in ca.je 1. (a) Burn wounds prior to the first surgical procedure (day 28 postburn). (b) Healed skin grafts on the right knee, left
thigh, abdomen, che,st and right elbow (day 61 postburn).
 7: E JaneiiEJi?urns 23 (1’998) 259-263 261

(4

(4

Fig. 2. Patient in case 2. (a and b) Subdermal burns on day 11 postburn. (c and d) Healed skin grafts on day 42 postburn.
262 7: E: JarzeZlBwm
physical status therefore the anaesthetic risk by her was
extremely high (Table 1). The burns were initially
treated with daily bathing and silver sulphadiazine
cream topically. The late skin grafting of the unhealed
areas which measured 6 per cent of the body surface
was accomplished in three surgical procedures on days
28, 39 and 51 postburn (Table 2). Each time 5 per cent
EMLA cream was applied in a thick layer on the donor
areas and covered with an occlusive dressing
110-140 min before the skin graft harvesting. The
EMLA cream was applied on granulation tissue in a
thin layer 45-60 min before surgery and also covered
with an occlusive dressing. In the operating theatre the
EMLA cream was washed away and the operative field
was prepared in the usual manner. Skin grafts were
harvested with a Davies ‘Gold’ Duplex electric derma-
tome [Chas. F. Thackray, Woburn, MA, USA Inc.].
The cutting thickness was set at number four
(0.23 mm). The donor site was the patient’s right thigh
for each of the surgical procedures. Tangential excision
of a 2 mm thick layer of granulation tissue was
performed using a Watson knife. Bleeding of the
granulation tissue was controlled by gauzes soaked in
epinephrine solution. Skin grafts meshed 1:3 were
applied immediately. The serum lidocaine level 3 h
after the application and 1 h after the removal of the
cream was 0.73 ;lmol/l. Intraoperative monitoring of
the patient was performed by the anaesthetist. The
patient did not experience any pain during the surgical
procedures whatsoever and did not receive any
sedatives nor systemic analgesics during the skin
grafting. Blanching of the donor site skin was observed
in all three surgical procedures. The only discomfort
the patient complained of was the need to lay still on a
‘very narrow bed’. All skin grafts were taken 98 per
cent and all donor areas healed uneventfully.
On postburn day 61 the patient was discharged from
the burns unit to a home for the elderly. All donor
areas were completely healed, the burn area was
healed 99 per cent. Six months postburn the skin
grafted areas were stable and the donor areas were of
a usual appearance (Fig. la and b).
2.2. Case 2
A 6%year-oid housewife sustained a flame and hot
liquid thermal injury to her back, right shoulder, right
upper extremity and right thigh. She fell on a gas
cooker during a epileptic seizure. She suffered an 8 per
cent TBSA burn. A full thickness burn of the back,
right shoulder, right upper extremity and right thigh
involved 4 per cent TBSA. The rest of the burn was
deep partial thickness. She was referred to the author’s
unit 11 days postburn from the regional hospital due to
her poor physical status. She was in group III of the
A.S.A. classification of physical status. After daily baths
24 (1998) 259-263
Table 3
Case 2: surgical procedures performed
Days Burn wounds and their size Size of Amount of
postburn the skin EMLA
graft cream used
(cm’) (g)
31 Back, shoulder, upper extremity, 270 85
abdomen (4 per cent TBSA)
-___ ~~
and topical application of silver sulphadiazine cream
skin grafting was carried out on day 31 postburn. All
the burn wounds were skin grafted entirely under local
anaesthesia with EMLA cream in one surgical
procedure. EMLA cream was applied onto the donor
site on the left thigh 130 min and onto granulations
45 min prior to surgery. The area on the right upper
extremity and right abdomen which ‘was covered with
skin autografts measured 4 per cent TBSA (Table 3).
The surgical technique was the same as for case 1.
During the operation the only complaint of the patient
was due to the discomfort created when the upper
extremity was in an elevated position. The taking of the
skin grafts and the healing of the donor sites were
uneventful. The patient was discharged from the unit
on day 42 postburn with the burn wounds healed (Fig.
