Cochrane Review: Adjusting the pH of lidocaine for reducing pain on injection
Authors: Cepeda M Soledad , Tzortzopoulou Aikaterini , Thackrey Michael , Hudcova Jana , Arora Gandhi Preeti , Schumann Roman 
Published: January 2012

Background

Lidocaine administration produces pain due to its acidic pH.

Objectives

The objective of this review was to determine if adjusting the pH of lidocaine had any effect on pain resulting from non‐intravascular injections in adults and children. We tested the hypothesis that adjusting the pH of lidocaine solution to a level closer to the physiologic pH reduces this pain.

Search methods

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, to June 2010); Ovid MEDLINE (1966 to June 2010); EMBASE (1988 to June 2010); LILACS (1982 to June 2010); CINAHL (1982 to June 2010); ISI Web of Science (1999 to June 2010); and abstracts of the meetings of the American Society of Anesthesiologists (ASA). We checked the full articles of selected titles. We did not apply any language restrictions.

Selection criteria

We included double‐blinded, randomized controlled trials that compared pH‐adjusted lidocaine with unadjusted lidocaine. We evaluated pain at the injection site, satisfaction and adverse events. We excluded studies in healthy volunteers.

Data collection and analysis

We separately analysed parallel‐group and crossover trials; trials that evaluated lidocaine with or without epinephrine; and trials with pH‐adjusted lidocaine solutions < 7.35 and ≥ 7.35. To explain heterogeneity, we separately analysed studies with a low and higher risk of bias due to the level of allocation concealment; studies that employed a low and a higher volume of injection; and studies that used lidocaine for different types of procedures.

Main results

We included 23 studies of which 10 had a parallel design and 13 were crossover studies. Eight of the 23 studies had moderate to high risk of bias due to the level of allocation concealment.

Pain associated with the infiltration of buffered lidocaine was less than the pain associated with infiltration of unbuffered lidocaine in both parallel and crossover trials. In the crossover studies, the difference was ‐1.98 units (95% confidence interval (CI) ‐2.62 to ‐1.34) and in the parallel‐group studies it was ‐0.98 units (95% CI ‐1.49 to ‐0.47) on a 0 to 10 scale. The magnitude of the pain decrease associated with buffered lidocaine was larger when the solution contained epinephrine. The risk of bias, volume of injection, and type of procedure failed to explain the heterogeneity of the results.

Patients preferred buffered lidocaine (odds ratio 3.01, 95% CI 2.19 to 4.15). No adverse events or toxicity were reported.

Authors' conclusions

Increasing the pH of lidocaine decreased pain on injection and augmented patient comfort and satisfaction.

Plain Language Summary

Adjusting the pH of lidocaine solution for reducing pain on injection

Lidocaine is frequently used to anaesthetize the skin prior to invasive procedures. Its administration produces pain that is thought to be due to the acidic pH of commercial preparations (pH levels between 3.5 and 7.0 compared with the physiologic pH which is between 7.35 and 7.45). The objective of this review was to determine the effect of increasing the pH of a commercial lidocaine preparation on pain associated with its injection in adults and children. We included 23 studies with 1067 participants in the meta‐analysis. Increasing the pH of lidocaine reduced pain and improved patients' comfort and satisfaction. No adverse events were reported. Therefore, increasing the pH of commercial lidocaine solutions with bicarbonate immediately prior to their use should be considered.