Randomized comparison of efficacy of paracetamol, lornoxicam, and tramadol representing three different groups of analgesics for pain control in extracorporeal shockwave lithotripsy

2022 Recommendations of the AFU Lithiasis Committee: Extracorporeal shock wave lithotripsy (ESWL)

Extracorporeal shock wave lithotripsy (ESWL) is a minimally invasive technique for the fragmentation of urinary tract stones using shock waves under fluoroscopic and/or ultrasound guidance. ESWL results depend on the indication (stone size/composition, clinical context) and also on how it is performed. The stone structure, nature and density (Hounsfield units; evaluated by CT without contrast agent) influence the fragmentation achieved by ESWL. The upper size limit of kidney stones has been lowered to 15mm (1.68cm3) due to the increased risk of steinstrasse with larger sizes and the potential need of anesthesia and ureteral stenting. Conversely, the development of endourological technologies allows a finer stone fragmentation and/or better elimination, thus reducing the risk of steinstrasse and decreasing the potential number of sessions or additional interventions. METHODOLOGY: These recommendations were developed using two methods: the Clinical Practice Recommendations method (CPR) and the ADAPTE method, depending on whether the question was considered in the European Association of Urology (EAU) recommendations (https://uroweb.org/guidelines/urolithiasis [EAU 2022]) and their adaptability to the French context.

Intravenous paracetamol infusion and tramadol as agents for post operative pain relief in urosurgical patient: A randomized control trial

Analgesia is one of the most important consideration in perioperative setting as it determines the recovery and discharge of a patient. Among the drugs used for analgesia, non steroidal anti-inflammatory drugs and opioids are the most commonly used ones in the current scenario. The aim of this study was to compare the efficacy of intravenous (IV) paracetamol and IV tramadol in alienating pain postoperatively. 100 adult patients of ASA grade I & II in the age group of 25-55 years were randomized into two groups of 50 patients , scheduled for elective urosurgical procedures and  were administered IV paracetamol and IV tramadol 30 minutes before the completion of surgery for postoperative analgesia and assessment was done with visual analog scale (VAS)score. In the present study, both the drugs showed effective pain relief. The onset of analgesia is faster in tramadol group. In paracetamol group, the onset of analgesia was slightly delayed but pain scores significantly decreased after 60 min, and this was observed up to 6 h with a statistically significant decrease in post operative nausea vomiting( PONV )with paracetamol group . 

Postoperative Analgesic Efficacy of Preemptive and Postoperative Lornoxicam or Tramadol in Lumbar Disc Surgery

Objective

To compare preemptive and postoperative analgesic efficacy of tramadol and lornoxicam administered before anaesthesia induction in lumbar discectomy.

Methods

This randomised, double-blind trial was conducted on 60 ASA I and II patients undergoing lumbar discectomy. Group L (n=30) received 3×8 mg day^-1 lornoxicam, and Group T (n=30) received 3×1.5 mg kg^-1 day^-1 tramadol. A verbal rating scale (VRS), the duration of effective analgesia, the number of additional analgesics used, adverse effects and patient satisfaction were evaluated at the postoperative 30^th minute and 1^st, 2^nd, 4^th, 6^th, 8^th, 12^th and 24^th hours.

Results

There were no significant differences between Groups L and T regarding demographic and clinical characteristics, the number of additional analgesics and the duration of effective analgesia, adverse effects and patient satisfaction. VRS scores of the patients in Group T were significantly higher than those in Group L at the postoperative 30^th minute (p=0.050) and the 1st hour (p=0.005).

Conclusion

Lornoxicam, which was used for preemptive and postoperative analgesia in lumbar disc surgery, had provided adequate and effective analgesia such as tramadol. Moreover, preemptive analgesia was quite effective in prevention and treatment of postoperative pain.

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

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.

Renal impairment and analgesia: From effectiveness to adverse effects

Kidney pain is one of the clinically significant features of renal dysfunction. Mild to severe pain is seen in the lower back area. Painkillers are mostly recommended in these cases to relieve the symptom. Yet, several analgesics are associated with side effects that can worsen the state of the disease. This review is based on the studies conducted in these aspects analgesics used to treat kidney pain and their effectiveness, renal consequences of postoperative analgesia, and pharmacogenetics of these palliatives are briefly summarized in this paper.