2a--d).
3. IDiscussion
The number of high risk burn victims admitted to
the Ljubljana Burns Unit increases each year. The
majority of these patients are elderly people with
several concurrent diseases. This fact is not surprising
since 13 per cent of Slovenian population is older than
65. Therefore it is reasonable to anticipate that the
number of high risk burn victims treated in the institu-
tion will increase each year. The surgical treatment of
full thickness burns of minor or moderate severity
presents a specific problem among others due to a very
high risk of general or spinal regional aesthesia in this
group of patients. Their life is usually not directly
endangered by the burn wounds, but the risk of general
or spinal regional anaesthesia is, however, much
greater than the risk of the burn itself. But on the
other hand the quality of life is greatly impaired if such
wounds remain unhealed for a long period of time.
The use of EMLA cream in high risk patients is
effective in avoiding general anaesthesia. regional
anaesthesia and the injection of large doses of local
anaesthetics 1221. Plasma concentrations of both
lidocaine and prilocaine were found to be low after
percutaneous application of EMLA cream compared to
brachial plexus blockade with lidocaine [23]. This fact
may be effectively used in high risk burn victims with
 7: E Janeiic’/Bums 24 ( 1998) 259-263 263

minor or even moderate full thickness thermal injuries. cream in vasectomy: 2 randomized trials. J Urol 1992; 147:
98-99.
In such patients late skin grafting under the local
[I31 Ma&inlay GA. Save the prepuce. Painless separation of prepu-
anaesthesia ,with EMLA cream substantially reduces tial adhesions in the outpatient clinic. Brit Med J 1988; 297:
the risk of the general or regional anaesthesia. If the 590-591
burn wound is small the skin grafting may be accom- t141 Byrne M, Taylor-Robinson D, Harris JRW. Topical anaesthesia
plished in one surgical procedure. However, in patients with lidocaine-prilocaine cream for vulva1 biopsy. Brit J Obstet
Gynaecol 1989; 96: 497-499.
with larger wounds several surgical procedures may be
1151 Dixon JM. Outpatient treatment of non-lactational breast
necessary. It seems that the late skin grafting of the full abscesses. Brit J Surg 1992; 79: 56-57.
thickness burn wounds up to 10 per cent TBSA may be WI Bingham B, Hawthorne M. The use of anaesthetic EMLA
accomplished entirely under local anaesthesia with cream in minor otological surgery. J Laryngol Otol 1988; 102:
517.
EMLA cream.
1171 Sunderraj, P. Kirby, J. Joyce, P. W, Watson, A. A double-
masked evaluation of lignocaine-prilocaine cream (EMLA) used
to alleviate the pain of retrobulbar injection. Brit. J.
Ophthalmol 1991, 75: 130-132.
References
1181Pere P, Iizuka T, Rosenberg PH, Lindqvist C. Topical applica-
tion of 5% eutectic mixture of lignocaine and prolocaine
[l] Hallen B, Uppfeldt A. Does lidocaine-prilocaine cream permit
(EMLA) before removal of arch bars Brit J Oral Maxillofacial
painfree insertion of IV catheters in children? Anesthesiology
Surg 1992; 30: 153-156.
1982; 57: 3‘40-342.
1191 Lamarche Y, Lebel M, Martin R. EMLA partially relieves the
[Z] Clarke S, Radfort M. Topical anaesthesia for venepuncture. pain of EMG needling. Can J Anaesth 1992; 39: 805-808.
Archives of disease in childhood. J Brit Paediat Assoc 1986; 61:
1132-1134.
PO1 Ogborn MR. The use of a eutectic mixture of local anesthetic in
pediatric renal biopsy. Pediatric Nephrol 1992; 6: 276-277.
