J Opioid Manag, 2018. Pathan SA, Mitra B, Straney LD, Afzal MS, Anjum S, Shukla D, et al. Methods: The judicious use of parenteral narcotics is standard, and side effects and the potential for addiction with ED use are miniscule. Stones can grow anyplace in the urinary parcel, and they can shift essentially in size. 4 5 The important factors in the selection of first-line analgesia in the ED are efficacy, safety, the ease of rapid administration, and the logistics involved. The most common cause of a blockage in the urinary tract is a kidney stone. This chapter will focus on reviewing therapeutic options available to ED physicians that include traditional and most commonly used classes of analgesics such as non-steroidal anti-inflammatory drugs (NSAIDs) and opioids as well as more controversial and not yet widely accepted analgesic options that include intravenous acetaminophen (APAP), intravenous lidocaine, and intravenous ketamine. Cohen, E., et al., Comparison of ketorolac and diclofenac in the treatment of renal colic. Anesth Pain Med, 2014. : "Sublingual desmopressin is efficient and safe in the therapy of lithiasic renal colic". Pain reduction and need for rescue treatment were the outcomes of interest. Ann Emerg Med, 2006. Re: Pricop et al. This concept has not been honored in the above mentioned studies evaluating the use of parenteral ketorolac for renal colic whose analgesic ceiling dose is 10 mg.14 Furthermore, to prove this phenomenon in the ED, a recent randomized trial that compared analgesic efficacy of intravenous ketorolac at three single-dose regimens (10 mg, 15 mg, and 30 mg) for treating acute pain in the ED (including patients with renal colic) demonstrated similar pain relief between three doses up to 120 minutes post-ketorolac administration.15 Thus, the dosing regimen of ketorolac for treating patients with renal colic in the ED should be 10 mg per dose (15 mg due to ease of administering 0.5 mL). Kurdi, M.S., K.A. 14(1): p. 61-71. Am J Emerg Med, 2019. Ketamine is a non-competitive N-methyl-D-aspartate (NMDA) and glutamate receptor antagonist that reduces pain, opioid tolerance, and opioid-induced hyperalgesia.42 Ketamine given intravenously in low sub-dissociative, analgesic doses (0.1–0.3 mg/kg over 15 minutes) provides adequate analgesia with minimal effects on hemodynamics, cognition or consciousness.43, Several studies (all conducted outside of the U.S.) have investigated the analgesic efficacy of IV ketamine for the analgesic management of renal colic. An appreciation for the undesirable and potentially dangerous side effects of NSAIDs and opioids may require broadening the analgesic armamentarium of ED clinicians by considering alternative classes (and routes of administration) of analgesic medications, including lidocaine and ketamine, and intranasal opioids ( fentanyl). Titrate the dose and frequently assess for effect. 328(7453): p. 1401. Clinical Take Home Point: In this small, single center RCT magnesium sulfate reduced pain in renal colic at 20 minutes similar to morphine. doi: 10.1097/MJT.0000000000000526. In 2014 a Cochrane analysis was published citing the benefits of alpha blockers in the management renal colic (14). Renal colic is caused by a blockage in your urinary tract. and W.S. FOIA The recommended analgesic treatments are based on the NICE guideline on the assessment and management of renal and ureteric stones . (517) 337-0957. The use of non-steroidal anti-inflammatory drugs (NSAIDs) is the treatment of choice in patients with acute renal colic. Pain relief is the first step in managing acute renal colic. Ann Emerg Med, 2009. Risk factors for DVT and renal colic should be elicited during the history, as these can help narrow the diagnosis. Deva, Ketamine: Current applications in anesthesia, pain, and critical care. The cyclooxygenase-2 inhibitors, a new class of NSAIDs, may prove to be effective agents in the management of