J Gandhara Med Dent Sci

July - September 2026

ORIGINAL ARTICLE

https://doi.org/10.37762/jgmds.13-3.846

How to cite this article

Date of Submission: 01-05-2026

Date Revised: 10-04-2026

Date Acceptance: 05-05-2026

Correspondence

COMPARISON OF XYLOCAINE ADDITION TO PROPOFOL VS LOCAL TAPPING FOR

ALLEVIATING INJECTION PAIN

Aamir Waseem

, Qurat ul Ain Malik

, Aamir Bashir

, Muhammad Kashan Siddique

, Asma Samreen

, Ahsan

Jawaid

Waseem A, Malik Q U A, Bashir A,

Siddique M K,Samreen A, Jawaid A.

Comparison of Xylocaine Addition to

Propofol vs Local Tapping for

Alleviating Injection Pain. J Gandhara

Med Dent Sci. 2026; 13(3): 20-24.

Assistant Professor Department of

Anesthesia, Shalamar Hospital

Registrar , Department of Anesthesia,

Shalamar Hospital

Asma Samreen, Senior Registrar,

Department of Anesthesia, Shalamar

Hospital

asmasamreen5@gmail.com

+92-317-2604779

ABSTRACT

OBJECTIVES

To evaluate and compare the ecacy of xylocaine –propofol admixture and

local tapping in reducing the incidence and severity of propofol injection pain.

METHODOLOGY

This quasi-experimental comparative study was conducted at Shalamar

Hospital, Lahore, from August 2025 to December 2025, involving 120 adult

patients undergoing elective surgery under general anesthesia. Group A

received propofol mixed with 0.5 ml of 2% xylocaine, while Group B received

standardized local tapping for ve seconds before propofol administration.

Pain severity was assessed using a four-point verbal rating scale after the rst

5 ml of propofol.

RESULTS

Pain incidence and severity were signicantly lower in the xylocaine group.

No pain was reported by 63.3% of patients in Group A compared to 20.0% in

Group B, while severe pain occurred in only 1.7% versus 16.7%, respectively

(p < 0.001). The mean pain score was signicantly lower in Group A (0.50 ±

0.73) than in Group B (1.47 ± 1.04) (p < 0.001). Hemodynamic changes were

also smaller in the xylocaine group, with heart rate and systolic blood pressure

increasing by +2.7 bpm and +2.1 mmHg, compared to +6.7 bpm and +6.2

mmHg in the tapping group (p < 0.05). Adverse events were minimal, with only

one mild irritation case in Group A. Patient satisfaction was higher in Group

A, with 66.7% reporting being very satised compared to 30.0% in Group B.

CONCLUSION

It is concluded that xylocaine admixture is signicantly more eective than

local tapping in reducing propofol injection pain, stabilizing hemodynamic

responses, and improving patient satisfaction. Local tapping may oer partial

benet but should not replace xylocaine as the preferred technique for

minimizing discomfort during propofol administration.

KEYWORDS: Propofol Injection Pain, Xylocaine Admixture, Pain Reduction,

Anesthesia Induction, General Anesthesia, Patient Satisfaction

INTRODUCTION

Propofol remains one of the most widely used

intravenous induction agents in modern anesthesia

because of its rapid onset, short recovery prole,

antiemetic properties, and predictable

pharmacokinetics.

Pain is one of the most commonly

reported adverse experiences during the induction of

propofol anesthesia, ranging from 9.8% to 28.4% in

adults despite its popularity and its perception as a safe

anesthetic agent.

2,3

The pain experienced during

induction has a signicant impact on the ability to enjoy

a normal life.

The pain impacts satisfaction, perceptions

of anesthesia quality, and can incite several clinically

noteworthy behaviors over the induction period, such as

increasing patient anxiety, sympathetic stress responses,

and movement.

