The Journal of the American Dental Association
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

J Am Dent Assoc, Vol 135, No 9, 1243-1250.
© 2004 American Dental Association
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by MEIT, S. S.
Right arrow Articles by WILLIAMS, D.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by MEIT, S. S.
Right arrow Articles by WILLIAMS, D.

TRENDS

COVER STORY
JADA Continuing Education

Techniques for reducing anesthetic injection pain

An interdisciplinary survey of knowledge and application



SCOTT S. MEIT, Psy.D., VAN YASEK, Ph.D., C. KEN SHANNON, M.D., Ph.D., DAVID HICKMAN, D.D.S. and DORIAN WILLIAMS, M.D.


   ABSTRACT
TOP
 ABSTRACT
METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
Background. The authors conducted a study that considered family physicians’ and dentists’ knowledge and application of techniques to reduce the pain associated with anesthetic injections. They also assessed practitioners’ discomfort with patients’ injection pain and needle anxiety/phobia.

Methods. The authors designed a questionnaire about awareness and use of 10 techniques for reducing pain of anesthetic injection and mailed it to 2,000 randomly selected family physicians and general dentists. They analyzed the data to examine differences between disciplines regarding awareness and use of techniques, reasons for not using techniques, number of injections given per week, and predictive value of certain demographic variables on reported use of individual techniques and on practitioner reactions to patients’ pain and anxiety.

Results. The response rate was 35 percent. The authors used the {chi}2 test for differences between disciplines’ awareness of and use or nonuse of techniques, Wilcoxon testing to assess differences between disciplines’ median values of number of weekly injections and logistic regression to study demographic variables’ predictive values (P = .01). General dentists give more injections than do family physicians. Differences existed between disciplines’ awareness and use of eight of 10 techniques. Disciplines reported cost and time issues as reasons for not using some techniques. Number of years in practice and age were associated with use of six techniques. Dentists reported feeling greater personal effects of patients’ pain and needle anxiety/phobia than did family physicians.

Conclusions. Those not using pain-lessening techniques inaccurately identified time and cost as problems, suggesting that respondents may be less familiar with these techniques than otherwise reported. Further study is recommended.

Clinical Implications. Pain reduction techniques for anesthetic injection cost little to implement, are not time liabilities, and can lessen avoidable pain and reduce the incidence of needle phobia.

While physicians pledge to "do no harm," the history of medical practice retains a legacy of inflicting pain in the name of healing. Even into the early 1900s, American medicine conceptualized "spinal irritation" as the root of a great many ailments for which application of the cautery iron was standard treatment.1 To be fair, it can be argued that dentistry has acquired an even more infamous reputation for inflicting pain in providing care to patients. The literature regarding needle/blood-injury phobia clearly identifies a particularly unenviable provider-patient challenge for dentistry.2–6 Moreover, it is recognized that procedure-pain associations form quickly, generate avoidance . behavior (which is not easily extinguished) and contribute toward morbidity.3–5,7–11 Perhaps compelled by patient demand, the field of dentistry has made great strides toward alleviating procedure-related pain. Nowhere is this more evident than in the administration of local anesthetic injections.

Pain reduction techniques for anesthetic injection cost little to implement and are not time liabilities.

The administration of local anesthetic (whether to facilitate a dental restorative procedure, removal of a skin tag, biopsy or suturing), though routine, represents a cogent example of procedure-related pain in the ambulatory setting. More than 30 years ago, a British dentist, Dr. R. Boggia, first described the technique of warming anesthetic preparations as a means of decreasing the pain of injection.12 The warming of lidocaine to 37 C, or slightly beyond, as a means of effectively reducing injection pain has been replicated in numerous well-controlled studies.12–23 Warming has not been found to affect the anesthetic action or duration of effect adversely.15

