Article, Urology

Pain management of renal colic in the emergency department with intravenous lidocaine

a b s t r a c t

Objective: To describe our experience with intravenous lidocaine (IVL) to manage pain of renal colic origin in the emergency department (ED).

Methods: A retrospective analysis of all patients presenting with pain of renal colic origin from the periods of 2014 to 2017 by using the ED Electronic Medical Record database (Allscripts(TM)).

Results: Forty-four patients received IVL for renal colic over a three-year period. The average dose of IVL as a pri- mary analgesic was 117.2 mg, and as a rescue was 108 mg. Administration of IVL resulted in a decrease in overall pain score by 6.3 points (numerical rating scale), by 7.4 points when IVL was used as a primary analgesic, and by

5.2 points when IVL was given as a rescue. There were no documented adverse effects.

Conclusion: Intravenous lidocaine has a potential of being used for patients presenting to the ED with a pain of renal colic origin as a primary analgesic or as a rescue. Although promising, this therapy will need to be studied in prospective randomized fashion and larger patients’ population with underlying cardiac disease before it can be recommended for broad use in the ED.

(C) 2018

Introduction

Nephrolithiasis and renal colic affect approximately 12% of the pop- ulation and causes 1.2 million people to seek care in various health care facilities each year. It accounts for 1% of all ED visits and 1% of all hospital admissions. In 50% of people with a history of Kidney stones, recurrence rates approach nearly 50% after 10 years [1,2]. The pain of renal colic or- igin is multifactorial and is related to obstruction of urinary flow with subsequent increase in intrarenal and intra-ureteral pressure and prostaglandin-mediated ureteral spasm [1-3]. The provision of timely and effective analgesia for the most painful conditions, such as renal colic, is of utmost importance. Emergency department clinicians tradi- tionally employ opioid analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs) either alone or in combinations [3-9] for this condition. However, despite the fact that opioids and NSAIDs are the cornerstone of pain management in patients with renal colic their use is frequently precluded by patient co-morbidities and contraindications, or limited by rates of severe adverse effects [10,11]. In such instances utilization

* Corresponding author at: 965 48th St, Brooklyn, NY 11219, USA.

E-mail address: [email protected] (J. Drapkin).

of analgesic alternatives to opioids and/or NSAIDs such as intravenous lidocaine (IVL) merits consideration.

Lidocaine is a voltage-dependent sodium channel blocking agent (reversibly) that reduces transmission of pain signals in the sensory pathways and inhibits ectopic discharges from injured nerves [1,12]. Based on recent research, IVL administered at the dose of 1-1.5 mg/kg over 10-15 min provides good pain relief and causes minimal side ef- fects (dizziness, tinnitus, periorbital and perioral numbness) which are transient and rapidly reversible [13]. The data examining the analge- sic efficacy of IVL for patients with renal colic is limited to a case series and to two randomized controlled trials. Thus, the goal of the present in- vestigation is to describe the utilization of IVL for patients presenting to our ED with pain of renal colic origin.

Methods

Study design

We performed a retrospective analysis in which we collected data through chart review of adult patients 18 years of age and older present- ing to the ED with pain of renal colic origin whose final diagnoses were nephrolithiasis, renal colic, or Obstructive uropathy. We conducted this

https://doi.org/10.1016/j.ajem.2018.07.021

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S. Motov et al. / American Journal of Emergency Medicine 36 (2018) 18621864 1863

study at a 711-bed urban community teaching hospital with an annual ED patient census of N120,000 visits that was approved by the hospital’s institutional review board.

Study setting and population

The dataset included all patients 18 years of age and older presented to the ED between 2014 and 2017 with pain of renal colic origin and who received IVL for the purpose of pain control.

Table 2

Patient pain scores.

Pain scores

Overall Lidocaine given as first line

Initial pain

Post pain

Initial pain

Post pain

Initial pain

Post pain

8.29

2

8.24

0.88

8.33

3.11

p-Val

b0.0001

p-Val

b0.0001

p-Val

b0.0001

95% CI

4.93-7.58

95% CI

5.13-9.58

95% CI

3.66-6.78

MeanDiff

6.26

MeanDiff

7.35

MeanDiff

5.22

Lidocaine given as rescue

Study protocol

Two trained research associates utilized a standardized data collec- tion form and the ED electronic medical record database (Allscripts(TM)) to abstract data. The data obtained included: age, gender, chief com- plaint, final diagnosis, dose and route, frequency of lidocaine adminis- tration, and pain scores, as well as data on whether IVL was administered as a primary analgesic or as a rescue. Any discrepancies were reconciled by a third independent reviewer.