A novel triple oral regime provides effective analgesia during extracorporeal shockwave lithotripsy for renal stones

Context:

Analgesia during extracorporeal shockwave lithotripsy for renal stone is an essential component. It not only makes the procedure comfortable but also increases the stone-free rate.

Aims:

The aim of this study was to evaluate the efficacy of triple oral analgesic agents on stone fragmentation and pain relief in comparison to injectable analgesic agents.

Settings and Design:

This prospective randomized study included 68 patients of renal calculi of size 5–15 mm.

Subjects and Methods:

Group A had 32 patients, who received injection pentazocine and injection diclofenac, 45 min before the procedure. Group B consisted of 28 patients, who received a combination of oral acetaminophen, 325 mg, oral diclofenac 50 mg, and oral tramadol 37.5 mg, 45 min prior. Procedural findings, pain score visual analog scale (VAS), fragmentation rate, and outcome were recorded.

Statistical Analysis Used:

Independent t-test and Pearson's correlation test.

Results:

A total of 60 patients were analyzed. The mean age was 40.2 ± 11.8 years. Both groups were comparable in body mass index, stone size, number, and density. Group A required more shocks than Group B (4274 vs. 3693, P = 0.043). A lower energy level of shocks (kV) was tolerated in Group A (2.5 vs. 3.2, P = 0.002). Group A required more sittings than Group B (2.3 vs. 1.9, P = 0.037). VAS score was significantly less in Group B (2.9 vs. 4.9, P = 0.0001). The overall fragmentation rate was similar among groups (81.2% vs. 89.3%); hence, the successful outcome was (59.4% vs. 75.0%, P = 0.274). The occurrence of adverse events was also equivalent in both groups (P = 0.199).

Conclusions:

Triple oral regime provides better analgesic effect and quicker stone-free rate than injectable agents but with similar final outcome.

Analgesia for patients undergoing shockwave lithotripsy for urinary stones - a systematic review and meta-analysis

Background

Shock wave lithotripsy (SWL) is the first line treatment modality for a significant proportion of patients with upper urinary tracts stones. Simple analgesics, opioids and non-steroidal anti-inflammatory drugs (NSAIDs) are all suitable agents but the relative efficacy and tolerability of these agents is uncertain.

Objectives

To determine the efficacy of the different types of analgesics used for the control of pain during SWL for urinary stones.

Materials and Methods

We searched the Cochrane Renal Group’s Specialised Register, MEDLINE, EMBASE and also hand-searched reference lists of relevant articles (Figure-1). Randomised controlled trials (RCT’s) comparing the use of any opioid, simple analgesic or NSAID during SWL were included. These were compared with themselves, each-other or placebo. We included any route or form of administration (bolus, PCA). We excluded agents that were used for their sedative qualities. Data were extracted and assessed for quality independently by three reviewers. Meta-analyses have been performed where possible. When not possible, descriptive analyses of variables were performed. Dichotomous outcomes are reported as relative risk (RR) and measurements on continuous scales are reported as weighted mean differences (WMD) with 95% confidence intervals.

Results

Overall, we included 9 RCTs (539 participants from 6 countries). Trial agents included 7 types of NSAIDs, 1 simple analgesic and 4 types of opioids. There were no significant differences in clinical efficacy or tolerability between a simple analgesic (paracetamol) and an NSAID (lornoxicam). When comparing the same simple analgesic with an opioid (tramadol), both agents provided safe and effective analgesia for the purpose of SWL with no significant differences. There were no significant differences in pain scores between NSAIDs or opioids in three studies. Adequate analgesia could be achieved more often for opioids than for NSAIDs (RR 0.358; 95% CI 043 to 0.77, P=0.0002) but consumed doses of rescue analgesia were similar between NSAIDs and opioids in two studies (P=0.58, >0.05). In terms of tolerability, there is no difference in post-operative nausea and vomiting (PONV) between the groups (RR 0.72, 95% CI 0.24 to 2.17, P=0.55). One study compared outcomes between two types of NSAIDs (diclofenac versus dexketoprofen). There were no significant differences in any of our pre-defined outcomes measures.

