Effectiveness of eutectic mixture of local anesthetic cream and occlusive dressing with low dosage of fentanyl for pain control during shockwave lithotripsy

BACKGROUND AND PURPOSE: To investigate the effect and usefulness of Eutectic Mixture of Local Anesthetic (EMLA) applied with an occlusive dressing and used simultaneously with a low dose of fentanyl during shockwave lithotripsy (SWL). PATIENTS AND METHODS: One hundred sixty patients with kidney stones, aged between 19 and 68 years, were randomly divided into seven groups that were treated as follows: group 1: fentanyl 1 microg/kg by intravenous infusion (IV); group 2: IV fentanyl 0.25 microg/kg; group 3: occlusive dressing and IV fentanyl 0.25 microg/kg; group 4: placebo cream and IV fentanyl 0.25 microg/kg; group 5: EMLA cream and IV fentanyl 0.25 microg/kg; group 6: placebo cream and IV fentanyl 0.25 microg/kg with an occlusive dressing; and group 7: EMLA cream and IV fentanyl 0.25 microg/kg with an occlusive dressing. The mean arterial pressure (MAP), heart rate, ventilatory rate, and oxygen saturation (SpO(2)) were recorded on all patients. A visual analog scale 0-100 mm (VAS) was used for the evaluation of pain. The skin integrity was inspected to detect any lesions after SWL. RESULTS: The SpO(2) in group 1 was lower statistically than in the other groups. The VAS score in group 7 was clearly lower than in the others in the first, tenth, and twentieth minutes and at the end of SWL. In groups 6 and 7, additional fentanyl doses were lower than in the other groups, but only in group 7 was the total fentanyl dosage low. Skin lesions were not seen only in groups 3, 6, and 7. CONCLUSION: Use of EMLA and an occlusive dressing with low doses of fentanyl during SWL provides appropriate analgesia with minimal morbidity.     

The use of a eutectic mixture of local anesthetic in pediatric renal biopsy

Eight children undergoing percutaneous renal biopsy had eutectic mixture of local anesthetic (EMLA) cream substituted for dermal infiltration of local anesthetic. Five children reported no sensation of the initial skin puncture and only one child reported feeling a sharp object. EMLA cream may form a useful part of pediatric renal biopsy.     

The use of local anesthesia in second generation extracorporeal shock wave lithotripsy: eutectic mixture of local anesthetics

Extracorporeal shock wave lithotripsy (ESWL&) can be painful. Of our population of patients treated with a Siemens Lithostar device 51.4% needed intravenous analgesia. A eutectic mixture of local anesthetics, a hydrophylic cream containing 25 mg. lidocaine and 25 mg. prilocaine per gm., proved to be effective for local analgesia. Therefore, we investigated its effectiveness during ESWL. With randomized, double-blind application the eutectic mixture of local anesthetics and placebo were evaluated in 83 patients according to the percentage of patients who required intravenous analgesia during ESWL. Of 40 patients treated with the eutectic mixture of local anesthetics 12 (30%) needed supplementary fentanyl citrate, compared to 23 of 43 (53%) placebo treated patients. Although there is no statistical significance (p = 0.32), the eutectic mixture of local anesthetics does decrease pain during ESWL and it should be particularly useful for patients in whom intravenous analgesia is contraindicated.     

Efficacy of a eutectic mixture of local anesthetics as a topical anesthetic in minor otologic procedures.

A eutectic mixture of local anesthetics (EMLA), prepared as a cream, is an oil-in-water emulsion of 2 anesthetic agents lidocaine and prilocaine. Several clinical applications of EMLA cream, its effectiveness as a topical anesthetic, and its safety profile have been previously reported. We report our experience with EMLA cream in 17 adult and 24 pediatric patients. We find EMLA to be the preferred anesthetic for performing minor outpatient otologic procedures in adults. We also find EMLA to be a safe, well-tolerated alternative to general anesthesia in some pediatric patients. Potential cost savings of EMLA cream during pediatric myringotomies in the clinic are also discussed.     

Eutectic mixture of local anaesthetics is not effective for extracorporeal shock wave lithotripsy

Purpose

Eutectic mixture of local anaesthetics (EMLA®) produces cutaneous analgesia. This randomized, double blind, placebo controlled study evaluated the efficacy of EMLA cream during extracorporeal shock wave lithotripsy (ESWL) using the Dornier® MFL 5000 lithotripter.

Methods

Patients scheduled to undergo lithotripsy of renal or pelviureteric junction stones were randomized to receive either 30 g EMLA cream (E) or placebo (P) over the kidney area 60–90 min before the procedure. During lithotripsy all patients received alfentanil via a PCA machine (dose —10 μ · kg^?1, lockout time —three minutes, no basal infusion). Additional bolus doses of 5 μg · kg^?1 alfentanil were administered by the anaesthetist if analgesia was inadequate. Visual analogue scores (VAS) for pain were documented prior to application of the cream. On arrival in the post anaesthesia care unit VAS pain scores were documented for maximum pain and average pain felt during the procedure as well as for satisfaction of the analgesic technique used. Total time spent in the PACU and the Aldrete scores on arrival were compared.

