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Kiaei MM et al, 2018: Enteral diclofenac controls pain and reduces intravenous injection during extracorporeal shock wave lithotripsy.

Kiaei MM, Mohaghegh MR, Movaseghi G, Ghorbanlo M.
Hasheminejad Kidney Center, School of Medicine, Iran University of Medical Sciences, Tehran, Iran.
Department of Anesthesia and Critical Care, Hasheminejad Kidney Center, School of Medicine, Iran University of Medical Sciences, Tehran, Iran.

Abstract

Urinary system stones are the third most common disease of urinary system following urinary infection and prostate pathology. Extracorporeal shockwave lithotripsy (ESWL) is one of the methods used to treat Urolithiasis where shockwaves are transmitted through skin and body organs and crush the stones into small pieces. This is a painful procedure which usually requires analgesics. Each analgesic drug has its own advantages and disadvantages. The present research seeks to study the effectiveness of using diclofenac suppository in order to control pain and reduce need for venous drugs during ESWL procedure. This is a double blind clinical trial. 158 patients resorting to Shahid Hasheminezhad Specialized Center for ESWL were randomly selected to take part in this projects with due consideration of inclusion criteria. The patients were equally divided into the S (diclofenac suppository) and A (placebo) groups. 2 diclofenac suppositories were used in the S group 20 minutes prior to beginning ESWL. Then, ESWL was carried out in supine position using fluoroscopic conduction with standard method. The present research has studied pain scale of patients, operator's and patient's satisfaction during the operation and patient's hemodynamic parameters in three phases prior to, during, and after ESWL. SPSS v.17 was used to study the data and Chi-Square Tests and Repeated Measure ANOVA were used to analyze the results. The level of significance in the present research was set to P-value < 0.05.A review of pain scales across both groups showed that using diclofenac suppository has a significant influence in reducing the pain scale and, hence, need for venous drugs (P-value < 0.05). No significant difference was observed between the two groups in terms of heart beat and blood pressure changes in various times (P-value > 0.05). The results also report different satisfaction levels for patients and operators across the two groups (diclofenac suppository and placebo) (P-value < 0.05). Higher satisfaction levels were observed among both patients and operators in the group receiving diclofenac suppository. A general look at the data yields the conclusion that receiving pain killers (diclofenac suppository) before starting ESWL plays a more efficient role in reducing pain scales of patients and enhancing operators' satisfaction.

Eur J Transl Myol. 2018 May 2;28(2):7353. doi: 10.4081/ejtm.2018.7353. eCollection 2018 Apr 24.

 

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Comments 1

Hans-Göran Tiselius on Friday, 07 December 2018 08:21

How pain should be avoided during SWL has remained a matter of debate ever since this non-invasive method for stone removal was introduced in the clinical routine almost 35 years ago. The authors of this report correctly emphasize that pain control is an absolute prerequisite for successful SWL. Based on the results from this study the recommendation is to administer two suppositories of diclofenac 20 minutes before start of SWL. The dose is not mentioned in the article but the reviewer’s conclusion is that the pre-SWL dose was 50+50 mg? Moreover, it is understood that another suppository was given if pain-relief was not satisfactory, reaching the maximum dose of 150 mg!

Interestingly the authors used the Dornier HM3 lithotripter and although it is not mentioned my own interpretation is that the device was equipped with the modified reflector and generator system.

Although significantly different from Group A (Placebo) only 57% of the patients in Group S reported low pain experience. The corresponding number in Group A was ~ 8%. However only 33% of the patients in Group S were satisfied with the pain treatment! This outcome should of course be compared with the much lower satisfaction level recorded in Group A (66%). Obviously additional analgesics, apart from more diclofenac, were apparently not given and the question that comes up is: Were the authors completely satisfied with this result?

Nothing is mentioned about the results of SWL or if the treatment schedule was modified according to reactions by the patient.

The reviewer has used several different principles for dealing with shockwave pain in the electrohydraulic unmodified Dornier HM3 and MFL 5000 lithotripters, as well as the electromagnetic Modulith SLX and SLX-F2 lithotripters. The winning concept has been to give one suppository of diclofenac 30 minutes before SWL and to follow up with small intermittent doses of alfentanyl and propofol during the treatment session. The conclusion is that although diclofenac is of great value it is not enough for optimal SWL.

How pain should be avoided during SWL has remained a matter of debate ever since this non-invasive method for stone removal was introduced in the clinical routine almost 35 years ago. The authors of this report correctly emphasize that pain control is an absolute prerequisite for successful SWL. Based on the results from this study the recommendation is to administer two suppositories of diclofenac 20 minutes before start of SWL. The dose is not mentioned in the article but the reviewer’s conclusion is that the pre-SWL dose was 50+50 mg? Moreover, it is understood that another suppository was given if pain-relief was not satisfactory, reaching the maximum dose of 150 mg! Interestingly the authors used the Dornier HM3 lithotripter and although it is not mentioned my own interpretation is that the device was equipped with the modified reflector and generator system. Although significantly different from Group A (Placebo) only 57% of the patients in Group S reported low pain experience. The corresponding number in Group A was ~ 8%. However only 33% of the patients in Group S were satisfied with the pain treatment! This outcome should of course be compared with the much lower satisfaction level recorded in Group A (66%). Obviously additional analgesics, apart from more diclofenac, were apparently not given and the question that comes up is: Were the authors completely satisfied with this result? Nothing is mentioned about the results of SWL or if the treatment schedule was modified according to reactions by the patient. The reviewer has used several different principles for dealing with shockwave pain in the electrohydraulic unmodified Dornier HM3 and MFL 5000 lithotripters, as well as the electromagnetic Modulith SLX and SLX-F2 lithotripters. The winning concept has been to give one suppository of diclofenac 30 minutes before SWL and to follow up with small intermittent doses of alfentanyl and propofol during the treatment session. The conclusion is that although diclofenac is of great value it is not enough for optimal SWL.
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