Data analysis

The data analysis comprised of paired sample t-tests comparing pre and post pain scores in all patients receiving IVL; in patients receiving IVL as a first line medication, and in patients receiving IVL as a Rescue medication. None of the patients included in our study that received IVL had any absolute or relative contraindications to its use. Our retro- spective case series only evaluated patients with a final diagnosis of renal colic.

Results

There were 44 patients with pain of renal colic origin who received in IVL, 22 patients received lidocaine as a primary analgesic and 22 pa- tients received it as a rescue. All patients were placed on a cardiac mon- itor as well as a Pulse oximeter. The average dose of IVL as a primary analgesic was 117.2 mg (range: 76-200 mg), and as a rescue was 108 mg (range: 60-150 mg). The overall average IVL dosing was 113 mg (range: 60-200 mg) with an overall average weight-based dose of 1.5 mg/kg (Table 1).

Intravenous lidocaine was administered as a primary analgesic to 45% of patients, in combination with ketorolac to 45% of patients, and in combination with morphine to 10% of patients.

Intravenous lidocaine was given as a sole rescue analgesic, to 72%

(16) patients receiving ketorolac and to 10% (2) patients receiving mor- phine; and to 18% of patients (4) receiving a combination of morphine and ketorolac.

Administration of IVL resulted in decrease in overall pain score by

6.3 points, by 7.4 points when IVL was used as a primary analgesic, and by 5.2 points when IVL was given as a rescue (Table 2). Of note, 3 initial pain scores and 8 post pain scores were missing, thus data was analyzed in aggregate. There were no documented adverse effects re- lated to IVL administration.

Discussion

The severity of pain due to renal colic, which is often described as the worse pain imaginable, warrants timely, effective, and safe analgesia. Consequently, the use of NSAID’s and opioids, as well as their combina- tion, has been the cornerstone of ED pain management for this painful syndrome. However, in the pursuit of finding alternatives to the above mentioned therapeutic agents, intravenous lidocaine (preservative- free) is finding its way into the analgesic armamentarium of the ED. The mechanism by which IVL relieves pain in patients with renal colic involves a change in sympathetic smooth muscle tone towards ureteral relaxation through reducing the transmission of painful im- pulse in afferent sensory pathways [12,13]. Intravenous lidocaine 2% administered at a 1.5 mg/kg dose resulted in resolution of renal colic pain in 87% patients (7 out of 8) in a case series as well as in signifi- cant pain decrease in 90% of patients in a randomized controlled trial (in comparison to morphine) with the most common (transient) side effects of dizziness and nausea [13,14]. Similarly, the adminis- tration of IVL at a 1.5 mg/kg dose as the adjunct to intravenous mor- phine given at 0.1 mg/kg, demonstrated faster onset of analgesia and greater reduction in nausea and vomiting in comparison to intrave- nous morphine alone [15].

Our retrospective chart review demonstrated a significant change in pain score (N50% change from the baseline) when IVL was used as a pri- mary analgesic and as a rescue. Furthermore, the average dosing and range of IVL used in our study was well below the minimal toxic level of 4 mg/kg. One of the important findings of our study was the fact that a higher percentage of patients receiving intravenous ketorolac re- quired Rescue analgesia with IVL in comparison to patients receiving morphine.

Limitations

Our study was limited by its retrospective design, small sample size, and potential for a lack of accuracy of extracted data regarding prescrib- ing information. In addition, we could not completely asses the data with respect to safety of IVL, although indirect evidence, such as a lack of vital sign changes or the absence of Symptomatic treatment for side effects, would seem to support the absence of such effects. Lack of a con- trol group severely limited our ability to conclude that the results of this retrospective project were solely attributable to IVL use and not to other factors during the same time period.

Table 1

Patient demographics and lidocaine dosages.

Overall Lidocaine given as first

line

Dose (mean) (mg)

112.87

117.23

108.05

Dose range (mg)

60-200

76-200

60-150

Age (mean)

42.5

42

43

Sex M frequency (%)

33 (75%)

17 (77%)

16 (73%)

Sex F frequency (%)

11 (25%)

5 (23%)

6 (27%)

Lidocaine given as rescue

Conclusion

Despite the limitations, this study adds an additional layer of support for the utilization of IVL for patients presenting to the ED with pain of renal colic origin as a primary analgesic or as a rescue. Although prom- ising, this therapy will need to be studied in a prospective randomized fashion with a larger patient population, which includes patients with underlying cardiac disease, before it can be recommended for broad use in the ED.