Apart from warming techniques, buffering techniques also have been shown to be highly effective in reducing the pain of anesthetic injection.24–40 Intuitively, this makes sense, as the addition of sodium bicarbonate (a chemically basic substance) neutralizes the acidic preparation standard to lidocaine. A more scientific explanation holds that buffered lidocaine has a higher pH and is nonionized, thus facilitating dispersal through tissue and decreasing pain.21,41 A 1:9 bicarbonate:lidocaine ratio is recommended to accomplish the preparation.42 Finally, an apparent synergy of buffering and warming also has been demonstrated.43–45 The only drawback with buffering is that it returns lidocaine preparation to a relatively unstable form, reducing its shelf life substantially, from the typical three to four years41 to about one week, perhaps two or more if refrigerated.26,32,42,46 It has been observed, however, that studies noting week-to-week reductions in lidocaine concentration may not be clinically relevant.14,47 Indeed, the clinical efficacy of buffered lidocaine stored at room temperature for two months has been documented.47

To date, the medical literature advocating anesthetic warming and/or buffering techniques has resided almost exclusively with the medical subspecialties.

To date, the medical literature advocating warming and/or buffering techniques has resided almost exclusively with the medical subspecialties.13,15–19,21–24,37,31–36,38–40,43,48–63 Despite the fairly extensive literature documenting these techniques and their efficacy, it was not until 1998 that two scholarly pieces advocating buffering and warming techniques first appeared in the primary care medical literature.14,64 Since that time, an additional review of these techniques has appeared in a primary care nursing journal.42 The slow progression of technique from dentistry to medical specialties to primary care raises many issues, including those of training and differing evolutions of the health care arts (particularly as related to the perception of pain).

We undertook the study described here with the intent to

– investigate the extent to which buffering, warming and a variety of other injection pain–reducing techniques (such as distraction and pinching) have penetrated the knowledge base of family medicine as compared with that of general dentistry;
– assess the degree to which such techniques are practiced across these two health care disciplines;
– assess the effect on the health care provider of any pain and anxiety the patient feels.


   METHODS
TOP
 ABSTRACT
 METHODS
RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
In May 1998, we conducted a pilot survey among three primary care medical departments and one general dentistry department at the Robert C. Byrd Health Sciences Center at West Virginia University’s Morgantown campus. We designed the survey to elicit information on knowledge and use of various techniques for lessening the pain of anesthetic injection. We asked practitioners to provide information on their awareness of and use of 10 pain-lessening techniques: pH buffering of anesthetic solution; heating of anesthetic solution; pinching or applying pressure; controlling the speed of injection; use of appropriate needle gauge; use of vapocoolants; use of relaxation techniques; use of topical anesthetic; use of an aspirating syringe; and explanation of the procedure. In addition, we sought information regarding reason(s) for not using known techniques, preferred technique combinations, number of injections administered per week, the practitioner’s discomfort associated with being an agent of procedure-related pain, and the degree of difficulty experienced in dealing with patients who have needle anxiety/phobia. We collected demographic information on sex, years in practice and age category (≤ 30, 31–35, 36–40, 41–45, 46–50, 51–55, 56–60 and ≥ 61 years). For purposes of statistical analyses, we converted the age category data to single-number indexes (30, 33, 38, 43, 48, 53, 58 and 65).

After completing the pilot study, we revised the questionnaire and eliminated questions that we perceived to be unnecessary, corrected ambiguities and added questions where necessary. In July 1999, we mailed the revised questionnaire to 1,000 general dentists and 1,000 family physicians across the United States. Recipients were randomly selected from mailing lists obtained from the American Dental Association and the American Academy of Family Physicians. Responses were collected until September 1999.

Data analyses involved {chi}2 for differences between disciplines regarding awareness of and use of various techniques, and for reasons for not using techniques. We performed a Wilcoxon rank sum test to assess for differences between disciplines in median values of number of injections given per week. Using logistic regression, we studied the predictive value of demographic variables on reported use of individual techniques and on practitioners’ reactions to patients’ pain and anxiety. The level of significance for all statistical testing was .01.