renal colic. As an example, when morphine (5 mg x 2 doses IV) was combined with ketorolac (15 mg x 2 doses IV), analgesics efficacy, rates of rescue analgesia and side effects profile of the combined regimen were superior to either medication alone in adult patients presenting to the ED with acute renal colic.28 The attempt to replicate these results, however, failed in another randomized trial where analgesic efficacy of a combination group was found to be similar to the ketorolac group and the morphine group with slightly lower rates of rescue analgesia at 40 minutes.29, In situations where venous access cannot be established in a timely fashion, intranasal (IN) and nebulized (NEB) routes of administration might be beneficial. Clinical pharmacology: opioids. 72(2): p. 135-144 e3. Coll, D.M., M.J. Varanelli, and R.C. Pain Res Treat, 2016. However, morphine was quicker acting with more pain relief at 10 minutes. Copyright © 2016 Elsevier Inc. All rights reserved. Moore, C.L., et al., Imaging in Suspected Renal Colic: Systematic Review of the Literature and Multispecialty Consensus. Management of renal colic Matthew Bultitude,1 Jonathan Rees2 SUMMARY POINTS Renal colic is a common presentation (lifetime risk 12% in men, 6% in women) causing pain and morbidity Non-contrast computed tomography is the imaging method of choice, owing to its high sensitivity and specificity However, the interpretation of this analysis was limited by the fact that it was made up of small studies with a significantly heterogeneous population. Am J Emerg Med, 1999. Zamanian, F., et al., Morphine Suppository versus Indomethacin Suppository in the Management of Renal Colic: Randomized Clinical Trial. 4(1): p. e16222. 18(9): p. 772-6. On this outcome, desmopressin in comparison to opioid showed insignificant RR (1.82 with a 95% CI of 0.36-4.34; P=.72), but this need in desmopressin in comparison to desmopressin-opioid combination was 0.75 with a 95% CI of 0.56-0.99 and a significant RR (P=.042). Theoretically, these drugs do not impair platelet function. BMC Urol, 2012. This inhibitory activity blocks prostaglandin-mediated ureteral spasms resulting in analgesic relief in patients with renal colic.31 As a weak analgesic, acetaminophen is frequently combined with opioid and non-opioid agents to control moderate-to-severe pain. Ensuring that people receive NSAIDs by any route as first-line treatment, unless there are contraindications, reduces the need for additional pain relief and reduces ongoing pain. Objective: This meta-analysis of trials was conducted to evaluate the impact of desmopressin on renal colic pain relief in comparison to more typically used medications (opioids and nonsteroidal anti-inflammatory drugs [NSAIDs]). Morphine 10 mg IV has demonstrated similar analgesic efficacy to IV meperidine (100 mg) but with significantly reduced rates of side effects.25 Similarly, hydromorphone 1 mg IV for acute renal colic demonstrated increased pain relief, reduced need for rescue analgesia, and fewer hospital admissions in comparison to IV meperidine ( 50 mg).26 However, when hydromorphone is administered in equianalgesic dosing regimen as morphine, it does not provide superior analgesic efficacy, though it does result in higher rates of respiratory depression and euphoria.27 Consider morphine as a first-line agent for renal colic pain refractory to NSAIDs with hydromorphone reserved for patients with pain refractory to NSAIDs and multiple doses of morphine. Diclofenac is the most commonly used and can be given orally (50-75 mg), intramuscularly (75 mg), or rectally (100 mg) as an immediate dose. Pricop C, Branisteanu DD, Orsolya M, Puia D, Matei A, Checherita IA. Ten studies met our inclusion criteria and were analyzed. Hazhir, S., Y.A. 10 - Chronic Pain & Substance Use Disorder, Ch. J Med Case Rep, 2011. renal colic. IV fluids do not increase the intensity of renal colic. Kapila V, Kapila AK, Tailly T, Rappe B, Juul KV, Everaert K. Acta Clin Belg. Furthermore, NSAIDs are contraindicated in patients with severe congestive heart failure, renal insufficiency, and acute peptic ulcer disease.4 It is important to emphasize that ketorolac administration via intramuscular route for patients with renal colic is associated with unnecessary pain upon injection, the prolonged onset of analgesia (30-60 min), and lack of an analgesic response in about 25% of patients.5,6, In general, all NSAIDs are similar in their ability to relieve pain associated with renal colic. Methods: PubMed, EMbase, Scopus, CINHAL, and Cochrane Central Register of Controlled Trials were searched for clinical trials. 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. Provide adequate analgesia using NSAIDs initially, and titrate up the analgesic ladder (avoiding pethidine) according to pain Desmopressin as an adjuvant to opioids or NSAIDs in treatment of renal colic: a nationwide register-based study. Nimmo, Adverse effects of opioid analgesic drugs. 9 Although promising, IV lidocaine will need to be studied in larger populations with a broader age range and with underlying cardiac disease before it can be recommended for routine use in the ED.41, Ketamine's role as a safe and effective analgesic modality for treating a variety of acute painful conditions in the ED has been continuously expanding. Pan Afr Med J, 2015. Dr. Vanessa Harkins, DO is a Emergency Medicine Specialist in East Lansing, MI. Ann Emerg Med. Rapid and effective analgesia is one of the most critical aspect of managing patients with renal colic in the ED. Introduction: Using alpha blockers such as intravenous (IV) lidocaine has been deemed effective in controlling acute pain. 74(3): p. 391-399. This site needs JavaScript to work properly. Make an Appointment. 2(12): p. e1916454. Soleimanpour, H., et al., Parenteral lidocaine for treatment of intractable renal colic: a case series. The most commonly prescribed analgesics in renal colic are non-steroidal anti-inflammatory drugs (NSAIDs), opioids and paracetamol. Mozafari, J., et al., Comparing intranasal ketamine with intravenous fentanyl in reducing pain in patients with renal colic: A double-blind randomized clinical trial. Hosseininejad, S.M., et al., Efficacy and Safety of Combination Therapy with Ketorolac and Morphine in Patient with Acute Renal Colic; A Triple-Blind Randomized Controlled Clinical Trial. 8(3): p. 283-90. Eur Urol, 2018. BMJ, 2016. West J Emerg Med, 2017. NSAIDs relieve renal colic pain by inhibiting prostaglandin synthesis, thus preventing afferent arterial vasodilation and reducing ureteral edema, inflammation, and muscular hyperactivity.1,3,4 Oral (PO), rectal (PR), and intramuscular (IM) routes are associated with delayed onset of analgesia, but intravenously (IV) administered ketorolac provides rapid and effective analgesia (comparable with opioids).5 Disadvantages of NSAIDs administration in patients suffering from renal colic include lack of titratability, adverse effects including nausea, vomiting, feeling of heat or pressure in the chest, fatigue, and lethargy. Badr, and J.N. 9(1): p. 53-68. J Res Med Sci, 2013. Opioids should be considered the analgesics of choice when NSAIDs are contraindicated. A double-blind, randomized controlled trial. 73(4): p. 583-595. Anesth Essays Res, 2014. Sandhu, D.P., et al., A comparison of intramuscular ketorolac and pethidine in the alleviation of renal colic. LOJ, E.S., et al., Safety and Efficacy of Intravenous Lidocaine for Pain Management in the Emergency Department: A Systematic Review. 34(3): p. 443-8. Kidney stone disease (nephrolithiasis) is a common problem in primary care practice. Pooling of data showed that, on a scale of 1-10, pain reduction after 30 minutes was significantly higher in NSAID in comparison to desmopressin (3.39 with a 95% confidence interval [CI] of 4.62-2.16; P<.01), but this reduction was not significantly different between NSAID and desmopressin-NSAID combination (-0.28 with 95% CI of -0.62 to 0.05; P=.01). Schoenfeld, E.M., et al., Association of Patient and Visit Characteristics With Rate and Timing of Urologic Procedures for Patients Discharged From the Emergency Department With Renal Colic. Clinical pain management (acute pain). Ketorlac (30 mg IM/IV) has demonstrated substantial efficacy in this setting, and once pain relief is established, an oral NSAID can be substituted. Based on available evidence, NSAIDs are the first-line agents in alleviating the pain of renal colic, with opioids being used as a second-line agent (either as an adjunct to NSAIDs or as a rescue). Mid-Michigan Physicns Fam Med is a medical group practice located in Grand Ledge, MI that specializes in Family Medicine. 5(3): p. 165-170. J Accid Emerg Med, 2000. 4(1): p. e13175. 74(6): p. 690-3. 2014: p. 571326. A Systematic Review and Meta-analysis Comparing the Efficacy of Nonsteroidal Anti-inflammatory Drugs, Opioids, and Paracetamol in the Treatment of Acute Renal Colic. Make an Appointment. In the short term, your doctor will give you medicines to relieve the pain of renal colic. Results: Background on Medical Expulsive Therapy for Renal Colic. Larkin, G.L., et al., Efficacy of ketorolac tromethamine versus meperidine in the ED treatment of acute renal colic. Usually sharp in nature and may come in waves (intermittent) Originates in the flank and radiates around the abdomen to the testicle (men) or labia majora (women) Dysuria is common. Eray, O., et al., Intravenous single-dose tramadol versus meperidine for pain relief in renal colic. Theerth, and R.S. Family Medicine • 1 Provider. BONUS MATERIAL! 2016;37(7):865–72. OBJECTIVES: Renal colic is one of the most common painful disorders in patients referred to the emergency department. J Emerg Med, 1996. 2015 Nov;24(11):1155-60. doi: 10.1002/pds.3875. NSAIDs are the first-line treatment for renal colic pain because they have been shown to achieve greater reductions in pain scores, have a longer duration of action and result in a reduced need for additional analgesia in the short-term, compared with patients treated with opioid analgesics. 3 The increased efficacy of NSAIDs may be partially explained by the fact that prostaglandin production is part of the pathophysiological process of renal colic. A trial of tamsulosin (0.2–0.4 mg) may be beneficial, particularly in patients with stones > 5–6 mm.52. Evaluate for signs of sepsis in patients presenting with renal colic. 59(1): p. 61-77. Mid-Michigan Physicns Fam Med. Am J Emerg Med, 2016. Summary of relative risk (RR) for the need for rescue treatment in desmopressin in comparison to NSAID was 0.31 with a 95% CI of 0.13-0.74 and a significant RR (P<.04), but no difference was shown in desmopressin-NSAID combination in comparison to NSAID (0.70 with a 95% CI of 0.49-1.00; P<.19). NSAIDs relieve renal colic pain by inhibiting prostaglandin synthesis, thus preventing afferent arterial vasodilation and reducing ureteral edema, inflamm In: Macintyre PE, editor. Their analgesic effects occur primarily through mu-opioid receptor-mediated blockade of neurotransmitter release and pain transmission. Pain is the hallmark feature of ureteral colic. Caveats for Relieving Pain in Patients with Renal Colic. Soleimanpour, H., et al., Effectiveness of intravenous lidocaine versus intravenous morphine for patients with renal colic in the emergency department. Farnia, M.R., et al., Comparison of intranasal ketamine versus IV morphine in reducing pain in patients with renal colic. NSAIDs administered via parenteral and enteral routes follow the concept of "analgesic ceiling" - a pharmacological phenomenon that implies that there is a dosing threshold above which any further increase in a dose would not result in additive analgesia (better pain relief). Pharmaceuticals (Basel), 2010. Renal colic is among common causes of sudden and severe pain, especially in tropical areas . Bethesda, MD 20894, Copyright NCI CPTC Antibody Characterization Program. Prevention and treatment information (HHS). Abbasi, S., et al., Can low-dose of ketamine reduce the need for morphine in renal colic? 2017 Jan/Feb;24(1):e12-e19. Mefford, J.M., et al., A Comparison of Urolithiasis in the Presence and Absence of Microscopic Hematuria in the Emergency Department. Catapano, M.S., The analgesic efficacy of ketorolac for acute pain. PubMed, EMbase, Scopus, CINHAL, and Cochrane Central Register of Controlled Trials were searched for clinical trials. Rationale . 7(3): p. 148-51. 70(2): p. 177-184. Show Phone Number. Gao M, Rejaei D, Liu H. Ketamine use in current clinical practice. The urinary tract includes your kidneys, ureters, bladder, and urethra. Non-steroidal anti-inflammatory drugs (NSAIDs) The mechanism of pain generation in acute renal and ureteric colic is mediated by prostaglandins, thromboxane A2, and smooth muscle spasm [Steinberg, 2016]. Masoumi, K., et al., Comparison of clinical efficacy of intravenous acetaminophen with intravenous morphine in acute renal colic: a randomized, double-blind, controlled trial. Careers. Intravenous Acetaminophen for Renal Colic in the Emergency Department: Where Do We Stand? Options include: nonsteroidal anti-inflammatory drugs such as ibuprofen (Motrin IB, Advil) Providers Overview Location Reviews XX. 75(3): p. 540-2. Furthermore, in the U.S., there is up to a 300-fold cost differential between oral and rectal formulations of acetaminophen compared to IV formulations, which is likely not justified by any marginal improvement in pain relief.35 IV APAP may be advantageous among patients who are unable to tolerate opioids or NSAIDs, or the patient is restricted from oral medication administration. Eur J Clin Pharmacol, 1998. The most common analgesics that are used for pain relief in renal colic are non-steroidal anti-inflammatory drugs (NSAIDs), opioids, and paracetamol (6, 7). Roshani, A., et al., Assessment of clinical efficacy of intranasal desmopressin spray and diclofenac sodium suppository in treatment of renal colic versus diclofenac sodium alone. Sublingual desmopressin is efficient and safe in the therapy of lithiasic renal colic. . The main purpose of this study was to compare the efficiency of two methods of intravenous (IVF) and intranasal (INF) fentanyl administration in pain management in patients with severe renal colic. Find opioid alternatives, tips for specific conditions, and more. 48(2): p. 173-81, 181 e1. Jasani, N.B., R.E. Epub 2015 Sep 9. Exclude non-stone causes in patients presenting with renal colic. Sergey M. Motov, MD, FAAEM | Maimonides Medical CenterJohn P. Marshall, MD, MBA, FACEP | Maimonides Medical Center. Typically sudden onset of pain with a rapid crescendo. 2016 Feb;48(2):183-9. doi: 10.1007/s11255-015-1173-z. To date, NSAIDs and opiates are the most popular medications for renal colic pain management, ; NSAIDs inhibit prostaglandin E2 secretion, and opioids exert antinociceptive effects by inhibition of the release of excitatory transmitters … 8600 Rockville Pike Conclusion: Hollingsworth, J.M., et al., Alpha blockers for treatment of ureteric stones: systematic review and meta-analysis. Based on the two-decade-old research, ibuprofen 800 mg PO, ketorolac 30 mg IV or 60 mg IM, diclofenac 50-75 mg IM, and naproxen 500 mg PO are a few of the commonly used NSAIDs. Renal colic is a type of abdominal pain commonly caused by obstruction of ureter from dislodged kidney stones.The most frequent site of obstruction is the vesico-ureteric junction (VUJ), the narrowest point of the upper urinary tract.Acute obstruction and the resultant urinary stasis (disruption of urine flow) can distend the ureter (hydroureter) and cause a reflexive peristaltic … Renal colic classically presents as colicky, unilateral pain in the ‘loin-to-groin’ distribution, with vomiting, flank or renal angle tenderness and, occasionally, macroscopic haematuria. https://socmob.org/2013/02/nsaids-part-2-the-ceiling- effect/ ( accessed on 7/18/2020). Mazer-Amirshahi, M., S. Motov, and L.S. 1.3 . Int Urol Nephrol. NSAIDs part 2: The Ceiling Effect. Bektas, F., et al., Intravenous paracetamol or morphine for the treatment of renal colic: a randomized, placebo-controlled trial. Context: Renal colic is a common, acute presentation of urolithiasis that requires immediate pain relief. NSAIDs are the most effective form of pain relief for renal colic. Br J Urol, 1994. This study makes the argument that adding magnesium sulfate to the treatment of renal colic, may help spare opioids as 1 st line agents. Safdar, B., et al., Intravenous morphine plus ketorolac is superior to either drug alone for treatment of acute renal colic. The pain of renal colic origin is multifactorial. Urol J, 2010. Proper management of renal colic pain in emergency departments is of particular importance . Latta, K.S., B. Ginsberg, and R.L. Nedra Cannon Lcsw LLC. 2017 Aug; 70 (2):177-184. 14(1): p. 67-75. NSAIDs (parenteral ketorolac and oral ibuprofen in the U.S., parenteral diclofenac in the Middle East, and Europe) are mainstay therapies for patients with renal colic. Ann Emerg Med, 2017. Duthie, D.J. The analgesic action of desmopressin in renal colic. 11615 Hartel Rd Ste 108, Grand Ledge MI, 48837. Currently, morphine and hydromorphone are the most commonly used opioids for managing renal colic in the ED. Additionally, intranasal ketamine (1 mg/kg) has been found to provide similar analgesic relief compared to IV morphine (0.1 mg/kg) when measured up to 30 minutes in ED patients with renal colic46 but failed to provide comparable analgesia to IN fentanyl (1 mcg/kg) and resulted in higher rates of adverse effects.47 It is important to emphasize that the above mentioned studies despite their prospective, randomized design had numerous limitations and biases that limited their generalizability. Epub 2015 Dec 16. 54(4): p. 568-74. suspected renal colic. Pain management. Golzari, S.E., et al., Therapeutic approaches for renal colic in the emergency department: a review article. Nausea and vomiting are common. Pathan, S.A., et al., Delivering safe and effective analgesia for management of renal colic in the emergency department: a double-blind, multigroup, randomised controlled trial. For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on pain management. Would you like email updates of new search results? Am J Emerg Med, 2018. Cameron, A Systematic Review and Meta-analysis Comparing the Efficacy of Nonsteroidal Anti-inflammatory Drugs, Opioids, and Paracetamol in the Treatment of Acute Renal Colic. Most stones happen because of the development of minerals or different substances, like uric corrosive, which stay together in the pee and make a hard mass. Multiple studies comparing IV APAP (1 g administered over 15 min) to IV morphine (0.1 mg/kg bolus) have demonstrated either comparable31-33 or superior34 analgesia at 30 minutes with significantly fewer side effects (primarily nausea and vomiting) in the IV acetaminophen group. Thompson, J.F., et al., Rectal diclofenac compared with pethidine injection in acute renal colic. 35(3): p. 434-437. 19(5): p. 368-70. Eur J Anaesthesiol, 2002. Motov S, Yasavolian M, Likourezos A, Pushkar I, et al. European Association of Urology guidelines recommend nonsteroidal anti-inflammatory drugs (NSAIDs) as the preferred analgesia. Patients may present with the classic symptoms of renal colic and hematuria. Cochrane Database Syst Rev, 2015(6): p. CD006027. Epub 2017 Mar 23. Belkouch, A., et al., Does intranasal fentanyl provide efficient analgesia for renal colic in adults? Further research is needed to assess the safety and efficacy of intranasal ketamine in treating acute renal colic in ED patients. Avoiding renal colic starts with preventing the stones that cause the symptoms. Emerg Med Int, 2014. Renal colic may be excruciatingly painful and affected patients frequently need parenteral therapy for relief of symptoms. 2016: p. 4981585. 178(1): p. 101-3. 2nd edition.London: Hodder & Stoughton Limited; 2008. p. 68–79. 10.5 - Buprenorphine Initiation in the ED and MAT, http://empharmd.blogspot.com/2015/05/three-reasons-not-to-prescribe-tramadol.html. Azizkhani, R., et al., Comparing the analgesic effect of intravenous acetaminophen and morphine on patients with renal colic pain referring to the emergency department: A randomized controlled trial. Privacy, Help Juul KV, Schroeder MK, Rittig S, Nørgaard JP. 5: p. 256. National Library of Medicine Barkin, Meperidine: a critical review. Eur Urol. 29(11): p. 902-5. 2nd edition. However, the vast majority of patients will be discharged safely following the above analgesic regimen. Hosseininejad, S.M., et al., Comparing the analgesic efficacy of morphine plus ketamine versus morphine plus placebo in patients with acute renal colic: A double-blinded randomized controlled trial. Lancet, 2016. Pharmacoepidemiol Drug Saf. However, the analgesic advantage of IV APAP over opioids for managing the pain of renal colic is outweighed by the lack of titratability and concern for dosing errors. Give all medications by the IV route. Ann Emerg Med, 2019. Talati, J, Tiselius, H.-G, Albala, D.M, YE, Z. Urolithiasis: Basic Science and Clinical Practice. 12: p. 13. 20: p. 407. Am J Emerg Med, 2017. Am J Emerg Med, 2019. A double-blind randomized clinical trial. Ureters carry urine from your kidneys to your bladder. London: Hodder & Stoughton Limited; 2008. p. 113–29. O'Conner, and J.K. Bouzoukis, Comparison of hydromorphone and meperidine for ureteral colic. 17(1): p. 6-10. 299(6708): p. 1140-1. Renal colic is a pain you get on which urinary stones block part of your urinary lot. A randomized trial comparing pain relief of IV ketamine (0.15 mg/kg) given as an adjunct to IV morphine (0.1 mg/kg) demonstrated superior analgesic response at 10-minutes and 30-minutes post-medication administration in comparison to IV morphine alone.44 Similarly, research has shown that the addition of IV ketamine (0.2 mg/kg) to IV morphine (0.1 mg/kg) resulted in a more significant reduction of pain, nausea, and vomiting in comparison to morphine (0.1 mg/kg) alone but was associated with a higher frequency of dizziness.45. Motov, S., et al., Pain management of renal colic in the emergency department with intravenous lidocaine. Anesth Pain Med, 2014. Lidocaine is the voltage-dependent sodium channel blocking (reversibly) agent that reduces transmission of pain signals in sensory pathways and inhibits ectopic discharges from injured nerves.36 The mechanism by which IV lidocaine relieves pain in patients with renal colic involves a change in sympathetic smooth muscle tone towards ureteral relaxation by reducing the transmission of afferent sensory pathways.37, In situations where opioids or NSAIDs are contraindicated, or their use is associated with undesirable adverse effects, IV lidocaine (preservative-free) may be considered as an alternative. Accessibility 2017 Jun;72(3):179-185. doi: 10.1080/17843286.2016.1230569. 387(10032): p. 1999-2007. Bull Emerg Trauma, 2017. Am J Emerg Med, 2019. Motov, S., et al., Comparison of intravenous lidocaine/ketorolac combination to either analgesic alone for suspected renal colic pain in the ED. Afshar, K., et al., Nonsteroidal anti-inflammatory drugs (NSAIDs) and non-opioids for acute renal colic. However, the current data on non-invasive opioid administration for patients with renal colic is limited to a single observational study of 23 patients receiving fentanyl 1.5 mcg/kg IN (average dose of 106 mcg) where it was shown to result in an approximate 50% reduction in pain at 5 minutes post-administration.30.
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