1864 S. Motov et al. / American Journal of Emergency Medicine 36 (2018) 18621864

Grant support

This research did not receive any specific grant from funding agen- cies in the public, commercial, or not-for-profit sectors.

Conflicts of interest

All authors have completed and submitted the ICMJE Form for Dis- closure of Potential Conflicts of Interest. The authors have no indepen- dent disclosures or conflicts of interest.

Author contributions

Study concept and design: Motov.

Acquisition, analysis, or interpretation of data: all authors. Statistical analysis: Likourezos.

Drafting of the manuscript: Motov and Drapkin. Critical revision of the manuscript for important intellectual content:

Motov, Marshall, and Drapkin. Study supervision: Marshall.

References

  1. Golzari SE, Soleimanpour H, Rahmani F, et al. therapeutic approaches for renal colic in the emergency department: a review article. Anesth Pain Med 2014 Feb 13;4(1): e16222.
  2. Talati J, Tiselius H-G, Albala DM, et al. Urolithiasis: basic science and clinical practice. Springer Science & Business Media; Dec 22, 2012.
  3. Holdgate A, Pollock T. Systematic review of the relative efficacy of non-steroidal anti-inflammatory drugs and opioids in the treatment of acute renal colic. BMJ 2004;328(7453):1401.
  4. Hosseininejad SM, Amini Ahidashti H, Bozorgi F, et al. Efficacy and safety of combi- nation therapy with ketorolac and morphine in patient with acute renal colic; a triple-blind randomized controlled clinical trial. Bull Emerg Trauma 2017 Jul;5(3): 165-70.
  5. Davenport K, Waine E. The role of Non-steroidal anti-inflammatory drugs in renal colic. Pharmaceuticals 2010;3(5):1304-10.
  6. Afshar K, Jafari S, Marks AJ, et al. Nonsteroidal anti-inflammatory drugs (NSAIDs) and non-opioids for acute renal colic. Cochrane Database Syst Rev 2015 Jun 29;6: CD006027.
  7. O’Connor A, Schug SA, Cardwell H. A comparison of the efficacy and safety of mor- phine and pethidine as analgesia for suspected renal colic in the emergency setting. J Accid Emerg Med 2000;17:261-4.
  8. Jasani NB, O’Conner RE, Bouzoukis JK. Comparison of hydromorphone and meperi- dine for ureteral colic. Acad Emerg Med 1994 Nov-Dec;1(6):539-43.
  9. Safdar B, Degutis LC, Landry K, et al. Intravenous morphine plus ketorolac is superior to either drug alone for treatment of acute renal colic. Ann Emerg Med 2006 Aug;48

    (2) 173-81, 181.e1.

    Castellsague J, Riera-Guardia N, Calingaert B, et al. Individual NSAIDs and upper gas- trointestinal complications: a systematic review and meta-analysis of observational studies (the SOS project). Drug Saf 2012;35:1127-46.

  10. Duthie DJ, Nimmo WS. Adverse effects of opioid Analgesic drugs. Br J Anaesth 1987; 59:61-77.
  11. McGhie J, Serpell MG. Clinical pharmacology: local anesthetics. In: Macintyre PE, Walker SM, Rowbotham DJ, et al, editors. Clinical pain management (acute pain). 2nd edition. London: Hodder & Stoughton Limited; 2008. p. 113-29.
  12. Soleimanpour H, Hassanzadeh K, Mohammadi DA, et al. Parenteral lidocaine for treatment of intractable renal colic: a case series. J Med Case Reports 2011 Jun 29; 5:256.
  13. Soleimanpour H, Hassanzadeh K, Vaezi H, et al. Effectiveness of intravenous lido- caine versus intravenous morphine for patients with renal colic in the emergency department. BMC Urol 2012 May 4;12:13.
  14. Firouzian A, Alipour A, Rashidian Dezfouli H, et al. Does lidocaine as an adjuvant to morphine improve pain relief in patients presenting to the ED with acute renal colic? A double-blind, randomized controlled trial. Am J Emerg Med 2016 Mar;34 (3):443-8.