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Time: is 30 minutes long enough?

The clinical efficacy of EMLA cream for intravenous catheter placement in client-owned dogs

van Oostrom, H. and Knowles, T.G. 2018. Veterinary Anaesthesia and Analgesia. 45(5): 604-608

What did the research find?

EMLA cream applied for 60 minutes reduces the reaction of dogs to intravenous (IV) catheter placement.

How was it conducted?

202 client-owned dogs of various breed, sex, age, weight and demeanour being admitted to the University of Bristol Small Animal Hospital (Langford Vets) were enrolled following appropriate owner consent. Dogs that required sedation prior to IV catheter placement were excluded. Within the time limits of the study, dogs were randomly allocated into one of four groups as follows:

  • EMLA for 60 minutes (EMLA 60) = 50 dogs,
  • EMLA for 30 minutes (EMLA 30) = 51 dogs,
  • Placebo (E45 cream) for 60 minutes (Placebo 60) = 52 dogs,
  • Placebo (E45 cream) for 30 minutes (Placebo 30) = 49 dogs.

Once allocated to group, dogs had the skin over either the cephalic or saphenous vein clipped and EMLA or placebo cream applied at a dose approximate to 1.5g of cream per 10cm2 of skin (in accordance with manufacturer’s instructions) and covered with an occlusive foil dressing (Kitchen Cling Film). Aseptic preparation of the venepuncture site was performed following the allocated time and an 18-24 gauge IV catheter placed via routine technique. Catheters were placed by qualified veterinary surgeons, veterinary nurses and veterinary students. Interpretation of the dog’s behavioural response during catheterisation was performed by a primary investigator who was blinded to group allocation at this stage.

Results

No differences in signalment were found between groups and there was no effect of group allocation on either the success rate of catheter placement or the total number of attempts needed. The experience of catheter placer did not differ between groups and had no effect on the reaction of the dog to first venepuncture. Despite this, level of experience did have a significant impact on success rate (p = 0.001), with novice placers having the highest failure rate (40.9%) compared to moderately experienced (5.8%) and experienced placers (13.9%). The time taken for catheter placement was also significantly longer for the less experienced personnel (p < 0.001).

A large proportion of dogs, even in the placebo groups, did not react to IV catheter placement. Kruskal-Wallis analysis showed an overall difference between all treatment groups (p = 0.012). Pairwise statistical analysis showed a significantly lower overall reaction score in the EMLA 60 group than in the EMLA 30 and Placebo 60 groups. Interestingly, no other pairwise comparisons demonstrated a significant difference.

Why is this important

IV catheterisation in dogs is commonly performed. Despite this, aversive behaviours displayed by the dog can often make the procedure difficult. The topical use of EMLA cream, a eutectic mixture of the local anaesthetics lidocaine and prilocaine, at the venepuncture site is described in the literature as a way of reducing aversive behaviour in human patients (Fetzer, 2002). The authors of the current study report that despite this knowledge, the process has not become standard practice in veterinary medicine. They question that as the 60-minute waiting time after application (in accordance with manufacturer instructions) might be considered too long in a clinical setting, would a 30-minute application time in canine patients be both efficacious and assist with the catheterisation process?

The study did not find any significant difference in aversive behaviour when EMLA was applied for 30 minutes versus the Placebo 30 and Placebo 60 groups. Their results did however support the findings of Flecknell et al. (1990) that EMLA cream applied for 60 minutes reduces the incidence, and severity, of reaction of dogs to IV catheterisation. Despite supporting the overall findings, one important difference between the current study and the one performed by Flecknell et al. (1990) is that the current investigation was performed in a clinical veterinary setting, with client owned dogs of mixed signalment, meaning that these results are possibly more applicable to scenarios that may be seen in everyday veterinary practice.

Data from this study also suggests that less reaction did not necessarily affect the rate of successful catheter placement. This implies that the occasionally cited fear of EMLA induced vasoconstriction may be unjustified.

No adverse reactions to EMLA use were seen in any of the cases suggesting that its use in a clinical setting appears to have no negative side effects.

In conclusion,this study suggests that the routine use of EMLA cream in the clinical setting prior to IV catheterisation of dogs improves their welfare. However, as the cream only appears to be effective following 60 minutes of application, its successful use requires forward planning.

Article by
Dr. Dan Cripwell
BSc (Hons) BVSc CertAVP (EM) PgCert (VPS) MRCVS

Veterinary Technical Advisor UK
RCVS Recognised Advanced Veterinary Practitioner

Originally published: Thursday, 27th September 2018

References

Fetzer, S.J. 2002. Reducing venepuncture and intravenous insertion pain with eutectic mixture of local anesthetic: a meta-analysis. Nursing research51(2): 119-124.

Flecknell, P.A., Liles, J.H., Williamson, H.A. 1990. The use of lignocaine-prilocaine local anaesthetic cream for pain-free venepuncture in laboratory animals. Laboratory Animals. 24(2): 142-146.

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