Results

Eighty-three patients completed the study. Demographic data were similar between the two groups. Also, VAS for maximal pain, average pain and satisfaction and the total number of shock waves were similar although the EMLA group received more shock waves at the lower energy level (kV) (P < 0.0001). Total dose of alfentanil, dose as boluses, rate of alfentanil use, total number of PCA attempts and missed attempts were similar. The incidence of adverse events such as bradypnoea, airway obstruction, transient hypoxaemia, pruritus and nausea were small and similar. There was a slightly higher incidence of inadequate analgesia documented by the anaesthetist in the EMLA group. There was no difference between the groups with regards to duration of stay in the PACU, incidence of nausea or Aldrete scores on admission to PACU.

Conclusions

During lithotripsy EMLA cream does not modify the pain perceived nor does it have any opioid sparing effect. It does not facilitate early discharge from the PACU.     

Minimally invasive percutaneous nephrolithotomy: an alternative to retrograde intrarenal surgery and shockwave lithotripsy

Purpose

There is a lack of studies comparing shock wave lithotripsy (SWL), retrograde intrarenal surgery (RIRS) and minimally invasive percutaneous nephrolithotomy (MIP) in renal stone treatment. This study compared treatment outcome, stone-free rate (SFR) and stone-free survival (SFS) with regard to stone size and localization.

Methods

This analysis included 482 first-time-treated patients in the period 2001–2007. Detailed clinical information, stone analysis and metabolic evaluation were evaluated retrospectively. Outcome, SFR and SFS were analyzed with regard to size (<1 vs. ≥1 cm) and localization (lower vs. non-lower pole).

Results

Higher SFRs in lower and non-lower pole stones ≥1 cm were confirmed for RIRS and MIP (p < 0.0001). A regression model confirmed a higher risk of non-lower pole stone persistence for SWL versus RIRS (OR: 2.27, p = 0.034, SWL vs. MIP (OR: 3.23, p = 0.009) and larger stone burden ≥1 versus <1 cm (OR: 2.43, p = 0.006). In accordance, a higher risk of residual stones was found in the lower pole for SWL versus RIRS (OR: 2.67, p = 0.009), SWL versus MIP (OR: 4.75, p < 0.0001) and stones ≥1 cm versus <1 cm (OR: 3.02, p = 0.0006). In RIRS and MIP patients, more complications, stenting, prolonged disability, need/duration of hospitalization and analgesia were noticed (p < 0.05). Overall SFS increased from SWL, RIRS, to MIP (p < 0.001). SWL showed lower SFS for non-lower pole (p = 0.006) and lower pole stones (p = 0.007).

Conclusions

RIRS and MIP were shown to have higher stone-free rates and SFS compared to SWL. The price for better outcome was higher, considering tolerable complication rates. Despite larger preoperative stone burden, MIP achieved high and long-term treatment success.     

Comparison of three analgesic regimens for pain control during shockwave lithotripsy using Dornier Delta Compact lithotripter: a randomized clinical trial

PURPOSE: To compare the efficacy and adverse effects of oral diclofenac, topical eutectic mixture of local anesthesia (EMLA), and their combination for pain control during shockwave lithotripsy (SWL) and to investigate the need for supplemental analgesia, patient satisfaction, and overall treatment outcomes. PATIENTS AND METHODS: A series of 240 consecutive patients with urolithiasis scheduled for SWL between May 2006 and December 2006 were randomized equally into three groups that were treated as follows: group A oral (tablet) diclofenac sodium 60 minutes prior to SWL (50 mg for body weight <70 kg; 100 mg for body weight >70 kg); group B occlusive dressing of EMLA (5 g) 60 minutes prior to SWL; group C combination of oral diclofenac sodium (in the prescribed dose) and occlusive dressing of EMLA (5 g) 60 minutes prior to SWL. A visual analog scale (VAS) was used for the subjective evaluation of pain. The various parameters were recorded and analyzed statistically. RESULTS: The total number of shock waves delivered, the maximum voltage used, and SWL duration were statistically greater in group C (P < 0.0001). The VAS scores at 15, 30, 45, 60, and 120 minutes and the supplemental analgesia requirement were statistically less in group C (P < 0.0001). The stone fragmentation rate, stone-free rate at 3 months (88.75%), and modified Efficiency Quotient (0.64) were statistically greater in group C (P < 0.0001). The post-SWL auxiliary procedure rate (P < 0.0001) and Steinstrasse rate (P = 0.03) were statistically less in group C. CONCLUSIONS: The use of a combination of oral diclofenac sodium and an occlusive dressing of EMLA cream during SWL provides adequate analgesia with minimal morbidity, avoids the need for parenteral analgesics and their attendant side effects, and improves the success rate of SWL.     

