A Randomized, Crossover Comparison of Injected Buffered Lidocaine, Lidocaine Cream, and No Analgesia for Peripheral Intravenous Cannula Insertion

      Study objective

      We compare pain and anxiety associated with peripheral intravenous (IV) cannula insertion after pretreatment with no local anesthesia, 4% lidocaine cream, or subcutaneously injected, buffered 1% lidocaine.


      In a randomized, crossover design, 3 peripheral IVs were inserted in each of 70 medical students or nurses. In random order, insertion sites were pretreated with nothing, lidocaine cream, or injected, buffered lidocaine. After each IV insertion, subjects recorded pain, anxiety, and preference (as patient and provider) for each technique on a 10-point numeric rating scale. Higher scores indicated greater pain, anxiety, and preference.


      Median pain scores (interquartile range [IQR]) were 7 (4 to 8) without local anesthesia, 3 (2 to 5) with lidocaine cream, and 1 (1 to 2) with injected, buffered lidocaine. Median anxiety scores (IQR) were 4 (2 to 7) without local anesthesia, 2 (1 to 4) with lidocaine cream, and 2 (1 to 3) with injected, buffered lidocaine. There was no detectable difference in anxiety scores between lidocaine cream and injected, buffered lidocaine. Most IV placement attempts were successful, regardless of technique. Seventy percent of subjects indicated they would “always” request buffered lidocaine for peripheral IV insertion.


