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Three Part Question

In [children undergoing venepuncture after EMLA cream] does [stripping the stratum corneum with adhesive tape] reduce [time of onset, pain and distress of the procedure]?

Clinical Scenario

A 2 year old child presents to the emergency department with a limp. The child is mildly pyrexial and has some limitation of movement. You decide to take blood as part of your diagnostic strategy to exclude septic arthritis. The parents are keen to get on with the tests and are disappointed that the EMLA cream you intend to use takes so long to work. The paediatric emergency nurse suggests using tape to "clean" the skin prior to application in order to get the EMLA to work faster. You have no idea what she is talking about but wonder whether there is any evidence to show that she is right.

Search Strategy

Medline 1966-04/02 using the OVID interface.
[EMLA.mp OR eutectic.mp OR ({exp anesthesia, local OR exp anesthetics, local OR exp Lidocaine OR local anaesthetic$.mp OR local anesthetic$.mp} AND {exp administration, topical OR topical.mp})] AND [exp adhesives OR exp bandages OR TAPE.mp] LIMIT to human AND English.

Search Outcome

47 papers were found of which one was relevant to the three part question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Singer AJ et al, 1998, USA	68 alert adult patients requiring intravenous cannulation in the ED. Patients were randomised to receive tape stripping. All measurements made on 100mmVAS. Scotch tape was applied and stripped 20 times to remove the stratum corneum.	PRCT	Success rate for cannulation	91% for tape stripping vs. 74% without p=0.056	Adult patients No blinding of person perfoming IV cannulation Convenience sample rather than sequential Only small differences in VAS scores found
			Pain during tape stripping	4.8mm +/-7.4mm
			Pain during cannulation	Less with tape stripping 29.7mm vs. 39mm p=0.017

Comment(s)

The single study found shows a small benefit to tape stripping, but only involves adult patients undergoing venepuncture. It is debatable whether the small differences in VAS seen are clinically important (normally at least a change of 10mm would be considered significant). In our practice EMLA is almost exclusively used in children. There is an amount of pain that is attributable to the tape stripping procedure, though this is a low value. However applying the tape and stripping it 20 times is likely to be distressing for many children. This adult study does not address the likely difficulties in applying this technique in children. It is our perception that they would find the tape stripping distressing. For this reason we do not feel that it is possible to extrapolate the results of this study to children.

Clinical Bottom Line

Tape stripping the stratum corneum increases the effectiveness of EMLA in adults by a small degree. Its effectiveness in children is unknown.

Level of Evidence

Level 3 - Small numbers of small studies or great heterogeneity or very different population.

References

1. Singer AJ, Shallat J, Valentine SM, et al. Cutaneous tape stripping to accelerate the anesthetic effects of EMLA cream: a randomized, controlled trial Acad Emerg Med 1998;5(11):1051-6.