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Common topical local anesthetic preparations for use prior to venipuncture or venous cannulation in children

Common topical local anesthetic preparations for use prior to venipuncture or venous cannulation in children
Agent Dose Onset of action (minutes) Duration of action (minutes) Depth of anesthesia (mm) Precautions, adverse effects, and comments*
Lidocaine administration via a needle-free delivery system (J-tip) 2 to 2.5 mg (0.2 to 0.25 mL of buffered 1% lidocaine solution) delivered using compressed CO2. 1 to 3 60 5 to 8
  • Ensure that the device is not applied directly over a vein during administration.
Liposomal lidocaine (LMX4, LMX5) LMX4 (liposomal lidocaine 4%):
  • Age <4 years: 1 g applied to puncture site (6.25 cm2 of skin).
  • Age ≥4 years: 1 to 2.5 g applied to puncture site (6.25 cm2 of skin).
Supplied as 5 g, 15 g, and 30 g tube.		 30 60 to 120 See lidocaine-prilocaineΔ
  • Available over-the-counter.
Tetracaine (amethocaine) gel (Ametop, Angel) Tetracaine 4%:
  • Age ≥1 month: Apply 1 g of gel to puncture site (6.25 cm2 of skin) under an occlusive dressing.
Supplied as 1.5 g tubes designed to deliver 1 g when squeezed.		 30 to 45 250 to 360 See lidocaine-prilocaineΔ
  • Do not use in infants younger than one month of age.
  • Capillary dilation with skin redness is typical and transient.
Self-heating lidocaine and tetracaine patch (Synera) 70 mg lidocaine and 70 mg tetracaine per patch:
  • Apply one patch to intact skin for 20 to 30 minutes and promptly remove. After one failed attempt, one additional patch may be applied in children. Simultaneous application of more than one patch is not recommended in children ≤12 years.
20 to 30 90 up to 8
  • Do not use in patients with para-aminobenzoic acid hypersensitivity.
  • The heating element contains iron. Thus, the patch must be removed before some diagnostic procedures, especially magnetic resonance imaging.
  • Prolonged application of the patch to intact skin or application to broken skin or mucous membranes may result in serious local anesthetic toxicity.
  • Approximately 90% of the drug dose remains in the patch after use. Fold the medicated side of the patch over on itself before discarding.
  • Transient skin erythema and swelling at the application site is common with routine use.
Lidocaine-prilocaine (eutectic mixture of local anesthetics [EMLA], Oraqix, Lidopril, Priloxx) Typical dose for venipuncture or venous cannulation:
  • Age ≥3 months and weight ≥5 kg: Apply 1 to 2 g of EMLA cream over no more than 10 cm2 of skin under an occlusive dressing at the puncture site.
Dosing based on patient weight:
  • <5 kg: Apply up to 1 g per 10 cm2 area under an occlusive dressing 60 minutes prior to procedure. Maximum dosing for a 24-hour period: Maximum total dose (for all sites combined): 1 g; maximum application area: 10 cm2; maximum application time: 1 hour.
  • ≥5 kg to ≤10 kg: Apply 1 to 2 g per 10 cm2 area under an occlusive dressing for at least 60 minutes prior to procedure. Maximum dosing for a 24-hour period: Maximum total dose (for all sites combined): 2 g; maximum application area: 20 cm2; maximum application time: 4 hours.
  • >10 kg to ≤20 kg: Apply 1 to 2 g per 10 cm2 area under an occlusive dressing for at least 60 minutes prior to procedure. Maximum dosing for a 24-hour period: Maximum total dose (for all sites combined): 10 g; maximum application area: 100 cm2; maximum application time: 4 hours.
  • >20 kg: Apply 1 to 2 g per 10 cm2 area under an occlusive dressing for at least 60 minutes. Maximum dosing for a 24-hour period: Maximum total dose (for all sites combined): 20 g; maximum application area: 200 cm2; maximum application time: 4 hours.
Supplied as 5 g and 30 g tube.		 60 60 to 120

3 at 60 min

5 at 120 min

6 at 180 to 240 min
  • Do not use in children with methemoglobinemia.
  • May cause methemoglobinemia with excessive application or in infants younger than 12 months of age with predisposition to methemoglobinemia (eg, G6PD deficiency or taking methemoglobin-inducing medication).
  • Use with caution in children with atopic dermatitis (potential for increased absorption) or hepatic impairment (decreased breakdown of absorbed medication) because of increased risk of local anesthetic toxicity. Rarely associated with contact dermatitis.
* Local anesthetic toxicity (arrhythmias, seizures, coma, and death) may occur if these agents are applied to large areas of the skin for prolonged periods of time or applied to broken skin, rashes, or areas of skin irritation. For more information refer to UpToDate graphics and topics on local anesthetic toxicity.
¶ Immediate-type allergy (including anaphylaxis) to local anesthetics is rare. However, contact dermatitis to topical anesthetics can occur. Avoid topical use in children with a history of blistering skin lesions or localized eczema following past application. For further discussion of the assessment and management of immediate and delayed hypersensitivity due to local anesthetics, refer to UpToDate topics on allergic reactions to local anesthetics.
Δ Both liposomal lidocaine and tetracaine gel provide more complete anesthesia than lidocaine-prilocaine, but the depth of anesthesia appears to be similar.
Dosing:
  1. Eichenfield LF, Funk A, Fallon-Friedlander S, Cunningham BB. A clinical study to evaluate the efficacy of ELA-Max (4% liposomal lidocaine) as compared with eutectic mixture of local anesthetics cream for pain reduction of venipuncture in children. Pediatrics. 2002;109(6):1093-1099.
  2. Fein JA, Zempsky WT, Cravero JP; Committee on Pediatric Emergency Medicine and Section on Anesthesiology and Pain Medicine; American Academy of Pediatrics. Relief of pain and anxiety in pediatric patients in emergency medical systems. Pediatrics. 2012;130(5):e1391-e1405.
  3. Koh JL, Harrison D, Myers R, Dembinski R, Turner H, McGraw T. A randomized, double-blind comparison study of EMAL and ELA-Max for topical anesthesia in children undergoing intravenous insertion. Paediatr Anesth. 2004;14(12):977-982.
  4. Luhmann J, Hurt S, Shootman M, Kennedy R. A comparison of buffered lidocaine versus ELA-Max before peripheral intravenous catheter insertions in children. Pediatrics. 2004;133(3 pt 1):e217-e220.
  5. Ametop (Tetracaine 4 percent) gel. Alliance Pharmaceuticals Ltd, United Kingdom, 9/3/2018.
  6. Synera Prescribing Information. Galen US Inc., Souderton, PA; March 2014.
Depth of analgesia:
  1. Wahlgren C, Quiding H. Depth of cutaneous analgesia after application of a eutectic mixture of the local anesthetics lidocaine and prilocaine (EMLA cream). J Am Acad Dermatol 2000; 42:584.
  2. Bjerring P, Arendt-Nielsen L. Depth and duration of skin analgesia to needle insertion after topical application of EMLA cream. Br J Anaesth 1990; 64:173.
  3. Synera Prescribing Information. Galen US Inc., Souderton, PA; March 2014.
  4. FAQ. J-TIP Needle-Free Injection System website. http://www.jtip.com/faq.html. Accessed March 19, 2015.
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