      In adult health care providers, pain and anxiety associated with peripheral IV insertion is significantly reduced by using topical lidocaine cream or injected, buffered lidocaine. Injected, buffered lidocaine reduces IV insertion pain more than lidocaine cream, without affecting success. Adults desire the use of local anesthetic techniques for IV insertion for themselves and for their patients.
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        • Brislin R.P.
        • Stayer S.A.
        • Schwartz R.E.
        • Pasquariello C.A.
        Analgesia for venepuncture in a paediatric surgery centre.
        J Paediatr Child Health. 1995; 31: 542-544
        • Cummings E.A.
        • Reid G.J.
        • Finley G.A.
        • et al.
        Prevalence and source of pain in pediatric inpatients.
        Pain. 1996; 68: 25-31
        • Walco G.A.
        • Cassidy R.C.
        • Schechter N.L.
        Pain, hurt, and harm.
        N Engl J Med. 1994; 331: 541-544
        • Chyun D.
        Patients' perceptions of stressors in intensive care and coronary care units.
        Focus Crit Care. 1989; 16: 206-211
        • Ashburn M.A.
        Burn pain: the management of procedure-related pain.
        J Burn Care Rehabil. 1995; 16: 365-371
        • Smith D.P.
        • Gjellum M.
        The efficacy of LMX versus EMLA for pain relief in boys undergoing office meatotomy.
        J Urol. 2004; 172: 1760-1761
        • Koh J.L.
        • Harrison D.
        • Myers R.
        • et al.
        A randomized, double-blind comparison study of EMLA and ELA-Max for topical anesthesia in children undergoing intravenous insertion.
        Paediatr Anaesth. 2004; 14: 977-982
        • Kleiber C.
        • Sorenson M.
        • Whiteside K.
        • et al.
        Topical anesthetics for intravenous insertion in children: a randomized equivalency study.
        Pediatrics. 2002; 110: 758-761
        • Eichenfield L.F.
        • Funk A.
        • Fallon-Friedlander S.
        • et al.
        A clinical study to evaluate the efficacy of ELA-Max (4% liposomal lidocaine) as compared with eutectic mixture of local anesthetics cream for pain reduction of venipuncture in children.
        Pediatrics. 2002; 109: 1093-1099
        • Chen B.K.
        • Cunningham B.B.
        Topical anesthetics in children: agents and techniques that equally comfort patients, parents, and clinicians.
        Curr Opin Pediatr. 2001; 13: 324-330
        • Friedman P.M.
        • Fogelman J.P.
        • Nouri K.
        • et al.
        Comparative study of the efficacy of four topical anesthetics.
        Dermatol Surg. 1999; 25: 950-954
        • Taddio A.
        • Soin H.K.
        • Schuh S.
        • et al.
        Liposomal lidocaine to improve procedural success rates and reduce procedural pain among children: a randomized controlled trial.
        CMAJ. 2005; 172: 1691-1695
        • Masters J.E.
        Randomised control trial of pH buffered lignocaine with adrenaline in outpatient operations.
        Br J Plast Surg. 1998; 51: 385-387
        • Brown D.
        Local anesthesia for vein cannulation: a comparison of two solutions.
        J Infus Nurs. 2004; 27: 85-88
        • Bartfield J.M.
        • Ford D.T.
        • Homer P.J.
        Buffered versus plain lidocaine for digital nerve blocks.
        Ann Emerg Med. 1993; 22: 216-219
        • Bartfield J.M.
        • Gennis P.
        • Barbera J.
        • et al.
        Buffered versus plain lidocaine as a local anesthetic for simple laceration repair.
        Ann Emerg Med. 1990; 19: 1387-1389
        • Brogan G.X.
        • Singer A.J.
        • Valentine S.M.
        • et al.
        Comparison of wound infection rates using plain versus buffered lidocaine for anesthesia of traumatic wounds.
        Am J Emerg Med. 1997; 15: 25-28
        • Brogan Jr, G.X.
        • Giarrusso E.
        • Hollander J.E.
        • et al.
        Comparison of plain, warmed, and buffered lidocaine for anesthesia of traumatic wounds.
        Ann Emerg Med. 1995; 26: 121-125
        • Christoph R.A.
        • Buchanan L.
        • Begalla K.
        • et al.
        Pain reduction in local anesthetic administration through pH buffering.
        Ann Emerg Med. 1988; 17: 117-120
        • Klein E.J.
        • Shugerman R.P.
        • Leigh-Taylor K.
        • et al.
        Buffered lidocaine: analgesia for intravenous line placement in children.
        Pediatrics. 1995; 95: 709-712
        • McKay W.
        • Morris R.
        • Mushlin P.
        Sodium bicarbonate attenuates pain on skin infiltration with lidocaine, with or without epinephrine.
        Anesth Analg. 1987; 66: 572-574
        • Ong E.L.
        • Lim N.L.
        • Koay C.K.
        Towards a pain-free venepuncture.
        Anaesthesia. 2000; 55: 260-262
        • Colaric K.B.
        • Overton D.T.
        • Moore K.
        Pain reduction in lidocaine administration through buffering and warming.
        Am J Emerg Med. 1998; 16: 353-356
        • Bartfield J.M.
        • Homer P.J.
        • Ford D.T.
        • et al.
        Buffered lidocaine as a local anesthetic: an investigation of shelf life.
