The Use of Glyceryl Trinitrate Ointment with EMLA Cream for IV Cannulation in Children Undergoing Routine Surgery

Abstract

This prospective randomized controlled double-blind trial was performed to investigate whether glyceryl trinitrate (GTN) ointment, applied ten minutes after the removal of a eutectic mixture of local anaesthetic cream, lignocaine/ prilocaine (EMLA), influences site selection for intravenous cannulation in children. Eighty children aged between five and 15 years, having general surgery as day patients, received EMLA cream on both hands for 90 minutes prior to transfer to the theatre suite. Acting as their own controls, the children received GTN on one hand, and placebo on the other, after removal of the EMLA cream and ten minutes prior to the insertion of an intravenous cannula. The application of GTN or placebo to left or right hand was blinded and randomized. At induction, the hand with the visually best quality veins was selected and cannulated. The primary outcome was selection between the EMLA/GTN hand and EMLA/placebo hand. The selection having been made, the number of attempts at cannulation, ease of insertion and pain scores (VAS) for cannulation were also recorded. The choice of hand was positively influenced by the use of GTN, with the GTN hand chosen in 51 of 72 (70%) children who completed the protocol (P=0.001). The findings of this study suggest that the application of GTN after EMLA removal may be clinically useful in aiding cannulation in children.

Untitled

“…The addition of topical GTN positively affected venous dilatation ( P < 0.01), choice of cannulation site ( P < 0.001) and ease of cannulation ( P < 0.001). Similar findings were achieved when GTN was applied after EMLA removal [16]. …”

Venodilatation techniques to enhance venepuncture and intravenous cannulation

“…In the author's experience, local NTG has also been very successful in obtaining intravenous access in patients who are intravenous drug users. NTG ointment can be used concomitantly with local anesthetic ointments to provide concomitant venodilatation and anesthesia (39,40). Transdermal isosorbide dinitrite ointment has also been shown to dilate veins on the hand, but takes significantly longer (on average, 39 min) to achieve significant venodilatation comparable to NTG (41).…”

A randomized controlled trial comparing the AccuVein AV300 device to standard insertion technique for intravenous cannulation of anesthetized children

“…Insertion of an intravenous (IV) cannula is one of the most commonly performed procedures in pediatrics and almost universally accompanies pediatric anesthesia. The first‐attempt success rate of intravenous cannulation of children was 34% (1) in one study and 92% (2) in another, although success is highly practitioner‐dependent (1). Factors predictive of difficulty include younger age, a history of prematurity, dark skin, and obesity (3–6).…”

“…Factors predictive of difficulty include younger age, a history of prematurity, dark skin, and obesity (3–6). Many techniques have been used in attempts to improve success, including active warming (7), glyceryl trinitrate ointment (2), and ultrasonography (8–10). Some techniques require a degree of planning, cooperation of the patient (7), considerable staff time and training (8,9), and more than one operator (8).…”