This is particularly the case during high-

stress situations in emergency surgeries (or pediatrics)

where agitation secondary to injection pain can create

chaos in an otherwise manageable scenario. This has led

most practitioners to seek the simplest, most eective,

and safest techniques for alleviating discomfort (without

adding too much complexity to the induction sequence)

to the optimal level of discomfort.

The complex

mechanisms responsible for propofol pain involve not

only pathways associated with pain but also those

associated with injury or damage. The lipid emulsion in

propofol, for example, causes direct injury to the venous

endothelium, resulting in pain, but also activates the

kinin cascade, which, as a secondary cascade, can lead

to a burning pain. Adding to the complexity of responses

to propofol and the pathways involved is the patient and

the adverse characteristics they bring to propofol

anesthesia.

The pathways, along with the adverse

propofol injection.

characteristics of patients to the propofol, all factor into

why no single technique or intervention has helped end

the signicant debate over the optimal techniques of

For quite some time, adding lidocaine

J Gandhara Med Dent Sci

July - September 2026

Comparison of Xylocaine Addition to Propofol vs Local Tapping

to a mixture has been considered the gold standard.

The

addition of xylocaine to propofol is believed to reduce

endothelial irritation, reduce nerve conduction, and

control the release of inammatory mediators.

Numerous sources have shown the location of the

lidocaine as a rational pharmacological option, as there

is a decrease in the frequency as well as the severity of

the pain.

More questionable, however, is the stability of

the propofol–lidocaine mixture, the best concentration of

the mixture, and the variations of the propofol in

question. Also, lidocaine is eective. However, some

practitioners wish to avoid modication of the drug

mixtures, and lidocaine is the result of that.

In contrast,

local tapping is the option modern anesthetic workows

prefer: a fully non-drug technique based on the gate

control theory of pain. Propofol, chemically known as

2,6-

diisopropylphenol, is lipid

-rich and thus cannot

dissolve in water. Propofol requires a lipid-based

solution because its oily properties inhibit ecient entry

into the bloodstream. The precursor solution is made

from soybean oil, egg lecithin, and glycerol, which gives

it a white, opaque appearance. Propofol has isopropyl

side chains that make it hydrophobic, resulting in a thick,

difcult-to-mix solution with water.

Affecting

numerous other patients, those who receive propofol

injections emerge from the procedure with immense

post-operative pain. The infusion emulsion can result in

infection and, if taken for a long duration, can adversely

affect blood lipid levels.

There are new studies in

which propofol is dissolved in cyclodextrin liquids,

microemulsions, and water-soluble drug release systems,

rather than the traditional lipid emulsion.

Injection pain

in propofol has been a problem since the rst clinical

trial in 1977, and numerous methods including mixing

lidocaine with propofol in the same syringe, pre-

treatment with lidocaine or procaine, cooling, warming,

or diluting the propofol solution, injecting propofol into

a large vein, and the prior injection of ondansetron,

ketamine, opioids, magnesium sulfate, ketorolac or

tramadol have been applied.

Studies on

metoclopramide pre-treatment and propofol premixed

with lidocaine as two eective and safe methods have

also been documented.

METHODOLOGY

This quasi-experimental comparative study was

conducted at Shalamar Hospital, Lahore, from August

2025 to December 2025, involving 120 adult patients

undergoing elective surgery under general anesthesia.

Ethical approval was obtained before the start of the

study. Written informed consent was secured from all

patients after explaining the aim, procedure, and

potential risks of the interventions. The sample size was

calculated using the WHO Sample Size Calculator

version 2.0, which is commonly utilized in clinical

research across Pakistan. Using the formula for a single

population proportion,

n = Z² × p(1–p) / d²

With a 95% condence level (Z = 1.96), expected

proportion p = 0.50, and margin of error d = 0.10, the

minimum required sample size was calculated to be 96.

To strengthen the study's power and compensate for

potential dropouts or incomplete responses, the nal

sample size was increased to 120 participants.