Conclusion

Simple analgesics, NSAIDs and opioids can all reduce the pain associated with shock wave lithotripsy to a level where the procedure is tolerated. Whilst there are no compelling differences in safety or efficacy of simple analgesics and NSAIDs, analgesia is described as adequate more often for opioids than NSAIDs.

Pharmacology of Acetaminophen, Nonsteroidal Antiinflammatory Drugs, and Steroid Medications: Implications for Anesthesia or Unique Associated Risks

Acetaminophen, nonsteroidal antiinflammatory drugs (NSAIDs), and corticosteroids, historically used in perioperative management, are potent analgesic medications. They primarily inhibit the cyclooxygenase (COX) enzyme, decreasing the synthesis of prostaglandins, and modulating pain and temperature. Acetaminophen does not inhibit this synthesis at the inflammatory site. The primary mechanism of action of corticosteroids involves regulation of nuclear expression of genes involved in inflammatory pathways and other systemic effects. Metaanalyses have added purposeful perioperative indications, clarified misconceptions, and established protocols for administering these drugs. Some indications, doses, clinical considerations, and adverse effects need to be further studied.

Pain management in trauma: A review study

Background:

Pain in trauma has a role similar to the double-edged sword. On the one hand, pain is a good indicator to determine the severity and type of injury. On the other hand, pain can induce sever complications and it may lead to further deterioration of the patient. Therefore, knowing how to manage pain in trauma patients is an important part of systemic approach in trauma. The aim of this manuscript is to provide information about pain management in trauma in the Emergency Room settings.

Methods:

In this review we searched among electronic and manual documents covering a 15-yr period between 2000 and 2016. Our electronic search included Pub Med, Google scholar, Web of Science, and Cochrane databases. We looked for articles in English and in peer-reviewed journals using the following keywords: acute pain management, trauma, emergency room and injury.

Results:

More than 3200 documents were identified. After screening based on the study inclusion criteria, 560 studies that had direct linkage to the study aim were considered for evaluation based World Health Organization (WHO) pain ladder chart.

Conclusions:

To provide adequate pain management in trauma patients require: adequate assessment of age-specific pharmacologic pain management; identification of adequate analgesic to relieve moderate to severe pain; cognizance of serious adverse effects of pain medications and weighting medications against their benefits, and regularly reassessing patients and reevaluating their pain management regimen. Patient-centered trauma care will also require having knowledge of barriers to pain management and discussing them with the patient and his/her family to identify solutions.

Shockwave Lithotripsy Practice Pattern Variations Among and Between American and Canadian Urologists: In Support of Guidelines

PURPOSE

Shockwave lithotripsy (SWL) is a widely utilized form of treatment for urolithiasis. There are new evidence-based recommendations regarding pre-SWL patient work-up and the performance of SWL. The purpose of this study is to determine practice patterns for SWL and to determine if regional variation exists between Canada and the United States.

MATERIALS AND METHODS

A 19-question survey was prepared. Canadian urologists were surveyed through e-mail correspondence. In the United States, members of the Endourologic Society and members of two large stone management groups were surveyed. Canadian and American results were compared using the chi-square and Fisher's exact tests.

RESULTS

Ninety-four Canadian urologists and 187 U.S. urologists completed the survey. Practice patterns differed between countries. Intravenous sedation was more commonly used in Canada (Canada 94.7% vs United States 17.9%, p < 0.001); routine antibiotics were more commonly given in United States (Canada 2.1% vs United States 78.1%, p < 0.001); a shock rate of 2 Hz was more common in Canada (Canada 76.6% vs United States 16.2%, p < 0.00001); rate of discontinuing ASA for renal and ureteral stone treatment was higher in the United States (renal Canada 88.3% vs United States 95.7%, p < 0.02; ureteral Canada 62.4% vs 90.3%, p < 0.0001); and ureteral stents were more commonly used if treating a large stone or patients with solitary kidneys in the United States (large stones Canada 58.2% vs United States 88.8%, p = 0.0001; solitary kidney Canada 50.6% vs 66.3%, p = 0.02).

CONCLUSIONS

This study highlights the absence of standardization of SWL. Significant regional differences exist in practice patterns and performance of SWL between Canadian and American urologists.

