Comparing two local anesthesia techniques for extracorporeal shock wave lithotripsy

A comprehensive painkillers screening by assessing zebrafish behaviors after caudal fin amputation

Recently, the usage of zebrafish for pain studies has increased in the past years, especially due to its robust pain-stimulated behaviors. Fin amputation has been demonstrated to induce a noxious response in zebrafish. However, based on the prior study, although lidocaine, the most used painkiller in zebrafish, has been shown to ameliorate amputated zebrafish behaviors, it still causes some prolonged effects. Therefore, alternative painkillers are always needed to improve the treatment quality of fin-amputated zebrafish. Here, the effects of several analgesics in recovering zebrafish behaviors post-fin amputation were evaluated. From the results, five painkillers were found to have potentially beneficial effects on amputated fish behaviors. Overall, these results aligned with their binding energy level to target proteins of COX-1 and COX-2. Later, based on their sub-chronic effects on zebrafish survivability, indomethacin, and diclofenac were further studied. This combination showed a prominent effect in recovering zebrafish behaviors when administered orally or through waterborne exposure, even with lower concentrations. Next, based on the ELISA in zebrafish brain tissue, although some changes were found in the treated group, no statistical differences were observed in most of the tested biomarkers. However, since heatmap clustering showed a similar pattern between biochemical and behavior endpoints, the minor changes in each biomarker may be sufficient in changing the fish behaviors.

Is unilateral transversus abdominis plane block an analgesic alternative for ureteric shock wave lithotripsy?

Background:

Various sedative and analgesic techniques have been used during shock wave lithotripsy (SWL).

Aim:

This study aimed at evaluating the efficacy of ultrasound-guided unilateral transversus abdominis plane (TAP) block as an analgesic technique alternative during ureteric SWL.

Settings and Design:

Prospective randomized comparative study.

Materials and Methods:

Fifty patients scheduled for ureteric SWL were randomly allocated into two equal groups: Group (F) received 1.5 mcg/kg fentanyl intravenous and group (T) received unilateral TAP block with injection of 25 ml of bupivacaine 0.25% (62.5 mg).

Statistical Analysis:

Statistical analysis was performed using SPSS program version 19 and EP16 program.

Results:

The visual analog scale was significantly less in group (T) than in group (F) both intra-operatively (at 10, 20, 30, and 40 min) and postoperatively (at 10 min intervals in the postanesthesia care unit [PACU]) (P < 0.001). Rescue analgesia with pethidine during the procedure and in the PACU was less (P < 0.001) in the group (T) than group (F) with a median of 20 mg versus 55 mg, respectively. The higher sedation scores observed in group (F) at 15, 25, and 35 min during the procedure, and at 20 min during the PACU time were statistically highly significant (P < 0.001), but only significant at 10 min (P = 0.03) and 30 min (P = 0.007) during the PACU time. There was also highly significant decrease (P < 0.001) in the time of PACU stay in group (T) (38.2 ± 6.6 min) compared with group (F) (89.2 ± 13.39 min). We recorded 6 patients in group (F) (24%) who have developed respiratory depression (respiratory rate < 10 breaths/min) compared to 0% in group (T) (P = 0.022). In addition, in group (F) nausea was noted in 8 patients (32%) and vomiting in 6 patients (24%), which was statistically significant when compared to group (T) (0%) (P = 0.01 and 0.022, respectively).

Conclusion:

Ultrasound-guided unilateral TAP block is an effective alternative analgesic technique during ureteric SWL.

The Effect of EMLA Cream on Patient-Controlled Analgesia with Remifentanil in ESWL Procedure: A Placebo-Controlled Randomized Study

BACKGROUND

To alleviate stinging pain in the skin entry area and visceral discomfort in patients who are undergoing ESWL.

OBJECTIVES

This study was designed to investigate the effectiveness of the EMLA cream in combination with remifentanil patient-controlled analgesia (PCA) in patients undergoing ESWL treatment.

PATIENTS AND METHODS

Sixty patients were divided into two double-blind randomized groups. Those in the first group were administered 3-5mm of EMLA 5% cream on a marked area; the second group received, as a placebo, a cream with no analgesic effect in the same amount. All patients were administered a remifentanil bolus with a PCA device. Arterial blood pressure, oxygen saturation, and respiratory rate were recorded throughout the procedure; postoperative side effects, agitation, and respiratory depression were measured after. Visual Analogue Scale (VAS) scores were taken preoperatively, perioperatively, directly postoperatively, and 60 minutes subsequent to finishing the procedure.

RESULTS

There were no statistically significant differences in the frequency of PCA demands and delivered boluses or among perioperative VAS. No significant side effects were noted. Patient satisfaction was recorded high in both groups.

CONCLUSIONS

EMLA cream offered no advantage over the placebo cream in patients undergoing ESWL with remifentanil PCA.

Drugs for pain management in shock wave lithotripsy

Objective. With this review, we provide a comprehensive overview of the main aspects and currently used drugs for analgesia in shockwave lithotripsy. Evidence Acquisition. We reviewed current literature, concentrating on newer articles and high-quality reviews in international journals. Results. No standardized protocols for pain control in SWL exist, although it is crucial for treatment outcome. General and spinal anaesthesia show excellent pain control but are only recommended for selected cases. The newer opioids and nonsteroidal anti-inflammatory drugs are able to deliver good analgesia. Interest in inhalation anaesthesia with nitrous oxide, local anaesthesia with deep infiltration of the tissue, and dermal anaesthesia with EMLA or DMSO has recently rekindled, showing good results in terms of pain control and a favourable side effect profile. Tamsulosin and paracetamol are further well-known drugs being currently investigated. Conclusion. Apart from classically used drugs like opioids and NSARs, medicaments like nitrous oxide, paracetamol, DMSA, or refined administration techniques for infiltration anaesthesia show a good effectiveness in pain control for SWL.