   RESULTS
TOP
 ABSTRACT
 METHODS
 RESULTS
DISCUSSION
 CONCLUSION
 REFERENCES
 
The cross-sectional survey of family medicine physicians and dentists resulted in return of 699 questionnaires, for a response rate of 35 percent. Eighteen of these questionnaires had unacceptable or missing entries for proper identification of discipline and were not included in the data analyses. The remaining questionnaires were those received from 349 physicians and 332 dentists.

The number of injections administered per week varied significantly between the disciplines, with family practitioners reporting a median category of six to 20 injections and dentists reporting 21 to 50 (P < .001). Table 1Go shows comparisons by discipline of family physicians and dentists of reported awareness and use of 10 techniques for modification of the pain associated with the administration of local anesthetic by injection.


View this table:
[in this window]
[in a new window]
  		TABLE 1 FAMILY PHYSICIANS’ AND DENTISTS’ AWARENESS AND USE OF LOCAL ANESTHETIC INJECTION TECHNIQUES, BY DISCIPLINE.

 
Physicians were more likely to report awareness of pH buffering of anesthetic solution and of vapocoolant use, while dentists were more likely to report awareness of anesthetic solution warming, pinching or pressure application, controlled speed of injection, relaxation techniques, use of topical anesthetics and aspiration techniques. Physicians were more likely to report use of pH buffering, vapocoolants and procedural explanation, while dentists were more likely to report use of warming, pinching or pressure application, controlling the speed of injection, relaxation techniques, topical anesthetics and aspiration.

Figure 1Go shows a comparison of the proportions of family physicians and dentists reporting use and awareness of each technique. The reported use and awareness was significantly greater among physicians for pH buffering and use of vapocoolants, while it was higher among dentists for warming, pressure application, relaxation techniques, use of topical anesthetics and aspiration techniques.



View larger version (30K):
[in this window]
[in a new window]
  		Figure 1. Use/awareness of local anesthetic injection techniques, by discipline (percentage). FP: Family physician.

 
As shown in Figure 2Go, for those reporting not having used a technique on the basis of the time involved, we performed a comparison by discipline for eight relevant techniques. For those reporting not using a technique on the basis of cost concerns, we did a comparison by discipline for four relevant techniques (also shown in Figure 2Go).



View larger version (29K):
[in this window]
[in a new window]
  		Figure 2. Reported nonuse of techniques due to time requirements and costs by discipline (percentage). FP: Family physician.

 
There was a trend toward more concern regarding time requirements and costs of these techniques among the family practitioners. Family practitioners reported significantly (P < .01) more concern regarding time requirements for pH buffering, vapocoolant use, relaxation techniques and topical anesthetic use. Family practitioners reported more concern regarding costs of vapocoolants, topical anesthetic and aspiration, while dentists reported more concern regarding costs of warming.

We used nominal logistic regression to study associations, in univariate models and across disciplines, of the independent predictive value of the demographic variables of provider sex, age and number of years in practice on the reported use of techniques (Table 2Go). At the .01 level of significance, the likelihood of use of heat, pinching or pressure, topical anesthetics or an aspirating syringe increased with the number of years in practice. Likelihood of use of aspiration also increased with age. Likelihood of use of pH buffering or vapocoolant decreased with the number of years in practice. Likelihood of use of vapocoolant also decreased with age. Use of appropriate needle gauge, relaxation techniques, controlled injection speed or procedure explanation were not significantly correlated with any of the demographic variables entered.


View this table:
[in this window]
[in a new window]
  		TABLE 2 DEMOGRAPHIC PREDICTORS FOR USE OF INJECTION TECHNIQUES: LOGISTIC REGRESSION RESULTS.

 
In a separate analysis, we used ordinal logistic regression to study the predictive value of several demographic factors—age, number of years in practice, sex and discipline—for the dependent variables of reported effect of the patient’s injection pain on the provider and of the reported difficulty of dealing with the patient’s needle anxiety/phobia (Table 3Go). Only discipline was a significant predictor at the .01 level of significance, with dentists more likely to report feeling greater effects of both patients’ injection pain and difficulty in dealing with patients’ needle anxiety/ phobia.