        Ann Emerg Med. 1992; 21: 16-19
        • Serour F.
        • Mandelberg A.
        • Mori J.
        Slow injection of local anaesthetic will decrease pain during dorsal penile nerve block.
        Acta Anaesthesiol Scand. 1998; 42: 926-928
        • Zaybak A.
        • Khorshid L.
        A study on the effect of the duration of subcutaneous heparin injection on bruising and pain.
        J Clin Nurs. 2008; 17: 378-385
        • Fialkov J.A.
        • McDougall E.P.
        Warmed local anesthetic reduces pain of infiltration.
        Ann Plast Surg. 1996; 36: 11-13
        • Scarfone R.J.
        • Jasani M.
        • Gracely E.J.
        Pain of local anesthetics: rate of administration and buffering.
        Ann Emerg Med. 1998; 31: 36-40
        • Morris R.
        • McKay W.
        • Mushlin P.
        Comparison of pain associated with intradermal and subcutaneous infiltration with various local anesthetic solutions.
        Anesth Analg. 1987; 66: 1180-1182
        • Mader T.J.
        • Playe S.J.
        • Garb J.L.
        Reducing the pain of local anesthetic infiltration: warming and buffering have a synergistic effect.
        Ann Emerg Med. 1994; 23: 550-554
        • Arndt K.A.
        • Burton C.
        • Noe J.M.
        Minimizing the pain of local anesthesia.
        Plast Reconstr Surg. 1983; 72: 676-679
        • Brown J.
        • Larson M.
        Pain during insertion of peripheral intravenous catheters with and without intradermal lidocaine.
        Clin Nurse Spec. 1999; 13 (quiz 286-288): 283-285
        • Fry C.
        • Aholt D.
        Local anesthesia prior to the insertion of peripherally inserted central catheters.
        J Infus Nurs. 2001; 24: 404-408
        • Soliman I.E.
        • Broadman L.M.
        • Hannallah R.S.
        • et al.
        Comparison of the analgesic effects of EMLA (eutectic mixture of local anesthetics) to intradermal lidocaine infiltration prior to venous cannulation in unpremedicated children.
        Anesthesiology. 1988; 68: 804-806
        • Eidelman A.
        • Weiss J.M.
        • Lau J.
        • et al.
        Topical anesthetics for dermal instrumentation: a systematic review of randomized, controlled trials.
        Ann Emerg Med. 2005; 46: 343-351
        • Kundu S.
        • Achar S.
        Principles of office anesthesia: part II.
        Am Fam Physician. 2002; 66: 99-102
        • Luhmann J.
        • Hurt S.
        • Shootman M.
        • et al.
        A comparison of buffered lidocaine versus ELA-Max before peripheral intravenous catheter insertions in children.
        Pediatrics. 2004; 113: e217-e220
        • Fillingim R.B.
        • Ness T.J.
        Sex-related hormonal influences on pain and analgesic responses.
        Neurosci Biobehav Rev. 2000; 24: 485-501
        • Fillingim R.B.
        Sex, gender, and pain: women and men really are different.
        Curr Rev Pain. 2000; 4: 24-30
        • Powell C.V.
        • Kelly A.M.
        • Williams A.
        Determining the minimum clinically significant difference in visual analog pain score for children.
        Ann Emerg Med. 2001; 37: 28-31
        • Todd K.H.
        • Funk K.G.
        • Funk J.P.
        • et al.
        Clinical significance of reported changes in pain severity.
        Ann Emerg Med. 1996; 27: 485-489
        • Kelly A.M.
        Does the clinically significant difference in visual analog scale pain scores vary with gender, age, or cause of pain?.
        Acad Emerg Med. 1998; 5: 1086-1090
        • Todd K.H.
        • Funk J.P.
        The minimum clinically important difference in physician-assigned visual analog pain scores.
        Acad Emerg Med. 1996; 3: 142-146
        • Dupont W.D.
        • Plummer W.D.
        PS power and sample size program available for free on the Internet.
        Controlled Clin Trials. 1997; 18: 274
        • Hollander M.
        • Wolfe D.A.
        Nonparametric Statistical Methods.
        2nd ed. John Wiley & Sons, New York, NY1999
        • R Development Core Team
        A language and environment for statistical computing.
        (ISBN 3-900051-07-0) R Foundation for Statistical Computing, Vienna, Austria2008 (Accessed January 15, 2008)
        • Pershad J.
        • Steinberg S.C.
        • Waters T.M.
        Cost-effectiveness analysis of anesthetic agents during peripheral intravenous cannulation in the pediatric emergency department.
        Arch Pediatr Adolesc Med. 2008; 162: 952-961
        • Evans G.R.
        • Gherardini G.
        • Gurlek A.
        • et al.
        Drug-induced vasodilation in an in vitro and in vivo study: the effects of nicardipine, papaverine, and lidocaine on the rabbit carotid artery.
        Plast Reconstr Surg. 1997; 100: 1475-1481
        • Burgher S.W.
        • McGuirk T.D.
        Subcutaneous buffered lidocaine for intravenous cannulation: is there a role in emergency medicine?.
        Acad Emerg Med. 1998; 5: 1057-1063
        • Sacchetti A.D.
        • Carraccio C.
        Subcutaneous lidocaine does not affect the success rate of intravenous access in children less than 24 months of age.
        Acad Emerg Med. 1996; 3: 1016-1019