Analgesia for pain control during extracorporeal shock wave lithotripsy: Current status

Purpose of Review

A cooperative patient is essential in maintaining stone targeting for optimal fragmentation during extracorporeal shock wave lithotripsy (ESWL). Therefore, it is important to choose an appropriate analgesic with minimal adverse effects. The guidelines for pain management during ESWL have not been established.

Current Status

Various analgesic agents including opioids (morphine, pethidine, and fentanyl), nonsteroidal anti-inflammatory drugs (NSAIDS - diclofenac, propofol, ketorolac, and piroxicam), local anesthetic agents and a number of combinations have been used during ESWL by various techniques (general anesthesia, regional anesthesia, subcutaneous and intravenous injections, patient-controlled analgesia, and monitored anesthesia care). Cutaneous creams like eutectic mixture of local anesthesia (EMLA) whether used alone or in combination with oral NSAIDS have also been used and are able to reduce analgesic requirements. Topical application of a combination of dimethyl sulfoxide and lidocaine has also been found to be effective.

Conclusion

The ideal analgesic, offering optimal pain control, minimal side effects, and cost-effectiveness is still elusive. Opioids administered using various techniques, provide effective analgesia, but require active monitoring of patient for potential adverse effects. Combination therapy (oral NSAID and occlusive dressing of EMLA, DMSO with lidocaine) offers an effective alternative mode for achieving analgesia with minimal morbidity. This therapy avoids the need for general anesthesia, injectable analgesics, and opioids along with their side effects.

Pain perception during shock wave lithotripsy: does it correlate with patient and stone characteristics?

BACKGROUND

To investigate the correlation of various clinical parameters [number of shock wave lithotripsy (SWL) sessions, body mass index, patient age, gender, and stone characteristics] with pain perception during the SWL procedure.

METHODS

A total of 88 patients who underwent 165 SWL sessions for renal or ureteral stones in our institution were included in the study. The degree of pain perception during the procedure was evaluated with a 10-point visual analog scale.

RESULTS

A significant p value was reached when the cut-off value for stone burden was taken as 100 mm(2). Mean pain scores during the SWL procedures were affected by gender and the number of SWL sessions. However, they were not affected by laterality, patient age, body mass index, and location of stones.

CONCLUSION

Our results suggest that patient comfort is better during the first SWL session than in the following sessions for renal or ureteral stones with a stone burden of less than 100 mm(2). In addition, severity of pain during SWL treatment may be better tolerated in males than in females.

Epidural anesthesia is effective for extracorporeal shock wave lithotripsy of pancreatic and biliary calculi

AIM: To evaluate the efficacy of thoracic epidural analgesia for extracorporeal shock wave lithotripsy (ESWL).

METHODS: ESWL is an effective, non-invasive technique for the treatment of difficult pancreatic and large bile duct calculi. The procedure is often painful and requires large doses of analgesics. Many different anesthetic techniques have been used. Patients with either large bile duct calculi or pancreatic duct calculi which could not be extracted by routine endoscopic methods were selected. Thoracic epidural anesthesia (TEA) was routinely used in all the subjects unless contraindicated. Bupivacaine 0.25% with or without clonidine was used to block the segments D6 to D12. The dose was calculated depending on the age, height and weight of the patient. It was usually 1-2 mL per segment blocked.

RESULTS: Ninety eight percent of the 1509 patients underwent ESWL under TEA. The subjects selected were within American Society of Anesthesiologists grade I to III. ESWL using EA permitted successful elimination of bile duct or pancreatic calculi with minimal morbidity. The procedure time was shorter in patients with TEA than in those who underwent ESWL under total intravenous anesthesia.

CONCLUSION: Almost all patients undergoing ESWL with EA had effective blocks with a single catheter insertion and local anesthetic injection.

Patient tolerance during cystoscopy: a randomized study comparing lidocaine hydrochloride gel and dimethyl sulfoxide with lidocaine

PURPOSE

Cystoscopy is one of the most common examinations in urologic outpatient clinics. Various anesthetic approaches have been used to make cystoscopy more tolerable for patients. The aim of the present prospective randomized study was to evaluate the efficacy of lidocaine hydrochloride gel compared to dimethyl sulfoxide (DMSO) with lidocaine in rigid cystoscopy.

MATERIALS AND METHODS

Male patients requiring 17F rigid cystoscopy were eligible for inclusion in this study. A total of 140 patients were divided into two groups: group 1 (n=70) received approximately 11 mL of 2% lidocaine gel intraurethrally, while in group 2 (n=70) approximately 10 mL of 40% DMSO with an amount of lidocaine equal to that in the lidocaine gel was smeared around the scope and external urethral meatus. A penile clamp was placed for 15 minutes and 5 minutes in group 1 and group 2, respectively. Immediately after cystoscopic examination pain was scored on a 10-cm visual analog scale.

RESULTS

The mean pain scores after the procedure for group 1 and group 2 were 3.9+/-1.1 and 2.1+/-1.0, respectively. The pain scores were significantly lower for group 2 than for group 1 (P=0.015). No patients needed additional anesthetic agents or sedatives due to insufficient analgesia, and there were no serious side effects in either group.

CONCLUSIONS

Our study has shown that DMSO with lidocaine gel causes significantly less delivery discomfort in the male urethra than lidocaine hydrochloride gel. The advantages of DMSO with lidocaine are the mixture takes less time to act and had lower pain scores.