View this table:
[in this window]
[in a new window]
  		TABLE 3 DEMOGRAPHIC PREDICTORS FOR EFFECTS ON PROVIDER OF PATIENTS’ RESPONSES TO PAIN AND DIFFICULTY IN DEALING WITH NEEDLE ANXIETY/PHOBIA: LOGISTIC REGRESSION RESULTS.

 

   DISCUSSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
CONCLUSION
 REFERENCES
 
Our findings indicate that the responding dentists administered significantly more injections than did the responding family physicians. They also reported higher overall use of pain-reducing techniques than did the family physicians. Indeed, while a physician generally is credited with being the first to use ether as an anesthetic, a dentist performed the first teaching demonstration of the technique.65,66 Dentistry quickly embraced the practice of anesthesia, preceding medicine’s recognition of anesthesiology as a "respectable" discipline by nearly 100 years.66

Clearly, most dental procedures require the use of local anesthetic, while many patient visits to physicians do not. The oral cavity is richly endowed with nociceptive neurons and is psychologically important in that it is associated strongly with sensory gratification and physical attractiveness.67 The head also is culturally important as the perceived "seat of personality." Procedures occurring in this area of the body, then, arouse a strong sense of vulnerability in the patient. Thus, patients are more likely to judge dentists on the basis of pain avoidance, while they may judge physicians on other criteria such as attentiveness and allocating sufficient time for patient visits. The effective control of pain and allaying of psychological vulnerability or fear thus have become compulsory to the effective practice of dentistry, though it perhaps is not of equal status in the practice of medicine, as demonstrated by the predictive value of discipline on level of effect on the practitioner of patients’ pain and needle anxiety/phobia. The historical era of training for both disciplines may be important in practitioners’ selection of techniques, since the likelihoods of use of six techniques were predicted by the number of years in practice and two were predicted by age.

Comparison of the two disciplines’ use of the two techniques of primary interest, heating the anesthetic solution and pH adjustment or buffering, is notable. More family physicians reported awareness and use of pH buffering, while dentists—almost all of them—were aware of and more likely to report use of warming techniques. Among family physicians’ reasons for not using warming, the most frequently reported was time. In reality, there is little involved in arranging for a set amount of lidocaine to be kept warm in a bath appliance. Likewise, a predetermined amount of pH-adjusted lidocaine can be prepared in advance. The fear of losing clinic time by using such a technique, then, perhaps is exaggerated.

Both family physicians and dentists reported not using these two techniques because of perceived cost. Heating anesthetic preparations, however, can be accomplished with a hemostat-regulated "bath," which ranges in price from $100 to a few hundred dollars. Adjusting pH also can be accomplished at negligible cost, as is indicated throughout much of the literature on the subject. Furthermore, the adjusted solution will remain stable for at least one week, with clinical efficacy demonstrated for as long as two months.47 If waste of solution remains a concern, clinicians can adjust the pH balance of a lidocaine solution, within the syringe, at the time of injection. Among dentists, however, an alternative disincentive could rest simply with the apparatus. Dentists generally use rubber-stopped glass carpules that are ready for injection (in contrast with physicians, who draw anesthetic solutions into the syringe from a larger bottle). While the study questionnaire included an "other" category among reasons for nonuse, this specific issue of practicality (that is, injection apparatus) was not differentiated.

Regarding the use of vapocoolants and topical anesthetic, the kinds of procedures performed and physical site of administration likely explain the differences between the disciplines in awareness and use. While family physicians usually perform procedures on intact skin, dentists are much more likely to perform procedures on mucous membranes, which are more amenable to topical anesthetics because such tissues have a faster rate of absorption. Vapocoolants are more difficult to deliver and control intraorally than are topical anesthetics. Therefore, the higher use of topical anesthetic and lower use of vapocoolants that we found among responding dentists would be expected.

The techniques of applying pressure, controlling the speed of the injection, using an appropriate needle gauge and using an aspirating syringe were considered and used more extensively by the dentists. Physicians were more likely to report not using these techniques (as well as relaxation techniques and topical anesthetics) owing to time constraints. In addition to time constraints, physicians also reported that cost was an issue in not using topical anesthetics.

