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Local Anesthesia for Infant LP – Which Is Best?

April 5, 2018

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The J-tip needle-free injection of lidocaine was no better than topical anesthetic (EMLA) in reducing infant LP pain scores, but it improved LP procedural success.

Why does this matter?
There is much debate over local anesthesia for infant LP.  The consensus of the literature is that it improves success.  But the best method to give it is not known.

Would you want a LP without local anesthetic?
This was a RCT of infants 0-4 months using the J-tip needle-free injection system with 1% buffered lidocaine + fake EMLA cream (32 patients) vs J-tip with saline + real EMLA cream (34 patients).  There was no difference in Neonatal Faces Coding Scale.  But the J-tip group was twice as likely to have success with the LP across all provider experience levels.

I need to editorialize a bit.  I have been injecting lidocaine for infant LP for almost 20 years.  I infiltrate both the L4-L5 and L3-L4 interspaces with one stick.  It totally obscures the landmarks, but that is immediately resolved by gentle massage with my thumb and a piece of gauze over the area for about 30 seconds.  Anecdotally, I have noticed little change after applying EMLA.  It seems to hurt just as bad, as this study confirms.  Only lidocaine infiltration seems to help, in my opinion. This way, the L4-L5 stick is painless. And if unsuccessful, I move up one interspace and the L3-L4 stick is also painless.  That’s worked like a charm for me for almost 2 decades, and it is what I teach all my residents.  Seriously, would you want a LP with no lidocaine?  Then how is it ethical to do that to an infant?  The counterargument goes that the lidocaine is one stick and a successful LP is one stick.  But how often are you successful on the first stick?

A Randomized Double Blind Trial of Needle-free Injected Lidocaine Versus Topical Anesthesia for Infant Lumbar Puncture.  Acad Emerg Med. 2018 Mar;25(3):310-316. doi: 10.1111/acem.13351. Epub 2017 Dec 26.

Peer reviewed by Thomas Davis.

What are your thoughts?