[3j Nott MR. Peacock JL. Relief of injection pain in adults. EMLA
WI Goodacre T, Sanders R, Watts DA, Stoker M. Split skin
cream for 5 minutes before venepuncture, Anaesthesia 1990; 45: grafting using topical local anaesthesia (EMLA): a comparison
772-774. with infiltrated anaesthesia. Brit J Plast Surg 1988: 41: 533-538.
141 Ruse11 GN, Desmond MJ, Fox MA. Local anesthesia for radial
artery cannulation: a comparison of a lidocaine-prilocaine
PI Strombeck JO, Uggla M, Lillieborg S. Percutaneous anaesthesia
with a lidocaine-prilocaine cream (EMLA) for cutting split-skin
emulsion and lidocaine infiltration. J Cardiothoracic Anesth grafts. Eur J Plast Surg 1985; 11: 49-52.
1988; 2: 30’3-312.
1231 Ohlsen L, Englesson S, Evers H. An anaesthetic lindocainei
[51 Halperin PL, Koren G. Attias D et al. Topical skin anesthesia prilocaine cream (EMLA) for epicutaneous application tested
for venous, subcutaneous drug reservoir and lumbar punctures for cutting split skin grafts. Stand. J Plast Reconstr Surg 1985;
in children Pediatrics 1989; 84: 281-284 19: 201-209.
[61 Watson AR, Szymkiw P. Morgan AC. Topical anaesthesia for
1241 Holm J. Andren B, Grafford K. Pam control in the surgical
fistula carmulation in haemodialysis patients, Nephrology debridement of leg ulcers by the use of a topical lidocaine-
Dialysis Transplantation 1988; 3: 800-802. prilocaine cream, EMLA. Acta Dermato-Venereol 1990; 70:
171 Rosdahl I: Edmar B, Gisslen H, Nordin P, Lilieborg S. Curet- 132-136.
tage of molluscum contagiosum in children: analgesia by topical 1251 Hansson C, Holm J, Lilieborg S, Syren A. Repeated treatment
application of a lidocaineiprilocaine cream (EMLA).Acta with lidocaineiprilocaine cream (EMLA) as a topical anaes-
Dermato-Venerol 1988; 68: 149-153. thetic for the cleansing of venous leg ulcers. A controlled study.
[X1 Lanigan SW. Cotterill JA. Use of a lignocaine-prilocaine cream Acta Dermato-Venereol 1993; 73(3): 231-233.
as an analgesic in dye laser treatment of port-wine stains. Lasers WI Enander Malmros I, Nilsen T. Lillieborg S. Plasma concentra-
Med Sci 1987; 2: 87-89. tions and analgesic effect of EMLA (hdocaineiprilocaine) cream
[9] Jones SK, Handfield-Jones S, Kennedy CTC. Does EMLA for the cleansing of leg ulcers. Acta Dermato-Venereol 1990;
reduce the discomfort associated with local-anaesthetis infiltra- 70: 227-230.
tion? Clin Exp Dermatol 1990; 15: 177-179. 1271 Jakobson B, Nilsson A. Methemoglobinemia associated with a
[lo] Hallen A, Ljunghall K Wallin J. Topical anaesthesia with local prilocaine-lidocaine cream and trimetoprim-sulphamethoxazole.
anaesthetis (lindocaine and prilocaine, EMLA) cream for A case report. Acta Anaesthesiol Stand 1985; 29: 453-455.
cautery of genital warts Genitourinary Med 1987; 63: 316-319. W Frayling IM, Addison GM, Chattergee K, Meakin G. Methae-
[ll] McDonald PF; Berry AM. Topical anaesthesia for extracor- moglobinaemia in children treated with priiocaine-lignocaine
poreal shock wave lithotripsy. Brit J Anaesthesia 1992; 69: cream. Brit Med J 1990; 301: 153-154.
399-400. 1291 Tinker JH, Roberts SL. Anesthesia risk. In: Miller RD ed.
1121 Honnens de Lichtenberg M; Krogh J, Rye B, Miskowiak J. Anesthesia, 2nd ed. 1986; New York: Churchill Livingstone, p.
Topical araesthesia with eutetic mixture of local anesthetics 365.