Intravenous Lidocaine for Intractable Renal Colic Unresponsive to Standard Therapy

Lidocaine coinfusion alleviates vascular pain induced by hypertonic saline infusion: a randomized, placebo-controlled trial

Background

Hypertonic saline solution has been frequently utilized in clinical practice. However, due to the nonphysiological osmolality, hypertonic saline infusion usually induces local vascular pain. We conducted this study to evaluate the effect of lidocaine coinfusion for alleviating vascular pain induced by hypertonic saline.

Methods

One hundred and six patients undergoing hypertonic saline volume preloading prior to spinal anesthesia were randomly allocated to two groups of 53 each. Group L received a 1 mg/kg lidocaine bolus followed by infusion of 2 mg/kg/h through the same IV line during hypertonic saline infusion; Group C received a bolus and infusion of normal saline of equivalent volume. Visual analogue scale (VAS) scores of vascular pain were recorded every 4 min.

Results

The vascular pain severity in Group L was significantly lower than that in Group C for each time slot (P < 0.05). The overall incidence of vascular pain during hypertonic saline infusion in Group L was 48.0%, which was significantly lower than the incidence (79.6%) in Group C (P < 0.05).

Conclusion

Lidocaine coinfusion could effectively alleviate vascular pain induced by hypertonic saline infusion.

Trial registration

Chinese Clinical Trial Registry, number: ChiCTR1900023753. Registered on 10 June 2019.

Implementation of an Advanced Pharmacy Practice Model in the Emergency Department

STUDY OBJECTIVE

The objective of this retrospective descriptive study was to quantify clinical activities performed by pharmacists in an advanced pharmacy practice model in the emergency department (ED).

METHODS

Data from January 2015 to August 2017 extracted from the department of pharmacy's electronic documentation system and the hospital's electronic medical record were collected and reviewed. Cost savings was derived from the system with adaptation from the previous literature and had been validated by our institution's administration as an acceptable reflection of the impact for activity.

RESULTS

The ED pharmacy team participated in a total of 4106 clinical activities that resulted in a cumulative cost avoidance of $5 387 679. Overall, the most common clinical activities that the pharmacy team provided included pharmacotherapy consult (63.3%) and response to medical emergencies (20.7%). A total of 16 219 medication orders placed by ED clinicians were prospectively reviewed and 379 interventions were accepted by ED clinicians. Turnaround times for medication verification in median (interquartile range [IQR]) for 2015, 2016, and 2017 were 2 minutes (1-6 minutes), 3 minutes (1-6 minutes), and 2 minutes (1-5 minutes), respectively. A total of 14 peer-reviewed publications, primarily based on pharmacy practice or use of pharmacotherapy for acute pain, were published by a research program led by the ED pharmacotherapist.

CONCLUSION

We created and implemented an advanced practice model tailored to our institution's needs. The model maximized opportunities for pharmacists to provide direct patient care, practice at the top of their license, and encouraged the safe and effective use of medications.

Essential pharmacologic options for acute pain management in the emergency setting

Pain is the root cause for the overwhelming majority of emergency department (ED) visits worldwide. However, pain is often undertreated due to inappropriate analgesic dosing and ineffective utilization of available analgesics. It is essential for emergency providers to understand the analgesic armamentarium at their disposal and how it can be used safely and effectively to treat pain of every proportion within the emergency setting. A 'balanced analgesia' regimen may be used to treat pain while reducing the overall pharmacologic side effect profile of the combined analgesics. Channels-Enzymes-Receptors Targeted Analgesia (CERTA) is a multimodal analgesic strategy incorporating balanced analgesia by shifting from a system-based to a mechanistic-based approach to pain management that targets the physiologic pathways involved in pain signaling transmission. Targeting individual pain pathways allows for a variety of reduced-dose pharmacologic options - both opioid and non-opioid - to be used in a stepwise progression of analgesic strength as pain advances up the severity scale. By developing a familiarity with the various analgesic options at their disposal, emergency providers may formulate safe, effective, balanced analgesic combinations unique to each emergency pain presentation.

Does co-treatment with ultra-low-dose naloxone and morphine provide better analgesia in renal colic patients?

OBJECTIVE

This study attempted to evaluate the efficacy of ultra-low-dose intravenous (IV) naloxone combined with IV morphine, as compared to IV morphine alone, in terms of reducing pain and morphine-induced side effects in patients with renal colic.

METHODS

In this double-blind clinical trial, 150 patients aged 34 to 60 years old who presented to the emergency department (ED) with renal colic were randomly allocated to either an intervention group that received ultra-low-dose IV naloxone combined with IV morphine or to a control group that received morphine plus a placebo. The severity of pain, sedation, and nausea were assessed and recorded for all patients at entrance to the ED (T1), then at 20 (T2), 40 (T3), 60 (T4), 120 (T5), and 180 (T6) minutes after starting treatment. The Numeric Rating Scale (NRS) was used for the assessment of pain and nausea intensities, and the Ramsay Sedation Scale (RSS) was used to assess sedation.

RESULTS

A GEE model revealed that patients in the naloxone group had non-significantly reduced pain scores compared to those in the morphine group (coefficient = -0.68; 95% CI: -1.24 to -0.11, Wald X2 (1) = 5.41, p = 0.02). The sedation outcome demonstrated no statistically significant differences at T1 to T4 among patients with renal colic compared to the ones who only received morphine. At T5 and T6, 1.5% vs. 20% and 1.5% vs. 16.9% of subjects from the naloxone group versus the morphine group obtained RSS scores equal to 3, respectively (p = 0.001 and p = 0.004, respectively).

CONCLUSIONS

Compared to patients who only received IV morphine, co-treatment of ultra-low-dose naloxone with morphine could not provide better analgesia and sedation/agitation states in renal colic patients.