Transdermal diclofenac patchvs eutectic mixture of local anesthetics for venous cannulation pain

PURPOSE: To compare the efficacy and side effects of transdermal diclofenac patch with eutectic mixture of local anesthetic (EMLA) cream in attenuating venous cannulation pain. METHODS: Adult ASA I or II patients undergoing elective surgery were randomly divided into three groups of 150 each. Group 1 (Control) patients received a placebo patch; Group 2 (EMLA) patients received EMLA cream; Group 3 (Diclofenac) patients received a transdermal diclofenac patch. The patches were applied at the proposed venous cannulation site 60 min prior to cannulation and pain resulting from an 18G cannula was assessed on an ten-point visual analogue scale (VAS). The cannulation site was observed for blanching, erythema, induration and edema for up to 24 hr. RESULTS: The incidence of venous cannulation pain was 100% in the control group, as compared to 37% and 48% of patients who experienced pain in the EMLA (P = 0.001) and diclofenac (P = 0.001) groups, respectively. The severity of venous cannulation pain [median (VAS) with interquartile ranges] was also higher in the control group: 6 (3) as compared to VAS sores of 0 (1) and 0 (2) in the EMLA (P = 0.001) and diclofenac (P = 0.001) groups. Blanching occurred with greater frequency in the EMLA group compared with the diclofenac (P = 0.001 at six hours) and placebo groups (P = 0.001 at six hours). Erythema, induration and edema were reduced in the diclofenac group compared with the EMLA (P = 0.001 for all comparisons) and placebo groups (P = 0.04 for edema at six hours and P = 0.001 for other comparisons). CONCLUSION: Transdermal diclofenac patch and EMLA are equally effective in reducing venous cannulation pain, but signs of erythema, induration and edema are less frequently observed with the transdermal diclofenac patch.     

Continuous spinal anaesthesia using a standard epidural set for extracorporeal shockwave lithotripsy

Purpose

Continuous spinal anaesthesia (CSA) offers considerable advantages over “single shot” spinal or epidural anaesthesia since it allows titration of anaesthesia using small doses of local anaesthetics (LA). We evaluated the feasibility of CSA using a standard epidural set for extracorporeal shockwave lithotnpsy (ESWL).

Methods

Charts of 100 consecutive CSAs for ESWL were retrospectively reviewed. Lumbar CSA was performed using a 20G epidural catheter through an 18G Tuohy needle. The CSA was preplanned, or followed inadvertent dural puncture. Small LA boluses were injected to achieve the desired sensory level of anaesthesia. Demographic data, anaesthetic duration, LA doses, the most cephalad sensory level to pinprick, arterial blood pressure, heart rate, use of systemic sympathomimetics and complications were recorded.

Results

Mean age was 66.2 ± 9.9 (SD). The ASA status was III–IV in 54.1 % and 5.5% of the preplanned and inadvertent patients, respectively. In 85 anaesthetics, hyperbanc bupivacaine 0.1% (9.7 ± 7.5 mg) was used as the sole anaesthetic. Sensory level was T₄-T₈. Maximal decrease in systolic and diastolic blood pressures and heart rate was 19.0 ± 9.8%, 13.4 ± 13.3%, and 7.2 ± 11.7 respectively. Intravenous sympathomimetics were used in nine of 82 (11.0%) preplanned, and in six of 18 (33.3%) inadvertent anaesthetics. Post dural puncture headache appeared following two of 82 (2.5%) preplanned, and four of 18 (22.2%) inadvertent anaesthetics. No postanaesthetic neurological deficit was detected.

Conclusion

Continuous spinal anaesthesia, using a standard epidural set and hyperbaric bupivacaine is feasible for ESWL in high risk patients. Inadvertent dural puncture does not preclude CSA under these circumstances.     

Outcomes of shockwave lithotripsy for upper urinary-tract stones: a large-scale study at a single institution

PURPOSE: We investigated the risk factors having an impact on the achievement of stone-free status and on the success rate, as well as on the likelihood of recurrence, in patients undergoing shockwave lithotripsy. PATIENTS AND METHODS: We evaluated the characteristics and outcomes of 3023 patients (3254 renal units) with upper urinary-tract stones who underwent SWL at the Funabashi Clinic over a 13-year period. We assessed the stone-free and success rates for 2844 patients (3061 renal units) 3 months post-SWL. We also determined the recurrence rate for the 1078 patients (1139 renal units) who had achieved stone-free status at that time. RESULTS: Overall, stone-free status was achieved in 65.1% of patients, and the success rate was 85.7%. There were significant differences in the stone-free rates depending on patient age, history of urolithiasis, and presence of pyuria before SWL, as well as the number, location, size, and composition of the stones. Stones recurred in 326 of 1139 renal units (28.6%) during a mean follow-up of 36 months. The recurrence rates were 7.5%, 24.1%, and 33.0% after 1, 3, 5 years, respectively. Multiple stones, a history of urolithiasis, and stones located in the kidney or both kidneys plus the ureter significantly influenced recurrence. Multivariate analysis demonstrated that multiple stones were most significantly related to recurrence. CONCLUSION: Treatment with SWL has a low morbidity and high effectiveness. The number and location of stones and a history of urolithiasis significantly influence recurrence. Further studies of prophylactic therapy are required, especially for patients with these factors.