It is curious that while both disciplines professed knowledge of warming and pH adjustment techniques, respondents were in large part unaware of the ease and low cost of adopting these techniques. The relatively high awareness and use of controlling the speed of injection, use of appropriate needle gauge, relaxation techniques and procedural explanation among members of both disciplines, however, is reassuring.

Admittedly, a 35 percent survey return rate necessarily limits the generalizability of our findings. Nevertheless, it is notable that responding practitioners of both disciplines reported a high awareness of a variety of pain-reducing techniques. The focal techniques examined in this study (pH adjustment and warming), however, appear to be used to a lesser degree than might otherwise have been predicted given the extensive literature noting their efficacy.


   CONCLUSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
REFERENCES
 
The dentists in our study did report a greater degree of concern about (and discomfort with) patients’ pain and anxiety than did the physicians. In the case of dentists, the use of topical anesthetic before injection followed by a slow injection with a small-gauge needle may be sufficient to eliminate the need to use additional techniques (such as warming or pH adjustment). Of greater concern is the finding across disciplines that not using heating and pH adjustment or buffering is tied to perceptions of time and financial expenditure. Further study is needed, across health disciplines, to examine formal education regarding procedure-related pain and amelioration of such discomfort. It also may be useful to scrutinize the less formal messages health practitioners receive regarding perceived importance of controlling patient pain, both within their professions and as generated by consumer expectation.


   FOOTNOTES
 

Dr. Meit is an associate professor and the director, Behavioral Science Education, Department of Family Medicine, West Virginia University School of Medicine, Health Sciences Center, P.O. Box 9152, Morgantown, W.Va. 26506, e-mail "meits{at}rcbhsc.wvu.edu". Address reprint requests to Dr. Meit.


When this article was written, Dr. Yasek was a research assistant professor, Department of Family Medicine, West Virginia University School of Medicine, Morgantown. He now is the research education network coordinator, Department of Family Medicine, University of Wisconsin, Madison.


Dr. Shannon is an associate professor and the research director, West Virginia University School of Medicine, Morgantown.


Dr. Hickman is a professor, West Virginia University School of Dentistry, Morgantown.


Dr. Williams is an associate professor and the predoctoral director, Department of Family Medicine, West Virginia University School of Medicine, Morgantown.


Selected findings and concepts central to this article have been presented at the Association for Behavioral Sciences and Medical Education Conference, Santa Fe, N.M., October 2000; the National Association of Primary Care Research Group Conference, Amelia Island, Fla., November 2000; and the Hawaii International Conference on Social Sciences, Honolulu, June 2002.


The authors thank Jeannie Sperry, Ph.D., and Jeffrey Goodie, Ph.D., who provided early input regarding research questions and instrument design, and Michael Mazzacco, D.M.D., Ph.D., who contributed substantially to the initial data analysis.


   REFERENCES
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 

  1. Shorter E. From paralysis to fatigue: A history of psychosomatic illness in the modern era. New York: The Free Press; 1992.

  2. Glassman P, Peltier B. Guidelines for the administration of local anesthesia in fearful dental patients. J Calif Dent Assoc 1995;23(9): 23–6.[Medline]

  3. Marks I. Blood-injury phobia: a review. Am J Psychiatry 1988;145: 1207–13.[Abstract/Free Full Text]

  4. Ost LG. Acquisition of blood and injection phobia and anxiety response patterns in clinical patients. Behav Res Ther 1991;29:323–32.[Medline]

  5. Grassick P. The fear behind the fear: a case study of apparent simple injection phobia. J Behav Ther Exp Psychiatry 1990;21:281–7.[Medline]

  6. Taylor CB, Ferguson JM, Wermuth BM. Simple techniques to treat medical phobias. Postgrad Med J 1977;53(615):28–32.[Abstract/Free Full Text]

  7. De Jongh A, Bongaarts G, Vermeule I, Visser K, De Vos P, Makkes P. Blood-injury-injection phobia and dental phobia. Behav Res Ther 1998;36:971–82.[Medline]

