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Multiple puncture technique using anaesthetic cream (emla)

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  #1  
Old 4th February 2012, 02:13 PM
richardrobley richardrobley is offline
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Default Multiple puncture technique using anaesthetic cream (emla)

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Has anyone ever tried Emla anaesthetic cream when performing v/p multiple puncture technique on patients who do not want an anaesthetic injection. Very curious as a lot of patients are put off by the thought of having a painful anaesthetic.
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Old 4th February 2012, 02:18 PM
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Default Re: Multiple puncture technique using anaesthetic cream (emla)

I imagine you would be replacing ceiling tiles fairly quickly, given the depth that you have to insert the needle.
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Old 4th February 2012, 02:27 PM
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Default Re: Multiple puncture technique using anaesthetic cream (emla)

Checked some nursing sites and it's often used on children when fitting canula's, which are quite deep. Can also be used for skin grafts and minor skin operations??
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Old 4th February 2012, 03:01 PM
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Default Re: Multiple puncture technique using anaesthetic cream (emla)

Hi Richard,

From what i've read the elma cream is only effective in anaesthetising plantar skin in children and has no significant effect in adults.
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Old 4th February 2012, 03:06 PM
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Default Re: Multiple puncture technique using anaesthetic cream (emla)

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Old 5th February 2012, 05:04 AM
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Default Re: Multiple puncture technique using anaesthetic cream (emla)

Quote:
Originally Posted by richardrobley View Post
Has anyone ever tried Emla anaesthetic cream when performing v/p multiple puncture technique on patients who do not want an anaesthetic injection. Very curious as a lot of patients are put off by the thought of having a painful anaesthetic.
Hi Richard,

In my opinion, which isn`t to say is correct, Emla cream (which has to be correctly applied at least 2 hours prior to tx) is messy and rubbish. It is only a dermal anaesthesia so does not penetrate to the subcutaneous tissue where the needle must be inserted multiple times for VP tx.

I often use ethyl chloride as a pre-injection `numb-er`. It`s quick and effective.

Tip; Don`t underestimate the power of suggestion. NEVER use the phrase "painful anaesthetic". LA is utilised to render what would otherwise be painful procedures, painless. Pain is incredibly subjective and pts pick up on any spoken, or unspoken, hints that you as their health professional give them. Personally, I advise them that the injection does smart, but no more than an inoculation in the arm, which most can identify with and often reduces their unease.

Just my view, of course.
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Old 5th February 2012, 05:37 AM
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Wink Re: Multiple puncture technique using anaesthetic cream (emla)

I agree with Bel & other posters that Emla cream is likely to be of little use. I also sometimes use Ethyl Chloride pre- injection. I also agree that avoiding the 'needle' word is a very good idea. I always lay the patient down & tell them I will ask them to take a deep breath & then to breathe normally. I have found children respond better if I ask them to count slowly from 5 to 0. The only failed injection was with my daughter! She required a general anaesthetic & a consultant podiatric surgeon plus a full theatre team including consultant anaesthetist to perform a partial nail avulsion! She even needed Entonox prior to siting the cannula. Epic bloody fail!

Whoever said never work with children or animals was right on the money.

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Old 5th February 2012, 06:39 AM
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Default Re: Multiple puncture technique using anaesthetic cream (emla)

I can guarentee that it would make your patients confess!! No, its a horrible idea which would never work. Try it on yourself.

I generally ask patients how painful they found the tib block on a scale of one to ten. Its very rare that they say more than 3. A well executed tibial block is almost painless.
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Old 5th February 2012, 07:00 AM
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Default Re: Multiple puncture technique using anaesthetic cream (emla)

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Originally Posted by Robertisaacs View Post
A well executed tibial block is almost painless.
As is any block, with the right technique. Hows about completing that challenge, eh Smelly?
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Old 5th February 2012, 07:12 AM
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Default Re: Multiple puncture technique using anaesthetic cream (emla)

Quote:
Originally Posted by Robertisaacs View Post
I can guarentee that it would make your patients confess!! No, its a horrible idea which would never work. Try it on yourself.

