What Would You Do: Should Topical Anesthetics be Used to Numb the Skin Overlying an Implanted Port Prior to Noncoring Needle Insertion?

Oncology Nursing News, October 2011, Volume 5, Issue 6

Oncology nurses provide their expert opinions to answer the question of whether a topical anesthetic should be used to prior to noncoring needle insertion.

Interventions to reduce the pain of port access should be considered, especially in patients who have a low pain threshold. Several types of anesthetics are available including topical, injectable, and nonpharmacological methods. Studies on the use of these interventions are limited to peripheral IV access and the pediatric population. Caution should be used with topical anesthetic sprays (eg, ethyl chloride) over the port access area, as frequent use to access a port can be a cause of skin breakdown over the port access site.

Dawn Camp-Sorrell, MSN, FNP, AOCN®

Nurse Practitioner

St. Vincent’s Adult Clinic Birmingham, Alabama

For all patients with implanted ports, an assessment of pain issues and pain tolerance in relation to noncoring needle insertion should be performed. While many patients experience minimal discomfort and desire no additional intervention, some do. Options for anesthetics, such as topical lidocaine 2.5% and prilocaine 2.5% cream (EMLA® cream), should be considered. As a home care nurse, if no anesthetic cream is available, I have successfully used ice to numb the area for a few minutes prior to skin preparation and port access.

Lisa A. Gorski, RN, MS, HHCNS-BC, CRNI, FAAN

Clinical Nurse Specialist

Wheaton Franciscan Home Health & Hospice Milwaukee, Wisconsin

We use topical anesthetics frequently (eg, EMLA® cream) and apply them 1 hour prior to non-coring needle insertion. We place a transparent dressing over the area where the anesthetic cream has been applied and clean the anesthetic cream off prior to using an antiseptic and accessing the implanted port.

MiKaela Olsen, RN, MS, OCN®

Oncology and Hematology Clinical Nurse Specialist

Sidney Kimmel Comprehensive Cancer Center Johns Hopkins Hospital Baltimore, Maryland

Offering a topical anesthetic when accessing implanted ports is an important option for some patients. Minimally, patients should be aware of the option as part of the informed consent process (ie, being informed of alternative approaches to care). That said, there are times that the use of an anesthetic cream is impractical. For example, if the chemotherapy is being delivered by continuous infusion (eg, >24 hours, >96 hours, etc), using a topical anesthetic would require the therapy to stop for the period of time between removing the old non-coring needle and the time needed for the numbing agent to take effect, which is sometimes 30 to 45 minutes.

Minimally, patients should be aware of the option as part of the informed consent process (ie, being informed of alternative approaches to care). ”

Michael Smart, RN, BSN, OCN®

Oncology Staff Nurse

Huntsville Hospital Johns Hopkins Hospital Huntsville, Alabama

Some things to consider when deciding to offer a topical anesthetic prior to non-coring needle insertion include: (1) how the anesthetic is administered (injected intradermal anesthetics may increase the risk of infection from the additional needle sticks); (2) when an anesthetic cream needs to be applied (because it may take an hour for the full numbing effect to occur, patient scheduling needs to be considered, and patients may need to apply the cream prior to arrival); and (3) what will be administered (eg, the duration of action of topical anesthetic creams is ≥2 hours, and if vesicants are administered, the anesthetic action of the cream may diminish the patient’s sensation of discomfort around the non-coring needle site). Topical anesthetic sprays (eg, ethyl chloride) need to be used with caution. They should be sprayed at a distance of 3 to 9 inches for 4 to 10 seconds or until the skin just turns white. The length of spray time depends on the skin’s sensitivity to cold and factors such as blood flow and skin depth. Over-spraying increases the risk of skin alteration (redness, irritation). Other considerations are the short duration of action (the anesthetic effect lasts up to 1 minute) and that ethyl chloride spray is not a sterile product (although it has passed the Microbial Limit Test in accordance with the United States Pharmacopeia).

Lisa Schulmeister, RN, MN, APRN-BC, OCN®, FAAN

Oncology Nursing Consultant

New Orleans, Louisiana

If you have a clinical question for which evidence is lacking or controversial that you would like our experts to address, please submit it to jbroderick@onclive.com.