Investig Clin Urol.  2019 Jul;60(4):251-257. 10.4111/icu.2019.60.4.251.

Efficacy of pethidine, ketorolac, and lidocaine gel as analgesics for pain control in shockwave lithotripsy: A single-blinded randomized controlled trial

• Hashem A
• Ghobrial F
• Elbaset MA
• Atwa AM
• Fadallah M
• Laymon M
• El-Assmy A
• Sheir KZ
• Abol-Enein H

• KMID: 2450542
• DOI: http://doi.org/10.4111/icu.2019.60.4.251

Abstract

PURPOSE
To compare the safety and efficacy of xylocaine gel and ketorolac as opioid-sparing analgesia compared with pethidine for shock wave lithotripsy (SWL) pain.
MATERIALS AND METHODS
A single-blinded randomized controlled trial (RCT) was performed in 132 patients with renal and upper ureteral stones amenable to treatment with SWL. The first patient group received intravenous (IV) pethidine and placebo gel; the second group received IV ketorolac plus placebo gel; the third group received lidocaine gel locally plus normal saline IV. Stone disintegration was classified as none (no change from basal by kidney, ureter, bladder X-ray or ultrasound [US] imaging), partial (fragmented and >4-mm residual fragments), and complete (≤4-mm residual fragments). Stone disintegration was assessed by kidney-ureter-bladder X-ray and US imaging. Pain was evaluated by use of the Numeric Pain Rating Scale (NPRS).
RESULTS
The NPRS scores were highest in the xylocaine group at 10, 20, and 30 minutes (p=0.0001) with no significant difference between the ketorolac and pethidine groups, except at 10 minutes (p=0.03) and a near significant difference at 30 minutes (p=0.054) in favor of ketorolac. Results for stone disintegration (none, partial, and complete, respectively) were as follows: 25 (50.0%), 23 (46.0%), and 2 (4.0%) for pethidine; 19 (35.8%), 23 (43.4%), and 11 (20.8%) for ketorolac; and 26 (89.7%), 3 (10.3%), and 0 (0.0%) for lidocaine (p=0.008).
CONCLUSIONS
Ketorolac is a safe and more effective alternative to morphine derivatives for SWL analgesia. Lidocaine gel should not be used as mono-analgesia for SWL.

Keyword

Analgesia; Ketorolac; Lithotripsy

MeSH Terms

Analgesia
Analgesics*
Humans
Ketorolac*
Kidney
Lidocaine*
Lithotripsy*
Meperidine*
Morphine Derivatives
Shock
Ultrasonography
Ureter
Urinary Bladder
Analgesics
Ketorolac
Lidocaine
Meperidine
Morphine Derivatives

Figure

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  Fig. 1 CONSORT flowchart for study participants. BMI, body mass index; NSAIDs, nonsteroidal anti-inflammatory drugs. a:These patients received pethidine (our standard analgesia) and were excluded from our final analysis.

Reference

1. Salinas AS, Lorenzo-Romero J, Segura M, Calero MR, Hernández-Millán I, Martínez-Martín M, et al. Factors determining analgesic and sedative drug requirements during extracorporeal shock wave lithotripsy. Urol Int. 1999; 63:92–101. PMID: 10592496.

2. Vergnolles M, Wallerand H, Gadrat F, Maurice-Tison S, Deti E, Ballanger P, et al. Predictive risk factors for pain during extracorporeal shockwave lithotripsy. J Endourol. 2009; 23:2021–2027. PMID: 19821695.

3. Berwin JT, El-Husseiny T, Papatsoris AG, Hajdinjak T, Masood J, Buchholz N. Pain in extracorporeal shock wave lithotripsy. Urol Res. 2009; 37:51–53. PMID: 19183979.

4. Aboumarzouk OM, Hasan R, Tasleem A, Mariappan M, Hutton R, Fitzpatrick J, et al. Analgesia for patients undergoing shockwave lithotripsy for urinary stones-a systematic review and meta-analysis. Int Braz J Urol. 2017; 43:394–406. PMID: 28338301.

5. European Association of Urology. The EAU urolithiasis guidelines [Internet]. Arnhem: European Association of Urology;2018. 6. 18. cited 2018 Jun 23. Available from: http://uroweb.org/guideline/urolithiasis/.