I generally ask patients how painful they found the tib block on a scale of one to ten. Its very rare that they say more than 3. A well executed tibial block is almost painless.
Before I posted this question I was actually thinking of trying it on myself. Maybe I should, and video it! It could be the funniest video on here, lol
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Old 5th February 2012, 07:19 AM
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Default Re: Multiple puncture technique using anaesthetic cream (emla)

Quote:
Originally Posted by richardrobley View Post
Before I posted this question I was actually thinking of trying it on myself. Maybe I should, and video it! It could be the funniest video on here, lol
It`s the way to go. Best way I found of administering LA with the least amount of discomfort was by practising on myself....

I actually used to have a needle phobia, but that`s another story.
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Old 5th February 2012, 07:25 AM
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Default Re: Multiple puncture technique using anaesthetic cream (emla)

Quote:
Originally Posted by blinda View Post
It`s the way to go. Best way I found of administering LA with the least amount of discomfort was by practising on myself....

I actually used to have a needle phobia, but that`s another story.
Bet that wasn't the best day you've ever had, lol.
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Old 5th February 2012, 02:01 PM
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Default Re: Multiple puncture technique using anaesthetic cream (emla)

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Originally Posted by richardrobley View Post
Bet that wasn't the best day you've ever had, lol.
`Twas the time of my life.
http://www.youtube.com/watch?v=1PK2R0IwCiY

Apologies for the prolific posts this afternoon, guess the Welsh v Ireland game got me all fired up. http://www.youtube.com/watch?v=zv-7p1om0kc. Just imagine what could have happened if Hook was allowed to take that kick?
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Old 5th February 2012, 04:58 PM
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Default Re: Multiple puncture technique using anaesthetic cream (emla)

Quote:
Originally Posted by richardrobley View Post
Checked some nursing sites and it's often used on children when fitting canula's, which are quite deep. Can also be used for skin grafts and minor skin operations??

I/v canulation in children is usually via a butterfly canulae which is then used to administer any anaesthetic / drug required during surgery (a very small gauge needle which saves making their arm like a pin cushion).

It is in effect a very superficial procedure as the object is to canulate a supeficial vein.

Adults on the other hand in emergency blood loss situations may need the equivilent of a drain pipe or two intoduced into their venous system to carry a variety of large volume fluids.

The child may get the emla cream which at best lessens the needle stick side of it.

The adult in the circumstances described has no choice

BUT

In either scenario in my experience with the right technique neither should find it too much of a trial.

I have a rule in my practice which I think is somewhat overlooked in this profession...

THE AGE OF PAINLESS PODIATRY IS HERE !!

Ask yourselves with modern day anaesthetics properly administered, is there any reason for that not to be true??????

And BTW NOOOOOOOOOOOOOO you wouldnt use emla to provide anaesthesia in multiple needling because the patient would be screaming in pain before you had get past the second application of the needle !!Please try it on yourself and then see if you want to try it on others....NOT

Cheers
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Old 5th February 2012, 05:37 PM
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Default Re: Multiple puncture technique using anaesthetic cream (emla)

better a posterior tibial block ...
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Old 8th February 2012, 04:11 PM
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Default Re: Multiple puncture technique using anaesthetic cream (emla)

As a pond life student my view having seen the procedure and being told you need to penetrate 5-7mm into the VP, a tibial block is the way to go. If the patient is needle phobic you could use Entonox for both its Analgesic and Anxiolytic properties (Plenty of research on its use in cannulation and other painful procedures) and it is a Pharmacy item, not a POM :-)

Colin
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Old 8th February 2012, 04:44 PM
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Default Re: Multiple puncture technique using anaesthetic cream (emla)