  8. Hamilton JG. Needle phobia: a neglected diagnosis. J Fam Pract 1995;4(2)1:169–75.

  9. Ost LG, Fellenius J, Sterner U. Applied tension, exposure in vivo, and tension-only in the treatment of blood phobia. Behav Res Ther 1991;29:561–74.[Medline]

  10. Camner L. Treatment of a dental patient with injection phobia. Quintessence Int 1983;14:759–60.[Medline]

  11. Bernstein DA, Kleinknecht RA. Multiple approaches to the reduction of dental fear. J Behav Ther Exp Psychiatry 1982;13:287–92.[Medline]

  12. Boggia R. Heating local anaesthetic cartridges (letter). Br Dent J 1967;122:287.

  13. Courtney DJ, Agrawal S, Revington PJ. Local anaesthesia: to warm or alter the pH? A survey of current practice. J R Coll Surg Edinb 1999;44(3):167–71.[Medline]

  14. Whealton EG. Advances in office anesthesia. J Am Board Fam Pract 1998;11:200–6.[Medline]

  15. Ursell PG, Spalton DJ. The effect of solution temperature on the pain of peribulbar anesthesia. Ophthalmology 1996;103:839–41.[Medline]

  16. Bell RW, Butt ZA. Warming lignocaine reduces the pain of injection during peribulbar local anaesthesia for cataract surgery. Br J Ophthalmol 1995;79:1015–7.[Abstract/Free Full Text]

  17. Brogan GX Jr, Giarrusso E, Hollander JE, Cassara G, Maranga MC, Thode HC. Comparison of plain, warmed, and buffered lidocaine for anesthesia of traumatic wounds. Ann Emerg Med 1995;26(2):121–5.[Medline]

  18. Waldbillig DK, Quinn JV, Stiell IG, Wells GA. Randomized double-blind controlled trial comparing room-temperature and heated lidocaine for digital nerve block. Ann Emerg Med 1995;26:677–81.[Medline]

  19. Alonso PE, Perula LA, Rioja LF. Pain-temperature relation in the application of local anaesthesia. Br J Plast Surg 1993;46(1):76–8.[Medline]

  20. Davidson JA, Boom SJ. Warming lignocaine to reduce pain associated with injection. BMJ 1992;305:617–8.[Abstract/Free Full Text]

  21. Bainbridge LC. Comparison of room temperature and body temperature local anaesthetic solutions. Br J Plast Surg 1991;44(2):147–8.[Medline]

  22. Cragg AH, Berbaum K, Smith TP. A prospective blinded trial of warm and cold lidocaine for intradermal injection. AJR Am J Roentgenol 1988;150:1183–4.[Free Full Text]

  23. Bloom LH, Scheie HG, Yanoff M. The warming of local anesthetic agents to decrease discomfort. Ophthalmic Surg 1984;15:603.[Medline]

  24. Armel HE, Horowitz M. Alkalinization of local anesthesia with sodium bicarbonate: preferred method of local anesthesia. Urology 1994;43(1):101.[Medline]

  25. Bancroft JW, Benenati JF, Becker GJ, Katzen BT, Zemel G. Neutralized lidocaine: use in pain reduction in local anesthesia (published erratum appears in J Vasc Interv Radiol 1992;3[2]:394). J Vasc Interv Radiol 1992;3(1):107–9.[Medline]

  26. Bartfield JM, Homer PJ, Ford DT, Sternklar P. Buffered lidocaine as a local anesthetic: an investigation of shelf life. Ann Emerg Med 1992;21(1):16–9.[Medline]

  27. Bartfield JM, Ford DT, Homer PJ. Buffered versus plain lidocaine for digital nerve blocks. Ann Emerg Med 1993;22:216–9.[Medline]

  28. Bartfield JM, Lee FS, Raccio-Robak N, Salluzzo RF, Asher SL. Topical tetracaine attenuates the pain of infiltration of buffered lidocaine. Acad Emerg Med 1996;3:1001–5.[Medline]