A comparative study of intravenous paracetamol and intravenous tramadol for postoperative analgesia in laparotomies

Background:

Pain in the perioperative setting or thereafter plays a significant role in delaying an otherwise successful recovery. Hence, mitigation of such postoperative pain assumes importance. Among the various agents employed for such mitigation, opioids and non-steroidal anti-inflammatory drugs have for some time taken center stage. However, alas they are not without their share of adverse effects. This study was undertaken with the purpose of elucidating the efficacy of intravenous (IV) paracetamol as compared to IV tramadol in mitigating postoperative pain while observing its effect on hemodynamic stability and the presence of adverse drug reactions, if any.

Materials and Methods:

A total of 60 randomized cases aged ranges from 20 to 60 years of both sexes divided into two groups (each for paracetamol and tramadol) scheduled for laparotomies were administered IV paracetamol and tramadol for postoperative pain relief and assessed with visual analog scale (VAS) score and variations in vital parameters to ascertain extent of pain relief and post-operative nausea vomiting (PONV).

Results:

Data so collected was statistically interpreted, and observations extrapolated. Save for a perceptible decline in PONV with paracetamol group compared with tramadol group with a statistically significant P < 0.001, nothing statistically significant was observed in any other parameter, including VAS scores between either group.

Conclusion:

IV paracetamol is a safer alternative to tramadol with lesser PONV in the postoperative period translates into the lesser duration of hospitalization and hence earlier discharge.

Unfocused extracorporeal shock waves induce anabolic effects in osteoporotic rats

Unfocused extracorporeal shock waves (UESW) have been shown to have an anabolic effect on bone mass. Therefore we investigated the effects of UESW on bone in osteoporotic rats with and without anti-resorptive treatment. Twenty-week-old rats were ovariectomized (n = 27). One group was treated with saline and another group with Alendronate (ALN) 2.4 µg/kg, 3×/week. UESW were applied 2 weeks after ovariectomy. Thousand UESW were applied to one hind leg, the contra-lateral hind leg was not treated and served as control. With the use of in vivo micro-CT scanning it was shown that in saline treated rats trabecular bone volume fraction (BV/TV) was higher at 2 weeks follow-up in UESW treated legs compared to control legs. However, at 4 and 10 weeks no difference was found. In ALN treated animals UESW led to a pronounced anabolic response resulting in an increase in BV/TV at all time-points. Furthermore, UESW resulted in increased cortical volume (CtV), higher trabecular connectivity and, more plate-like and thicker trabeculae. Biomechanical testing showed that UESW lead to a higher maximum force before failure and higher stiffness in all treatment groups. With histology abundant areas of intramembranous bone formation along the periosteal cortex and within the bone marrow were observed. In conclusion this study shows promising results for the use of UESW in the treatment of osteoporosis, especially when this treatment is combined with an anti-resorptive treatment.

Comparison of three different analgesic protocols during shockwave lithotripsy

BACKGROUND AND PURPOSE

Shockwave lithotripsy (SWL) is one of the most important treatment modalities for urinary stone disease. The procedure may cause pain, and patient relaxation and cooperation are crucial in maintaining stone localization for optimal fragmentation and patient comfort during the procedure. As yet, there is not a standard analgesic protocol for patients undergoing SWL. We aimed to use three different analgesic agents and compare their efficacy during SWL in this study.

PATIENTS AND METHODS

Written informed consents were obtained from 95 patients with kidney stones, and they were randomized to receive lornoxicam (group L, n=32 patients), paracetamol (group P, n=31 patients), and tramadol with a patient-controlled analgesia device (group T, n=32 patients). All groups received patient-controlled analgesia with tramadol during the SWL procedure. The intensity of pain was evaluated with a visual analog scale (VAS).

RESULTS

The mean age of the patients was 41.87 ± 16.53 years, 44.07 ± 11.48 years, and 41.24 ± 14.82 years in group L, group P, and group T, respectively. No significant differences were found between the three groups concerning patient age, stone location, or session duration (P>0.05). The mean VAS scores and analgesic consumption were lower in group L compared with other groups (P<0.05).

CONCLUSION

The results of this study showed that additional administration of analgesics was decreased with intravenous lornoxicam in comparison with paracetamol and only tramadol.

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.