Commentary: a prospective comparison between neutralizing the ph of 1 lidocaine with epinephrine (buffering) and preoperative skin cooling in reducing the pain of infiltration of local anesthetic

COMMENTARY: A Prospective Comparison BetweenNeutralizing the pH of 1% Lidocaine with Epinephrine(Buffering) and Pre-Operative Skin Cooling in Reducing thePain of Infiltration of Local Anesthetic The author has indicated no significant interest with commercial supporters.
Dermatologicsurgeonshavelongbeentryingto sion, iontophoresis, skin warming, or pretreatment find ways to eliminate patient discomfort with tape stripping or acetone to enhance absorption associated with dermatologic procedures. Although and efficacy6; infusion of anesthesia using a pump to some dermatologic procedures, such as facial resur- control infusion rate and pressure7; regional blocks facing and extensive procedures performed on chil- using injectable anesthesia or intravenous anesthe- dren, require intravenous or general anesthesia,1 sia8; tumescence 9,10 with nonneutralized or neu- dermatologic surgical procedures usually require tralized solution at room temperature or warmed11; only local anesthesia, which is frequently adminis- and the use of skin cooling via application of ice tered via injection, to eliminate pain at the surgical cubes, gels, ethyl chloride spray, a chilled sapphire site. The article by Mohammed Alshahwan, MD, plate, or a device emitting cold air.12,13 titled “A Prospective Comparison Between Neu-tralizing the pH of 1% Lidocaine with Epinephrine The most common means to achieve anesthesia in (Buffering) and Preoperative Skin Cooling in dermatologic practice is to inject a premixed com- Reducing the Pain of Infiltration of Local Anes- bination of lidocaine and epinephrine around the thetic,” addresses the pain inherent in infusion of surgical site to attain excellent anesthesia so that the procedure itself is pain free, but patients oftenexperience some degree of pain with the initial Methods used to achieve anesthesia include injection needle stick and infiltration of the anesthetic agent.
of an anesthetic solution of lidocaine, mepivacaine, The author assessed patient perception of the degree bupivacaine, etidocaine, procaine, tetracaine, or of pain experienced using two different techniques chloroprocaine, all with or without epinephrine, of anesthetizing—pre-injection application of cold around the surgical site3; application of topical to the injection site and use of a buffered anesthetic anesthesia, such as lidocaine, lidocaine mixed with solution—to determine which technique provided prilocaine, lidocaine mixed with prilocaine and the most patient comfort during infiltration of the dibucaine, or tetracaine over and around the surgical anesthetic solution. He determined that buffering site4,5; application of topical anesthesia with occlu- the anesthetic solution with sodium bicarbonate *Advanced Dermatology and Skin Surgery Specialists, PA, Naples, Florida; †College of Medicine, University of SouthFlorida, Tampa, Florida 2012 by the American Society for Dermatologic Surgery, Inc.  Published by Wiley Periodicals, Inc. ISSN: 1076-0512  Dermatol Surg 2012;38:1660–1661  DOI: 10.1111/j.1524-4725.2012.02485.x provides patients with the most comfortable 4. Friedman PM, Fogelman JP, Nouri K, Levine VJ. Comparative study of the efficacy of four topical anesthetics. Dermatol Surg and least painful anesthesia infiltration experience, although the difference was not 5. Friedman PM, Mafong EA, Friedman ES, Geronemus RG.
Topical anesthetics update: EMLA and beyond. Dermatol Surg2001;22:1019–6.
With nearly 3.9 million dermatologic procedures 6. Sobanko JF, Miller CJ, Alster TS. Topical anesthetics for dermatologic procedures: a review. Dermatol Surg 2012;38: being performed annually in the United States,14 determining the least painful and most effective 7. True RH, Elliott RM. Microprocessor-controlled local anesthesia means of providing anesthesia will have a tre- versus the conventional syringe techniques in hair transplantation.
mendous effect on a large patient population. This study suggests that further comparative studies are 8. Blaheta H-J, Vollert B, Zuder D, Rassner G. Intravenous regional anesthesia (Bier’s Block) for botulinum toxin therapy of palmar indicated. Perhaps those studies should include hyperhidrosis is safe and effective. Dermatol Surg 2002;28: comparisons between aforementioned anesthetizing techniques as well as nontraditional techniques 9. Klein JA. The tumescent technique. Am J Cosmet Surg such as manipulation of environmental factors, forexample, sensory-stimulating tactile, auditory, and 10. Coldiron B, Coleman WP III, Cox SE, Jacob Cet al. ASDS guidelines of care for tumescent liposuction. Dermatol Surg visual diversions. It is likely that the overall benefit of diminishing pain associated with 11. Yang C-H, Hsu H-C, Shen S-C, Juan W-Het al. Warm and procedures will have the effect of decreasing neutral tumescent anesthetic solutions are essential factors for aless painful injection. Dermatol Surg 2006;32:1119–23.
procedure-associated anxiety and enhancing overall 12. Hughes PSH. Cold air anesthesia in dermasurgery: comparative study. Dermatol Surg 2006;32:165–6.
13. Henning JS, Firoz BF. The use of a cooling device as an analgesic before injectable local anesthesia in the pediatric population.
14. Cao LY, Taylor JS, Vidimos A. Patient safety in dermatology: a 1. The AAD/ASDS Liaison Committee. Current issues in review of the literature. Dermatol Online J 2010;16:3.
dermatology office-based surgery. Dermatol Surg 1999;25:806–15.
2. Al Shahwan MA. A prospective comparison between neutralizing the ph of 1% lidocaine with epinephrine (buffering) and Address correspondence and reprint requests to: Cyndi pre-operative skin cooling in reducing the pain of infiltration of Yag-Howard, MD, FAAD, Advanced Dermatology and local anesthetic. Dermatol Surg 2012;38:1654–9.
Skin Surgery Specialists, PA, 1000 Goodlette Road, Suite 3. Koay J, Orengo I. Application of local anesthetic. Dermatol Surg 100, Naples, FL 34102, or e-mail: yaghoward@aol.com

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