Participants were selected through a non-probability

consecutive sampling method. Adults aged 18-65 years,

ASA physical status I or II, Elective surgery requiring

propofol induction, and an intravenous cannula placed

on the dorsum of the hand were included. The known

The scale was chosen for its simplicity, reliability, and

suitability for rapid assessment during anesthesia

induction. Each patient's response was recorded

immediately to ensure accuracy. Heart rate and systolic

blood pressure were recorded just before and

immediately after propofol administration to observe

any autonomic changes potentially associated with pain

perception. These parameters helped identify whether

injection pain triggered measurable physiological stress

responses. The primary outcome of the study was the

severity of pain during propofol injection as rated by the

patient. Secondary outcomes included the overall

incidence of pain, reported discomfort, and any adverse

reactions related to either lidocaine admixture or the

allergy to lidocaine or propofol, chronic pain disorders,

communication barriers, analgesic use within 24 hours,

and difcult venous access or need for alternative

induction agents were excluded. Participants were

divided into two predened groups based on the

technique applied by the attending anesthesiologist.

Group A received propofol premixed with 0.5 ml of 2%

xylocaine immediately before injection, while Group B

received standardized local tapping for approximately

ve seconds at the injection site immediately before

propofol administration. This allocation method

reflected common clinical practice variations while

maintaining intervention consistency within each group.

All patients had an 18-G or 20-G intravenous cannula

inserted on the dorsum of the hand. Propofol was

administered at a standardized rate of 1 ml/sec in both

groups to maintain uniform pain-eliciting conditions.

After the initial 5 ml of propofol, each patient was asked

to describe the level of injection pain experienced. No

sedatives or analgesics aecting pain perception were

given before induction to avoid confounding the results.

Pain was assessed using a validated four-point verbal

rating scale, ranging from 0 (no pain) to 3 (severe pain).

tapping technique. These outcomes allowed a

comprehensive comparison of both interventions. All

collected data were entered and analyzed using SPSS

version 26.0. Categorical variables, such as pain severity

J Gandhara Med Dent Sci

July - September 2026

and pain incidence, were evaluated using the chi-square

test, while continuous variables, including changes in

heart rate and blood pressure, were analyzed using an

independent-samples t-test. A p-value of less than 0.05

was considered statistically signicant.

RESULTS

Data were collected from 120 patients; baseline

physiological parameters demonstrated close similarity

between the interventions.

Table 1: Baseline Demographic and Clinical Characteristics of

Patients (N = 120)

Variable

Group A (Xylocaine

+ Propofol) (n = 60)

Group B (Local

Tapping) (n = 60)

Age (years),

mean ± SD

37.8 ± 12.4 38.5 ± 11.9

Gender (Male),

n (%)

32 (53.3%) 31 (51.6%)

Baseline Heart Rate

(bpm), mean SD

82.4 ± 9.6 83.1 ± 10.1

Baseline Systolic BP

(mmHg), mean SD

123.5 ± 11.4 124.2 ± 10.9

Table 2: Comparison of Propofol Injection Pain Severity Between

Groups

Pain

Severity

Group A (Xyloc

caine + Propofol)

(n = 60)

Group B (Local

Tapping) (n = 60)

p-value

No Pain 38 (63.3%) 12 (20.0%) <0.001

Mild Pain 15 (25.0%) 18 (30.0%)

Moderate

Pain

6 (10.0%) 20 (33.3%)

Severe Pain 1 (1.7%) 10 (16.7%)

Mean Pain Score

- (0 3 scale)

0.50 ± 0.73 1.47 ± 1.04 <0.001

Patients with Any

Pain (Mild+Mod

erate+Servere)

22 (36.7%) 48 (80.0%) <0.001

Heart Rate

Change (bpm)

+2.7 ± 4.1 +6.7 ± 5.3 0.002

Systolic BP

Change (mmHg)

+2.1 ± 3.9 +6.2 ± 5.8 0.001

Table 3: Hemodynamic Changes Before and After Propofol

Injection

*Independent sample t-test comparing the change between groups.