6. Sharma NL, Alexander CE, Grout E, Turney BW. Shockwave lithotripsy: variance within UK practice. Urolithiasis. 2017; 45:193–201. PMID: 27216432.

7. Buckley MM, Brogden RN. Ketorolac. A review of its pharmacodynamic and pharmacokinetic properties, and therapeutic potential. Drugs. 1990; 39:86–109. PMID: 2178916.

8. Smith LA, Carroll D, Edwards JE, Moore RA, McQuay HJ. Single-dose ketorolac and pethidine in acute postoperative pain: systematic review with meta-analysis. Br J Anaesth. 2000; 84:48–58. PMID: 10740547.

9. De Oliveira GS Jr, Agarwal D, Benzon HT. Perioperative single dose ketorolac to prevent postoperative pain: a meta-analysis of randomized trials. Anesth Analg. 2012; 114:424–433. PMID: 21965355.

10. Castarlenas E, Jensen MP, von Baeyer CL, Miró J. Psychometric properties of the numerical rating scale to assess self-reported pain intensity in children and adolescents: a systematic review. Clin J Pain. 2017; 33:376–383. PMID: 27518484.

11. Takmaz SA, Inan N, Goktug A, Erdogan I, Sunay M, Ceyhan A. The analgesic effect of 8 and 16 mg lornoxicam administered before shock wave lithotripsy: a randomized, double-blind, controlled study. Urology. 2008; 72:282–285. PMID: 18485457.

12. Basar H, Yilmaz E, Ozcan S, Buyukkocak U, Sari F, Apan A, et al. Four analgesic techniques for shockwave lithotripsy: eutectic mixture local anesthetic is a good alternative. J Endourol. 2003; 17:3–6. PMID: 12639353.

13. Christian C, Thorsten B. The preferred treatment for upper tract stones is extracorporeal shock wave lithotripsy (ESWL) or ureteroscopic: pro ESWL. Urology. 2009; 74:259–262. PMID: 19646607.

14. Bach C, Zaman F, Kachrilas S, Kumar P, Buchholz N, Masood J. Drugs for pain management in shock wave lithotripsy. Pain Res Treat. 2011; 2011:259426. PMID: 22135735.

15. Sorensen C, Chandhoke P, Moore M, Wolf C, Sarram A. Comparison of intravenous sedation versus general anesthesia on the efficacy of the Doli 50 lithotriptor. J Urol. 2002; 168:35–37. PMID: 12050487.

16. Birch BR, Anson KM, Miller RA. Sedoanalgesia in urology: a safe, cost-effective alternative to general anaesthesia. a review of 1020 cases. Br J Urol. 1990; 66:342–350. PMID: 2224427.

17. Unlugenc H, Vardar MA, Tetiker S. A comparative study of the analgesic effect of patient-controlled morphine, pethidine, and tramadol for postoperative pain management after abdominal hysterectomy. Anesth Analg. 2008; 106:309–312. PMID: 18165596.

18. Akcali GE, Iskender A, Demiraran Y, Kayikci A, Yalcin GS, Cam K, et al. Randomized comparison of efficacy of paracetamol, lornoxicam, and tramadol representing three different groups of analgesics for pain control in extracorporeal shockwave lithotripsy. J Endourol. 2010; 24:615–620. PMID: 20184444.

19. Ganapathy S, Razvi H, Moote C, Parkin J, Yee I, Gverzdys S, et al. Eutectic mixture of local anaesthetics is not effective for extracorporeal shock wave lithotripsy. Can J Anaesth. 1996; 43:1030–1034. PMID: 8896855.

20. Escobar-Chávez JJ, Bonilla-Martínez D, Villegas-González MA, Rodríguez-Cruz IM, Domínguez-Delgado CL. The use of sonophoresis in the administration of drugs throughout the skin. J Pharm Pharm Sci. 2009; 12:88–115. PMID: 19470295.

21. Luh JJ, Huang WT, Lin KH, Huang YY, Kuo PL, Chen WS. Effects of extracorporeal shock wave-mediated transdermal local anesthetic drug delivery on rat caudal nerves. Ultrasound Med Biol. 2018; 44:214–222. PMID: 29107354.