Scent from flavored lip balm smeared inside anesthesia or oxygen masks can improve patient tolerance and reduce children’s pre-surgery anxiety without risk of fire hazard

My 8-year-old daughter recently had a tonsillectomy at Rainbow Babies & Children’s Hospital in Cleveland. The perioperative nurse came to her before she was wheeled back to the operating room and asked, “What flavor do you like? Cherry, blueberry, or watermelon?” When my daughter picked cherry, the nurse pulled a tube of lip balm from her pocket, and together, they coated the inside of a pediatric non-rebreather mask and anesthesia bag mask with it. The nurse explained that this way it would “smell good while (she) went to sleep.” My daughter loved it.

There is a body of research that suggests sweet or pleasant odors may improve pain tolerance.^1,2 Perhaps as a result, some pediatric anesthesia teams use flavored lip balms (e.g., cherry ChapStick) to coat the inside of masks that are used to provide anesthesia or to provide oxygen in support of procedural sedation. This seems to improve patient tolerance and reduce anxiety. Offering patients their pick of flavors may also increase their comfort by allowing them a small item of choice during a time when they feel events are beyond their control.

Some pediatric anesthesia teams use flavored lip balms to coat the inside of masks used to provide anesthesia or oxygen in support of procedural sedation.

Given the increasing use of the intranasal route of medication administration in emergency medicine (e.g., intranasal fentanyl 1–2 mg/kg for pain control or intranasal midazolam 0.4 mg/kg for procedural sedation) and the increasing use of emergency department procedural sedation in children often via ketamine (1 mg/kg IV, 4–5 mg/kg IM), whose dissociative effects may be aided by inclusion of pleasant sensations such as sweet smells, emergency physicians should include flavored lip balm in their practice. Consider offering lip balm to any patients who will receive intranasal medications or undergo procedural sedation (especially if using ketamine) or as a distraction and calming technique for children. Ideally, have more than one flavor to offer, as children are easier to calm if they are offered choices that make them participants in their care. Take the lip balm and liberally spread it over the inside surface of a non-rebreather mask. School children can be guided to do this themselves (and they often enjoy decorating the outside of the mask with stickers if you have any available). Allow patients to inhale from the coated mask prior to and immediately following the use of intranasal medications or during initiation and recovery from procedural sedation. Anecdotally, patients and their families are very appreciative of this small comfort we can provide.

If you choose to use this technique, be aware that several health care organizations have erroneously interpreted the National Fire Protection Association’s (NFPA) 1996 edition of the Standard for Health Care Facilities to mean that any petroleum-based product presents a fire hazard in the presence of oxygen.³ Fortunately, the Federal Aviation Administration (FAA) did laboratory testing on this very question in the 1960s. Its report, published by the Civil Aeromedicine Research Institute, found that “a large margin of safety exists in using hydrocarbon face, lip, and hair preparations in the presence of 100 percent oxygen at or below one atmosphere (760 mm Hg).”⁴ The report went on to list the physical properties of commonly used products, including ChapStick, in the presence of 100 percent oxygen. It found that the combustibility of these types of products was comparable to normal skin oils at pressures at or near one atmosphere. The FAA allows pilots using oxygen in flight to wear cosmetics or use lip balm.⁵ It is reasonable to assume that it is safe for our patients as well.

Dr. Mell is clinical assistant professor in the Department of Surgery at the University of Illinois at Urbana. He is the EMS Medical Director for EmCare’s North Division, EMS Assurance, the Newark (OH) Division of Fire, and Ohio Ambulance.

References

1. Prescott J, Wilkie J. Pain tolerance selectively increased by a sweet-smelling odor. Psychol Sci. 2007;18:308-11.
2. Bartolo M, Serrao M, Gamgebeli Z, et al. Modulation of the human nociceptive flexion reflex by pleasant and unpleasant odors. Pain. 2013;154:2054-2059.
3. Winslow E, Jacobson A. Dispelling the petroleum jelly myth. Am J Nurs. 1998;98:16RR.
4. Dille JR, Crane CR. The flammability of lip, face and hair preparations in the presence of 100 percent oxygen. Rep 62-27. Rep Civ Aeromed Res Inst US. 1963;Nov:1-5.
5. Oxygen equipment use in general aviation operations. Federal Aviation Administration Web site. Available at: www.faa.gov/pilots/safety/pilotsafetybrochures/media/Oxygen_Equipment.pdf. Accessed February 7, 2014.