Parameter

Group A

Pre-Inje

ction

Group A

Post-Inj

ection

Group B

Pre-Inje

ction

Group B

Post-Inje

ction

value

Heart Rate (bp

m),mean SD

82.4 ±

9.6

85.1 ±

10.3

83.1 ±

10.1

89.8 ±

11.5

0.014

Systolic BP (m

mHg),mean

123.5 ±

11.4

125.6 ±

12.1

124.2 ±

10.9

130.4 ±

13.6

0.021

Table 4: Adverse Events and Complications Observed After

Interventions (N = 120)

Adverse

Event /

Complication

Group A (Xyloc

caine + Propofol

(n = 60)

Group B (Local

Tapping) (n=60)

value

No Adverse

Event

59 (98.3%) 60 (100.0%)

0.315

Local Injection

-Site Irritation

1 (1.7%) 0 (0.0%)

Allergic

Reaction

0 (0.0%) 0 (0.0%)

Hematoma /

Bruising

0 (0.0%) 0 (0.0%)

Arrhythmia /

Signicant

Bradycardia

0 (0.0%) 0 (0.0%)

Serious

Adverse Event

0 (0.0%) 0 (0.0%)

*Independent sample t-test comparing the change

between groups.

Table 5: Patient Satisfaction Related to Injection Comfort and

Induction Experience

Satisfaction

Category

Group A (Xylocaine+

Propofol) (n = 60)

Group B (Local

Tapping) (n=60)

-value

Very Satised 40 (66.7%) 18 (30.0%) <0.001

Satised 15 (25.0%) 20 (33.3%) 0.324

Neutral 4 (6.7%) 12 (20.0%) 0.034

Dissatisfied 1 (1.6%) 8 (13.3%) 0.017

Very

Dissatisfied

0 (0.0%) 2 (3.3%) 0.151

DISCUSSION

This study compared the eectiveness of adding

xylocaine to propofol versus using local tapping at the

injection site to alleviate propofol injection pain. The

ndings clearly demonstrate that xylocaine admixture

signicantly outperforms local tapping in reducing both

the incidence and severity of injection pain. These results

align with the well-established pharmacological

rationale that lidocaine stabilizes neuronal membranes,

reduces venous irritation, and attenuates activation of

pain pathways triggered by propofol’s lipid emulsion

formulation. In contrast, local tapping, although simple

and non-pharmacological, produced only partial and

inconsistent relief. The markedly higher proportion of

patients experiencing no pain in the xylocaine group

(63.3%) compared with the tapping group (20.0%)

reinforces the superiority of pharmacological

modulation over sensory distraction techniques. The

mean pain score dierence observed between the two

groups (0.50 vs. 1.47) further supports this conclusion.

These ndings are consistent with previous studies

reporting that lidocaine admixture signicantly lowers

the pain associated with propofol induction. Many

regional and international studies report lidocaine-

induced reductions of 60-70% in incidence, closely

Comparison of Xylocaine Addition to Propofol vs Local Tapping

J Gandhara Med Dent Sci

July - September 2026

matching the pattern observed in this study. The

mechanism of action is believed to involve decreased

endothelial irritation, blunting of nociceptive impulses,

and inhibition of the kallikrein-kinin cascade, which is

implicated in propofol-associated venous pain.

Local

tapping may help reduce pain by activating A-beta

bers, consistent with the Gate control theory of pain.

Activation of these large-diameter mechanoreceptive

bers can inhibit the transmission of nociceptive signals

carried by type C bers in the spinal dorsal horn, thereby

reducing pain perception.

However, the variable eect

this method had in our study indicates that mere sensory

distraction is insucient to alleviate the chemical

discomfort during propofol administration. This is

further supported by the tapping group's more frequent

reports of moderate and severe pain. The present study

suggests that, while tapping is promoted as a low-

resource alternative, in cases where the comfort of the

propofol injection is a top priority, tapping should not be

the primary method. The study's hemodynamic results

also support the presence of clinically signicant

dierences between the interventions.

