Over coffee one of the vets mentions that the practice has run out of EMLA cream. They have been using it when placing intravenous catheters in dogs, cats and rabbits, and forgot to let you know that stock was getting low. The other assistant replies that they never use EMLA cream to place an intravenous catheter, and have never seen the need for it. There then follows a discussion around the advantages and disadvantages of local anaesthesia when placing catheters, particularly in small mammals – what should or should not be used, how far ahead of catheterisation should the cream be applied, how much to use, and whether the skin should be covered whilst it takes effect.
You decide to look into this in more detail........
Where are you going to start?
Well you could start with google or google scholar. If you or the practice has access to an online database such as the RCVS library then that would be helpful. Other options include Web of Science, Medline, PubMed or CAB Abstracts as well as any text books in the practice.
Once you have some evidence how do you know what is correct and what isn’t?
A good starting point is to look at how recent the article is, and whether it was published in a peer reviewed veterinary journal. That gives you some assurance that the information is up to date and has already been scrutinised by veterinary professionals.
After undertaking this, you find a variety of different references (some of these are listed at the end of the article) which would support the use of EMLA cream when placing an intravenous catheter but the time required to be most effective isn’t very clear. One paper (Chung et al, 2022), found that applying EMLA cream 60 minutes before catheterisation was preferable to 10 minutes before. Keating et al (2012) demonstrated that 20 minutes was sufficient to provide analgesia when carrying out tattooing of the pinna. In people application 30-60 minutes before intervention and covering the skin with a light dressing is advised and Varga (2014), agrees with this in rabbits, suggesting that an occlusive dressing should be placed over the EMLA cream and left in place for 45 – 60 minutes to take full effect.
As you can see there is a need for more studies to provide more substantial evidence but common sense would suggest that leaving the cream in place for a longer time rather than shorter would be associated with a deeper level of local anaesthesia.
You decide to discuss with colleagues at the next team meeting, and update the practice standard operating procedures to include the use of EMLA cream for all intravenous catheter placement.
Whilst carrying out this work, you also find some references on the use of multi-modal analgesia and pain scoring in rabbits. The practice does have a Standard Operating Procedure (SOP) for rabbit analgesia, and a checklist giving information about how to use the Rabbit Grimace Scale, but now you wonder just how many people in the practice are using these, and how reliable the results are. That’s the start of another QI study!
If you would like to learn more about how to apply quality improvement to your exotics cases in practice read on to find out more about our Quality Improvement in the Nursing Care of Exotics course running in May / June.
Quality Improvement in the Nursing Care of Exotics: 21st May – 18th June 2023
If you would like to find out more about how to carry out your own quality improvement studies in practice, with a particular focus on exotics, then sign up to our 4 week online course. The programme of study will cover the theory behind quality improvement, clinical governance, and benchmarking; look at how to find relevant evidence, carry out your own clinical audit or significant event audit and thus improve patient care for all exotics in your practice. The course is broken down into 10 sections and will work through things through videos, presentations and online discussions with your tutor and peers. Course materials will be available online for 4 weeks, but you can work through things at your pace within this time. CPD Certificates will be issued on completion for 10 hours CPD.
Book here
About the course tutor: Mary Fraser is a vet, dermatologist and veterinary nursing educator with almost 30 years’ experience. She has worked in veterinary nursing education, academia and practice and is an Associate Lecturer at Glasgow University, focussing on Evidence Based Practice for Veterinary Nurses and is an Associate Editor of Veterinary Evidence.
In 2000 she completed a PhD in canine atopic dermatitis, focussing on clinical research, and more recently completed a MRes on Clinical Decision Making in Veterinary Practice. She is one half of Girling & Fraser Ltd., who set up and deliver the Advanced Programme in Veterinary Nursing of Exotics – a programme of study that has been supporting veterinary nurses around the world to deliver high quality care for exotic species, for over 20 years. She was co-author of the text book Rabbit Medicine & Surgery for Veterinary Nurses. Currently she also works with human doctors overseeing education and assessment of physicians and promoting a one health approach.
If you would like to find out more about how to carry out your own quality improvement studies in practice, with a particular focus on exotics, then sign up to our 4 week online course. The programme of study will cover the theory behind quality improvement, clinical governance, and benchmarking; look at how to find relevant evidence, carry out your own clinical audit or significant event audit and thus improve patient care for all exotics in your practice. The course is broken down into 10 sections and will work through things through videos, presentations and online discussions with your tutor and peers. Course materials will be available online for 4 weeks, but you can work through things at your pace within this time. CPD Certificates will be issued on completion for 10 hours CPD.
Book here
About the course tutor: Mary Fraser is a vet, dermatologist and veterinary nursing educator with almost 30 years’ experience. She has worked in veterinary nursing education, academia and practice and is an Associate Lecturer at Glasgow University, focussing on Evidence Based Practice for Veterinary Nurses and is an Associate Editor of Veterinary Evidence.
In 2000 she completed a PhD in canine atopic dermatitis, focussing on clinical research, and more recently completed a MRes on Clinical Decision Making in Veterinary Practice. She is one half of Girling & Fraser Ltd., who set up and deliver the Advanced Programme in Veterinary Nursing of Exotics – a programme of study that has been supporting veterinary nurses around the world to deliver high quality care for exotic species, for over 20 years. She was co-author of the text book Rabbit Medicine & Surgery for Veterinary Nurses. Currently she also works with human doctors overseeing education and assessment of physicians and promoting a one health approach.