Quote:
Originally Posted by richardrobley View Post
Checked some nursing sites and it's often used on children when fitting canula's, which are quite deep. Can also be used for skin grafts and minor skin operations??
You cannot compare going 5-7 mm into the skin (puncture technique) with cannulisation. The Emla is only used in cannula insertion to numb the point of entry, in the skin, of the needle. The needle enters the vessel at a superficial level. I think most topical anaesthetics are placebo in effect as they really only work on mucous membrane -e.g. the gums.
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Old 8th February 2012, 06:52 PM
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Default Re: Multiple puncture technique using anaesthetic cream (emla)

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Originally Posted by Seamus McNally View Post
You cannot compare going 5-7 mm into the skin (puncture technique) with cannulisation. The Emla is only used in cannula insertion to numb the point of entry, in the skin, of the needle. The needle enters the vessel at a superficial level. I think most topical anaesthetics are placebo in effect as they really only work on mucous membrane -e.g. the gums.
Absolutely agree.

As other posters have stated, we have the ability to use tibial blocks, we're skilled at them, most other professions are not. Play to your strengths and use that which have been proved beyond doubt to be effective rather than experimenting with that which has proved to be ineffective and reap the huge benefits for both your patient and yourself.

All the best

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Old 8th February 2012, 07:59 PM
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Default Re: Multiple puncture technique using anaesthetic cream (emla)

Quote:
Originally Posted by richardrobley View Post
Has anyone ever tried Emla anaesthetic cream when performing v/p multiple puncture technique on patients who do not want an anaesthetic injection. Very curious as a lot of patients are put off by the thought of having a painful anaesthetic.
I rarely use a posterior tibial nerve block for doing the needling technique for plantar verrucae, but, rather, I use ethyl chloride spray to numb (i.e. temporarily freeze) the skin before giving the local anesthetic injection. Generally, 5-10 seconds of ethyl chloride spray at the desired site of needle puncture eliminates any pain from the initial needle stick. However, ethyl chloride spray does not prevent the discomfort from injection of the local anesthetic subdermally (which is generally mild). Care is taken to inject very slowly into the subdermal area of the plantar verrucae since pushing fluid too fast into the injection site causes increased pain. It takes about 5 minutes from the time the needle goes in for the local anesthetic injection until the time I can do the needling procedure for the verrucae plantaris lesion, with no pain whatsoever noted during the needling procedure.

Here is the ethyl chloride spray I use on a daily basis in my office for all injections. It simply is the best way to give injections, as far as I'm concerned.
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File Type: jpg Ethyl chloride spray.jpg (27.3 KB, 89 views)
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Old 9th February 2012, 12:55 AM
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Default Re: Multiple puncture technique using anaesthetic cream (emla)

Quote:
Originally Posted by Kevin Kirby View Post
I rarely use a posterior tibial nerve block for doing the needling technique for plantar verrucae, but, rather, I use ethyl chloride spray to numb (i.e. temporarily freeze) the skin before giving the local anesthetic injection. Generally, 5-10 seconds of ethyl chloride spray at the desired site of needle puncture eliminates any pain from the initial needle stick. However, ethyl chloride spray does not prevent the discomfort from injection of the local anesthetic subdermally (which is generally mild). Care is taken to inject very slowly into the subdermal area of the plantar verrucae since pushing fluid too fast into the injection site causes increased pain. It takes about 5 minutes from the time the needle goes in for the local anesthetic injection until the time I can do the needling procedure for the verrucae plantaris lesion, with no pain whatsoever noted during the needling procedure.

Here is the ethyl chloride spray I use on a daily basis in my office for all injections. It simply is the best way to give injections, as far as I'm concerned.
Thanks Kevin, that's really interesting, much appreciated.
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Old 9th February 2012, 03:18 AM
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Default Re: Multiple puncture technique using anaesthetic cream (emla)

Quote:
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... ethyl chloride spray I use on a daily basis in my office for all injections. It simply is the best way to give injections, as far as I'm concerned.
Indeed
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