Patients who

received xylocaine injection showed slight changes in

heart rate and systolic blood pressure after propofol

injection, indicating that nociceptive pain stimulation

was limited and that the induction was smoother. On the

other hand, the tapping group showed signicantly

greater increases in heart rate and systolic pressure,

consistent with activation of the sympathetic nervous

system by pain.

These results provide objective

verication of the more common subjective patient

outcomes and underscore the need to alleviate pain

during anesthesia induction. This need is even more

pronounced in vulnerable patient populations, where

uctuating hemodynamics could lead to dangerous

outcomes. Both interventions also have positive safety

proles. In the xylocaine group, only one person showed

mild, transient irritation at the injection site, and none

reported any adverse reaction of signicant conc ern.

This supports prior studies indicating that the

combination of lidocaine and propofol in small

quantities is usually well tolerated. The absence of issues

in either group supports the use of the described

approaches in anesthesia. In the xylocaine group, the

rates of very satised patients were double that of the

tapping-only group.

An even lower proportion of

patients in the xylocaine cohort were dissatised with the

propofol injection, indicating that pain at this step is a

common negative aspect that detracts from overall

anesthesia satisfaction. This study conrms the pain-

control-satisfaction correlation previously demonstrated.

The negative experience patients report during propofol

injection is a common one, and the study also

demonstrated strong ties between pain control and

overall satisfaction with the anesthetic experience.

LIMITATIONS

This study has several limitations that should be

acknowledged. The study was conducted at a single

center, which may limit the generalizability of the

ndings to other institutions with dierent patient

populations, clinical workows, or anesthesia practices.

Pain reporting relied on a verbal rating scale, which is

inherently subjective and may be inuenced by

individual pain thresholds, anxiety levels, or

communication styles. Only immediate pain responses

and short-term hemodynamic changes were assessed;

longer-term outcomes such as delayed discomfort or

post-injection complications were not evaluated. Finally,

the interventions were performed by dierent

anesthesiologists, which, despite standardized technique

instructions, may introduce operator-dependent

variability.

CONCLUSIONS

It is concluded that the addition of xylocaine to propofol

is signicantly more eective than local tapping in

alleviating propofol injection pain. Patients who

received the xylocaine-propofol admixture experienced

lower pain intensity, fewer hemodynamic changes, and

greater satisfaction than those managed with local

tapping alone. Both techniques were safe; however, local

tapping provided only limited, inconsistent relief,

whereas lidocaine oered a more reliable, clinically

meaningful reduction in discomfort. Therefore,

xylocaine admixture should be considered the preferred

method for minimizing propofol injection pain, while

tapping may be used as a supplementary measure in

settings where pharmacological intervention is not

feasible.

CONFLICT OF INTEREST: None

FUNDING SOURCES: None

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Aamir Waseem

Concept & Design; Data Acquisition; Data

Analysis/Interpretation; Drafting Manuscript; Critical Revision;

Supervision; Final Approval

Qurat ul Ain Malik -

Concept & Design; Data Acquisition; Data

Analysis/Interpretation; Drafting Manuscript;

Critical Revision;

Supervision; Final

Approval

Aamir Bashir

Concept & Design; Data Acquisition; Data

Analysis/Interpretation; Drafting Manuscript; Critical Revision;

Supervision; Final Approval

Muhammad Kashan Siddique -

Concept & Design; Data

Acquisition; Data Analysis/Interpretation; Drafting Manuscript;

Critical Revision; Final Approval

Asma Samreen -

Concept & Design; Data Acquisition; Data

Analysis/Interpretation; Critical Revision; Supervision; Final

Approval

Ahsan Jawaid -

Concept & Design; Data Acquisition; Data

Analysis/Interpretation; Critical Revision; Supervision; Final

Approval

The authors accept responsibility for all aspects of the work

and will ensure that any concerns regarding the accuracy or

integrity of any part are properly investigated and resolved.

AUTHORS CONTRIBUTION

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Comparison of Xylocaine Addition to Propofol vs Local Tapping