  29. Cohen EN, Levine DA, Colliss JE, Gunther RE. The role of pH in the development of tachyphylaxis to local anesthetic agents. Anesthesiology 1968;29:994–1001.[Medline]

  30. DiFazio CA, Carron H, Grosslight KR, Moscicki JC, Bolding WR, Johns RA. Comparison of pH-adjusted lidocaine solutions for epidural anesthesia. Anesth Analg 1986;65:760–4.[Abstract/Free Full Text]

  31. Eccarius SG, Gordon ME, Parelman JJ. Bicarbonate-buffered lidocaine-epinephrine-hyaluronidase for eyelid anesthesia. Ophthalmology 1990;97:1499–501.[Medline]

  32. Farrell HA, Waldman SR, Campbell JP, Jones RO. Duration of buffered lidocaine versus unbuffered lidocaine: a double-blind, randomized prospective study. Ear Nose Throat J 1995;74:416–8.[Medline]

  33. Hinshaw KD, Fiscella R, Sugar J. Preparation of pH-adjusted local anesthetics. Ophthalmic Surg 1995;26(3):194–9.[Medline]

  34. Martin AJ. pH-adjustment and discomfort caused by the intra-dermal injection of lignocaine (published erratum appears in Anaesthesia 1991;46:242). Anaesthesia 1990;45:975–8.[Medline]

  35. Newton CW, Mulnix N, Baer L, Bovee T. Plain and buffered lidocaine for neonatal circumcision. Obstet Gynecol 1999;93:350–2.[Medline]

  36. Parham SM, Pasieka JL. Effect of pH modification by bicarbonate on pain after subcutaneous lidocaine injection. Can J Surg 1996;39(1): 31–5.[Medline]

  37. Sarvela PJ, Paloheimo MP, Nikki PH. Comparison of pH-adjusted bupivacaine 0.75% and a mixture of bupivacaine 0.75% and lidocaine 2%, both with hyaluronidase, in day-case cataract surgery under regional anesthesia. Anesth Analg 1994;79(1):35–9.[Abstract/Free Full Text]

  38. Steinbrook RA, Hughes N, Fanciullo G, Manzi D, Ferrante FM. Effects of alkalinization of lidocaine on the pain of skin infiltration and intravenous catheterization. J Clin Anesth 1993;5:456–8.[Medline]

  39. Stewart JH, Chinn SE, Cole GW, Klein JA. Neutralized lidocaine with epinephrine for local anesthesia—II. J Dermatol Surg Oncol 1990;16:842–5.[Medline]

  40. Richtsmeier AJ, Hatcher JW. Buffered lidocaine for skin infiltration prior to hemodialysis. J Pain Symptom Manage 1995;10(3):198–203.[Medline]

  41. Christoph RA, Buchanan L, Begalla K, Schwartz S. Pain reduction in local anesthetic administration through pH buffering. Ann Emerg Med 1988;17(2):117–20.[Medline]

  42. Miller D. Taking the sting out of local anesthesia. Patient Care for the Nurse Practitioner March 2000: 49–57.

  43. Jones JS, Plzak C, Wynn BN, Martin S. Effect of temperature and pH adjustment of bupivacaine for intradermal anesthesia. Am J Emerg Med 1998;16(2):117–20.[Medline]

  44. Colaric KB, Overton DT, Moore K. Pain reduction in lidocaine administration through buffering and warming. Am J Emerg Med 1998;16:353–6.[Medline]

  45. Mader TJ, Playe SJ, Garb JL. Reducing the pain of local anesthetic infiltration: warming and buffering have a synergistic effect. Ann Emerg Med 1994;23:550–4.[Medline]

  46. Larson PO, Ragi G, Swandby M, Darcey B, Polzin G, Carey P. Stability of buffered lidocaine and epinephrine used for local anesthesia. J Dermatol Surg Oncol 1991;17:411–4.[Medline]

  47. Li J, Brainard D. Premixed buffered lidocaine retains efficacy after prolonged room temperature storage. Am J Emerg Med 2000; 18:235–6.[Medline]

