Comparison of eutectic mixture of local anesthetics cream with dorsal penile nerve block using lignocaine for circumcision in infants

Abstract

Objective: Circumcision is a commonly performed surgical procedure but choice of anesthesia remained an issue of research and debate. This study was conducted to find out the effectiveness of the eutectic mixture of local anesthetic (EMLA) cream with dorsal penile nerve block (DPNB) using lignocaine, for reduction of pain during circumcision. Methodology: This was comparative study carried out in Surgical Unit B of National Institute of Child Health Karachi, from May 2008 to October 2008. Patients under six month of age were randomized in to two groups (EMLA and DPNB) of fifty patients each. The effectiveness of pain control was assessed by measuring the baseline heart rate (HR), respiratory rate (RR) and Neonatal infant Pain Scale (NIPS scale) before the start of procedure and measuring of these parameters for each step of circumcision. Independent sample t -test was used to compare means and repeated ANOVA was used to compare means of HR, RR, oxygen (O2) saturations and NIPS. Results: The mean age in both the groups was 2.3 months. There was no statistically significant difference in baseline parameters in both the groups except the respiratory rate, which was significantly raised in DPNB group (33 breaths/min in EMLA and 38 in DPNB P < 0.04). During circumcision there was significant increase in heart rate in DPNB group, especially in step three and step four (p < 0.04). Oxygen saturation dropped in both the groups (baseline saturation 98% up to 91% in step 4). While assessing NIPS scores in both the groups, statistically significant difference was found between NIPS at step two and step four in two groups (p < 0.04). Conclusions: The overall pain control was equal in both the groups, although NIPS score was higher in DPNB in step two and four of circumcision. There was difference in application and cost. EMLA was easy to apply but has increased cost; while DPNB required expertise.

A comparison of anesthetic efficacy between dorsal penile nerve block (DPNB) with lidocaine and eutectic mixture of local anesthetics (EMLA) cream during neonatal circumcision

“…In the present study, the changes in SpO 2 were similar to the findings of Sabeen Mujeeb et al 8 who also noted a decrease in SpO 2 throughout the procedure without any statistically significant difference between both groups. Michael Holliday 34 et al who compared DPNB with lidocaine versus placebo also noted a similar decrease in SpO 2 in both groups.…”

“…This result is similar to the finding by Butler-O’Hara et al 11 who noted significantly higher NIPS scores among the patients who had EMLA cream during lysis of adhesions and tying. However, a different observation was made by Sabeen Mujeeb et al 8 who noted significantly higher NIPS scores during crushing and cutting among patients who had DPNB with lidocaine. These differences may be attributed to interobserver variability in scoring as well as to the fact that the behavioral changes assessed in the NIPS may be affected by factors other than pain, such as hunger or discomfort due to restraint.…”

“…The neural pathways related to painful stimuli, including the cortical and subcortical centers at which level pain is perceived are now known to be functional at birth. 8 9 Neonatal circumcision produces physiological changes, behavioral changes and adrenal cortical response that have been attributed to the pain response. 10–12 These form the basis of pain assessment.…”

“…Local anesthetic infiltration for procedures in neonates still poses a challenge. 20 With the advent of topical agents that have been reported to be equally effective with less morbidity, 8 this study comparing DPNB with lidocaine and EMLA cream during circumcision was intended to determine the best option for neonates in our setting.…”

Dorsal penile nerve block versus eutectic mixture of local anesthetics cream for pain relief in infants during circumcision: A meta-analysis

“…Lehr, V. T et al [ 15 ] also observed the largest mean difference in HR values between DPNB- and EMLA-treated infants at clamping (19±9.1 bpm) and cutting (18±9.6 bpm), although these were not significant (P = 0.13 and P = 0.18, respectively). Mujeeb Sabeen et al [ 21 ] demonstrated that the heart rate increased 12 times greater in EMLA group than the DPNB group. However, in this our study, there did not have any significant difference in analgesic efficacy between the study treatments according to the mean HR throughout the circumcision instead of several phase.…”