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venous cannulation is the most common invasive procedures in several patients in hospital , including anesthesiologists daily .
it leads to unwanted effects like pain , especially among patients who fear of needles .
fear of needles and pain associated with vein puncture is a common phobia in the general population .
fear of pain and anxiety associated with venous cannulation may contribute to the overall stress experienced by patients in the preoperative setting .
there is a lack of cooperation , low rate of the successful procedure attempts , repeated attempts , additional pain , and a prolonged total procedure time .
injection - injury consequently leads to avoidance among patients from medical care and blood donating or precipitating fainting episodes .
in addition , patients are often more satisfied with their doctors when they are treated by methods having minimal or no pain .
considering premedication relieves the anxiety and fear associated with pain as well as the pain itself . choosing the more effective analgesia
the effect of various pharmacological and nonpharmacological measures has been explored in several studies in order to minimize venous cannulation pain . however , there are a few cost - effective , simple and effective methods associated with pain reduction during venous cannulation .
these methods commonly comprised local skin infiltration , topical application of eutectic mixture of local anesthetics ( emla ) or nonsteroid anti - inflammatory drugs ( nsaids ) , topical alkaline vapocoolant spray , ibuprofen , etc .
injections in general and especially the placement of intravenous cannula are often the cause of pain and anxiety for many patients
. however , there is no  gold standard  and there is a need for the development of innovative analgesic methods that are simple to use , painless , effective with a minimal delay , without adverse effects , and cost - effective .
thus , clinical practice has recently interested to incorporate various techniques for decreasing the discomfort and pain of procedures involving routine needle punctures , such as vein puncture , intravenous catheter placement , and lumbar puncture .
emla , a local anesthetic cream composed of a eutectic mixture of lidocaine and prilocaine provides .
hence , a topical formulation may offer substantial benefits for prevention of needle and procedural pain .
a eutectic mixture of lidocaine and prilocaine ( emla ) is the first commercially developed topical transdermal anesthetic agent that provides adequate effective analgesic properties .
therefore , we aimed to compare the effect of elma cream and diclofenac gel in pain reduction in patients undergoing caesarian section surgery .
this controlled , randomized clinical trial study has assessed the effect of diclofenac gel , emla and placebo on vein puncture pain .
this study approved by the ethical committee of islamic azad university of tehran . the registration i d of study is registration i d in irct irct201008234618n1 .
ninety women aged 18 - 40 years old who were referred to imam ali hospital for elective cesarean section during 2010 , were selected randomly through random scheduling .
exclusion criteria include addiction to opium or analgesics , mental , visual and verbal inability , use of analgesic in last 24 h , anaphylactic response to nsaid . considering inclusion and exclusion criteria and homogeneity of samples , the researchers selected patients in cesarean section .
patients were allocated into three groups , diclofenac ( n = 30 ) , emla ( n = 30 ) and placebo ( n = 30 ) .
a sample size of 30 patients was calculated considering statistical power of 0.8 ( 1 ) and average effect of d = 0.7 .
the questionnaire includes socio demographic characters , i.e. age and weights were collected and visual analog scale ( vas ) was used to find the pain severity induced by venous puncture .
one hour before puncture , 2 g emla ( compound of 2.5% prilocaine , and 2.5% lidocaine tehran chemistry , iran ) covered the skin ( 2.5 cm  4 cm ) in the second group , diclofenac gel ( 1% ) ( behvasan , rasht ) ( 1.9 cm  3.8 cm ) was covered for patients left hand , and in the third group , placebo ( vaseline , pars hayan , iran ) include liquid and glycerine without lanolin and essence ) was covered on patient 's left hand . after 60 min ointments and gel were cleaned from the hand and side - effects were recorded .
then , venous puncture was done by angiocath number 3 - 5 min after puncture , pain was recorded by vas . the pain level categorization applied according polit and beck manual .
the nurses who assessed the patients were blind to the design of the study . beside descriptive method to calculate mean and standard deviation , we used anova and k to analysis the sample demographic characters .
ninety women aged 18 - 40 years old who were referred to imam ali hospital for elective cesarean section during 2010 , were selected randomly through random scheduling .
exclusion criteria include addiction to opium or analgesics , mental , visual and verbal inability , use of analgesic in last 24 h , anaphylactic response to nsaid . considering inclusion and exclusion criteria and homogeneity of samples , the researchers selected patients in cesarean section .
patients were allocated into three groups , diclofenac ( n = 30 ) , emla ( n = 30 ) and placebo ( n = 30 ) .
a sample size of 30 patients was calculated considering statistical power of 0.8 ( 1 ) and average effect of d = 0.7 .
the questionnaire includes socio demographic characters , i.e. age and weights were collected and visual analog scale ( vas ) was used to find the pain severity induced by venous puncture .
one hour before puncture , 2 g emla ( compound of 2.5% prilocaine , and 2.5% lidocaine tehran chemistry , iran ) covered the skin ( 2.5 cm  4 cm ) in the second group , diclofenac gel ( 1% ) ( behvasan , rasht ) ( 1.9 cm  3.8 cm ) was covered for patients left hand , and in the third group , placebo ( vaseline , pars hayan , iran ) include liquid and glycerine without lanolin and essence ) was covered on patient 's left hand . after 60 min ointments and gel were cleaned from the hand and side - effects were recorded .
then , venous puncture was done by angiocath number 3 - 5 min after puncture , pain was recorded by vas . the pain level categorization applied according polit and beck manual .
beside descriptive method to calculate mean and standard deviation , we used anova and k to analysis the sample demographic characters .
a total of 90 cases allocated in three groups , i.e. diclofenac ( n = 30 ) , emla cream ( n = 30 ) and placebo ( n = 30 ) . because of short term intervention there was no drop - out during interventions .
the findings of the current study showed that there was no significant difference in demographic variables between the three groups at baseline in respect of age , weight and height [ table 1 ] .
in addition , there was no significant difference in education ( p = 0.957 ) and place of residence ( p = 0.861 ) .
demographic data presented either as number of patients or meansd the distribution of pain severity during vein puncture in three groups is shown in table 2 .
our results showed that mild pain was more frequent in the diclofenac group versus two other groups [ figure 1 ] .
the mean and standard deviation of pain severity in the placebo group was 4.66  1.02 , emla group 2.3  0.9 and 1.76  0.91 in diclofenac group .
hence , it is clear that the least pain was observed in diclofenac group and placebo has the most pain severity during vein puncture .
frequency of pain severity induced by vein puncture in 3 groups by visual analog scale in patients undergoing cesarean section effectiveness of diclofenac and emla on pain comparing pain severity induced by vein puncture using in pair groups , we found that the placebo group had significantly more pain severity than diclofenac and emla groups ( p = 0.001 ) .
furthermore , mean of pain severity in diclofenac and emla groups was 1.76 and 2.3 , respectively ( p = 0.006 ) . whitening , redness , urticarial , and itching were the short side - effects of local drugs and were appearing in 1 h after drug prescription .
our results showed that in about 20% of emla ointment whitening was appeared , and 80% of patients , no side - effect was appeared . in two other groups ,
our results showed that there was a significant difference between group in relation with side - effects ( p = 0.0001 ) .
the results of our study showed that 93.33% of patients in diclofenac group and 63.33% in emla group had mild pain and 93.33% of patients in the placebo group had moderate pain during vein puncture .
mean score of pain severity were 4.66 , 2.3 , and 1.76 in the placebo , emla and diclofenac groups , respectively .
there was significant difference between the three groups in pain severity ( p = 0.001 ) .
evaluated pain severity in three group , i.e. sucrose 25% basement cream , emla cream and vaseline .
they reported that there was a significant difference between the three groups ( p = 0.001 ) .
the results comparing vein puncture pain between groups in current study indicated that pain severity in diclofenac group was less than emla group and the difference was significant ( p = 0.006 ) .
also compared the effect of diclofenac patch , emla cream and vaseline patch in pain reduction of 450 patients during vein puncture and indicated that all patients in the control group experienced vein puncture pain , but there was 37% pain reduction in emla group and 48% pain reduction in diclofenac patch ( p < 0.001 ) .
our results also showed that placebo group experience more pain compared with diclofenac and emla group ( p = 0.001 ) .
similar to our findings the results of saxena et al . showed that the mean pain severity in emla group was less than vaseline group ( p < 0.001 ) .
also reported that there is a significant difference in pain reduction between diclofenac patch and placebo patch ( p < 0.005 ) , which is in harmony with our findings of current study .
in last decades , several researches have been conducted aimed to evaluate effectiveness of medicines . however , rare studies exist targeted to examine the effectiveness of topical nonsteroidal anti - inflammatory drugs .
totally , the findings of the current study revealed that pain severity in diclofenac group was lower than placebo and emla cream .
this finding is in harmony with a study done by deshpande et al . , who reported higher effectiveness of diclofenac patch in comparing to emla among adult patients underwent surgery .
in addition , we explored the probable side - effects of drugs ( diclofenac gel , emla and baseline ) which indicated the side - effects , mostly was blanching , redness , urticarial , and pruritus mostly occurred our hour after vein puncture , the most common side - effect was blanching in the emla group which was present in 20% of cases and in 80% of cases there were no side - effects .
showed that blanching is a common side - effect of emla in the hour of use .
according to our findings emla and diclofenac gel reduce vein puncture pain significantly compared with placebo . however , we suggest using diclofenac gel rather than emla because it is more cost - effective and effective in the reduction of pain with less side - effects . hence , we suggest that there should be some policies in health care centers and treatment clinics of our country in a different ward to use diclofenac gel as a choice to vein puncture pain
we did not measure the anxiety level of samples , which is extremely related to pain severity .
the samples selected only from one center . we could not measure the effect of pain severity on birth related outcomes .
aim : this study was aimed to explore the effect of applying diclofenac gel and a eutectic mixture of local anesthetic ( emla ) cream on vein puncture pain severity with vein catheter in the patients undergoing cesarean section.materials and methods : the sample comprised 90 women undergoing elective cesarean section that referred to imam ali hospital 's maternity section in amol city ( northern iran ) . 
 data collection tools included visual analog scale for pain severity and a checklist for short term possible side - effects of diclofenac gel , emla cream and vaseline ointment as placebo.results:the pain of vein puncture with diclofenac gel and emla cream was significantly lower than that with the vaseline ointment ( p = 0.001 ) . 
 similarly , there was a significant difference between using diclofenac gel and emla cream in catheter insertion pain severity ( p = 0.006 ) . 
 in addition , there was no short term possible side - effect with using diclofenac gel and vaseline ointment , but a short term side - effect ( blanching ) was detected in 20% of subjects with emla cream.conclusion:compared to vaseline cream , emla cream and diclofenac gel application significantly reduces the pain severity associated with vein catheter insertion . 
 use of diclofenac gel is preferred compared with emla cream , because of economics , more efficiency purpose , and no side - effects .