  48. Ong EL, Lim NL, Koay CK. Towards a pain-free venepuncture. Anaesthesia 2000;55:260–87.[Medline]

  49. Yuen VH, Dolman PJ. Comparison of three modified lidocaine solutions for use in eyelid anesthesia. Ophthal Plast Reconstr Surg 1999;15(2):143–7.[Medline]

  50. Martin RG, Miller JD, Cox CC 3rd, Ferrel SC, Raanan MG. Safety and efficacy of intracameral injections of unpreserved lidocaine to reduce intraocular sensation. J Cataract Refract Surg 1998;24:961–3.[Medline]

  51. Palmon SC, Lloyd AT, Kirsch JR. The effect of needle gauge and lidocaine pH on pain during intradermal injection. Anesth Analg 1998;86:379–81.[Abstract]

  52. Krause M, Weindler J, Ruprecht KW. Does warming of anesthetic solutions improve analgesia and akinesia in retrobulbar anesthesia? Ophthalmology 1997;104:429–32.[Medline]

  53. Zehetmayer M, Rainer G, Turnheim K, Skorpik C, Menapace R. Topical anesthesia with pH-adjusted versus standard lidocaine 4% for clear corneal cataract surgery. J Cataract Refract Surg 1997;23:1390–3.[Medline]

  54. Lugo-Janer G, Padial M, Sanchez JL. Less painful alternatives for local anesthesia. J Dermatol Surg Oncol 1993;19:237–40.[Medline]

  55. Orlinsky M, Hudson C, Chan L, Deslauriers R. Pain comparison of unbuffered versus buffered lidocaine in local wound infiltration. J Emerg Med 1992;10:411–5.[Medline]

  56. Long CC, Motley RJ, Holt PJ. Taking the ‘sting’ out of local anaesthetics. Br J Dermatol 1991;125:452–5.[Medline]

  57. Harrison PV, Merckel J. Does lignocaine temperature alter pain perception during cutaneous local anaesthesia? (letter). Clin Exp Dermatol 1991;16:312.[Medline]

  58. Sapin P, Petrozzi R, Dehmer GJ. Reduction in injection pain using buffered lidocaine as a local anesthetic before cardiac catheterization. Cathet Cardiovasc Diagn 1991;23(2):100–2.[Medline]

  59. Dalton AM, Sharma A, Redwood M, Wadsworth J, Touquet R. Does the warming of local anaesthetic reduce the pain of its injection? Arch Emerg Med 1989;6:247–50.[Medline]

  60. Finkel LI, Berg DJ. Heating lidocaine appears to prevent painful injection (letter). AJR Am J Roentgenol 1987;148:651.[Medline]

  61. Kaplan PA, Lieberman RP, Vonk BM. Does heating lidocaine decrease the pain of injection? (letter). AJR Am J Roentgenol 1987;149:1291.[Medline]

  62. Arndt KA, Burton C, Noe JM. Minimizing the pain of local anesthesia. Plast Reconstr Surg 1983;72:676–9.[Medline]

  63. Oikarinen VJ, Ylipaavalniemi P, Evers H. Pain and temperature sensations related to local analgesia. Int J Oral Surg 1975;4(4):151–6.[Medline]

  64. Woodfin CB. Warming bupivacaine for intradermal anesthesia. J Fam Pract 1998;46:457.[Medline]

  65. Long CW. History of doctors’ day. Southern Medical Association Auxiliary. Available at: "www.sma.org/auxiliary/doctorsday/crawfordwlongmd.cfm". Accessed July 19, 2004.

  66. Waisel DB. The role of World War II and the European theater of operations in the development of anesthesiology as a physician specialty in the USA. Anesthesiology 2001;94(5):907–14.[Medline]

  67. Yagiela JA. Anesthesia and pain management. Emerg Med Clin North Am 2000;18:449–70.[Medline]





This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by MEIT, S. S.
Right arrow Articles by WILLIAMS, D.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by MEIT, S. S.
Right arrow Articles by WILLIAMS, D.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS