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Reviewer's Choice 

Gul A. et al., 2020: Intracutaneous sterile water injection for pain relief during extracorporeal shock wave lithotripsy: comparison with diclofenac sodium

Gul A, Gul M.
Department of Urology, University of Health Science, Bursa Yuksek Ihtisas Training and Research Hospital, 16100, Bursa, Turkey.
Department of Urology, Aksaray University School of Medicine, 68100, Aksaray, Turkey.
Laboratory of Reproductive Biology, Section 5701, Copenhagen University Hospital Rigshospitalet, University of Copenhagen, 2100, Copenhagen, Denmark.

Abstract

Various analgesic applications can be used during extracorporeal shock wave lithotripsy (SWL) for pain relief and maximal success rate. Intracutaneous sterile water injection (ISWI) has been shown to be effective in several types of pain, but a gap exists about its use during SWL. In this paper, we aimed to evaluate the effect of ISWI during SWL and compare that with diclofenac sodium injection used commonly to provide ideal patient contentment. Patients with kidney stone were randomized to have either ISWI therapy or intramuscular non-steroid anti-inflammatory drug (diclofenac sodium) injection. Using a syringe, 2-3 ml of sterile water was administered to the triangle area bounded by the 12th costal margin, the iliac crest and the vertebral spine in prone position. Visual analog scale (VAS) was employed to record pain scores of patients. Other parameters including stone size, SWL duration, total shock waves given, used energy and the necessity of rescue analgesia were also noted. A total of 524 patients were recruited, of those 216 patients were treated with ISWI and 308 patients had diclofenac sodium injections. The characteristics of the patients and shockwave therapy did not differ significantly between the two groups. Although the mean VAS scores prior to SWL and at every voltage increment during the procedure did not differ, more patients in the diclofenac sodium injection group required rescue analgesia with significantly greater side effects. ISWI is found to be as effective as the diclofenac sodium injection for pain management during SWL with lower adverse event rates.
Urolithiasis. 2020 Apr;48(2):103-108. doi: 10.1007/s00240-019-01147-9. Epub 2019 Jul 5. PMID: 31278470

1
 

Commentaires 1

Peter Alken le mercredi 2 décembre 2020 08:30

I was surprised to see this report on a practically unknown technique of pain management during ESWL. During many years, I have sporadically treated acute colicky pain with ISWI. The principle of action relates to the so-called referred pain. Sensory nerve fibers from skin and inner organs come together at the same level area of the spinal cord. For kidneys and ureters, these are the Th9 – L1-2 levels. Colicky pain of the upper urinary tract is perceived at or "referred to" the related dermatomes of the same spinal segment.
I asked the patient to show me the most painful area of the flank. There I injected at 3-6 sites intradermally ap. 0,3- 0,5 ml sterile water. Not all, but he majority of patients were immediately pain-free. A recent publication also reported good results with this procedure (1).

1 Moussa M, Papatsoris AG, Chakra MA. Intradermal sterile water injection versus diclofenac sodium in acute renal colic pain: A randomized controlled trial [published online ahead of print, 2020 Apr 29]. Am J Emerg Med. 2020;S0735-6757(20)30309-0. doi:10.1016/j.ajem.2020.04.079


https://www.storzmedical.com/images/blog/Gul.JPG

The exact mode of action also in the present application for EWSL is not known.
In the present paper, the authors generated pain in the dermatome area: “To settle the trigger point, the patients were rigorously palpated by a ballpoint pen with uniform intervals of 1 cm2 at the back area and when a patient winced or cried out, the trigger point was determined. Then antiseptic solution was applied to this area and 2–3 ml of sterile water was injected intracutaneously.”

This is my reviewer’s choice – especially if others are able to confirm the results

Peter Alken

I was surprised to see this report on a practically unknown technique of pain management during ESWL. During many years, I have sporadically treated acute colicky pain with ISWI. The principle of action relates to the so-called referred pain. Sensory nerve fibers from skin and inner organs come together at the same level area of the spinal cord. For kidneys and ureters, these are the Th9 – L1-2 levels. Colicky pain of the upper urinary tract is perceived at or "referred to" the related dermatomes of the same spinal segment. I asked the patient to show me the most painful area of the flank. There I injected at 3-6 sites intradermally ap. 0,3- 0,5 ml sterile water. Not all, but he majority of patients were immediately pain-free. A recent publication also reported good results with this procedure (1). 1 Moussa M, Papatsoris AG, Chakra MA. Intradermal sterile water injection versus diclofenac sodium in acute renal colic pain: A randomized controlled trial [published online ahead of print, 2020 Apr 29]. Am J Emerg Med. 2020;S0735-6757(20)30309-0. doi:10.1016/j.ajem.2020.04.079 [img]https://www.storzmedical.com/images/blog/Gul.JPG[/img] The exact mode of action also in the present application for EWSL is not known. In the present paper, the authors generated pain in the dermatome area: “To settle the trigger point, the patients were rigorously palpated by a ballpoint pen with uniform intervals of 1 cm2 at the back area and when a patient winced or cried out, the trigger point was determined. Then antiseptic solution was applied to this area and 2–3 ml of sterile water was injected intracutaneously.” This is my reviewer’s choice – especially if others are able to confirm the results Peter Alken
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mercredi 21 avril 2021

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