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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 33  |  Issue : 4  |  Page : 1362-1366

Use of local anesthetic cream to the skin during extracorporeal shock wave lithotripsy


1 Department of Urology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Urology, National Institute of Urology and Nephrology, Cairo, Egypt

Date of Submission04-May-2020
Date of Decision21-May-2020
Date of Acceptance31-May-2020
Date of Web Publication24-Dec-2020

Correspondence Address:
Emad Abd-Elhady Abu-Zekry
MBBCh, Kanater El-Khiria, Qualubia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_108_20

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  Abstract 


Objectives
To assess the efficacy of local anesthetic cream compared with nalufin for pain control during extracorporeal shock wave lithotripsy (SWL).
Background
Local anesthetic is a method of pain control for various procedures.
Patients and methods
This is a prospective randomized study of patients diagnosed with renal or ureteric stones and should receive SWL as treatment. A total of 80 patients were divided into two groups, with 40 patients each: eutectic mixture of local anesthetics (EMLA) group (group A) received EMLA cream and received nalufin intravenous injection on demand if pain was intolerable, and nalufin group (group B) received nalufin intravenous injection before SWL. Data were coded and entered to the International Business Machines Company for Statistical Package for Social Science, version 23.
Results
Group A tolerated more intense pain (P = 0.027), group B received more doses of nalufin (P = 0.000), patients of group B expressed more intense feeling of pain by face scale (P = 0.011), numerical pain score was more for the group B (P = 0.004), group A patients were more satisfied (P = 0.030), group A had less time in the hospital stay (P = 0.000), and group B experienced more percentage of complications (P = 0.000).
Conclusion
Using EMLA during SWL was successful for pain control and patient comfort and significantly reduced use of nalufin and reduced complications and hospital stay.

Keywords: eutectic mixture of local anesthetics, extracorporeal shock wave lithotripsy, lithotripsy, local anesthetic, nalufin


How to cite this article:
Badawy AA, Eldoray AEM, Elshazly MA, Abu-Zekry EA. Use of local anesthetic cream to the skin during extracorporeal shock wave lithotripsy. Menoufia Med J 2020;33:1362-6

How to cite this URL:
Badawy AA, Eldoray AEM, Elshazly MA, Abu-Zekry EA. Use of local anesthetic cream to the skin during extracorporeal shock wave lithotripsy. Menoufia Med J [serial online] 2020 [cited 2021 Apr 19];33:1362-6. Available from: http://www.mmj.eg.net/text.asp?2020/33/4/1362/304472




  Introduction Top


Since its introduction in early 1980s, shock wave lithotripsy (SWL) became the first-line treatment modality for renal and upper ureteric stones. It is a more safe, simple, and effective noninvasive procedure. ESWL is preferred as the first-line choice for renal and upper ureteric stones, which provides the maximum stone-free rate in the case of stone size smaller than 1.5 cm[1].

Several physical variables influencing treatment-related pain have been identified: an important role is played by the type of the shock wave size and source, site of stone burden (e.g., upper-pole stone near the ribs), peak pressure of the shock waves, diameter of the focal zone, and size of the aperture of the shock wave source which reflects the area of shock wave entry at the skin[2].

Pain of SWL is due to the formation, movement, and implosion of the shock wave-generated microbubbles in tissues or body fluids that lead to stimulation of the superficial nociceptors in the skin as well as the deeper, visceral nociceptors in the renal capsule, muscles, pleura, peritoneum, and periosteum[3].

One of the most important adverse effects related to SWL is the shock wave-related pain that occurs during the procedure, mainly owing to the entry of shock waves at the level of skin. Performing SWL on an outpatient basis is now possible without the need for general or spinal anesthesia. Nevertheless, SWL without anesthesia demands proper management of pain related to shock wave to ensure patient relaxation, co-operation, and satisfaction, as patient relaxation and co-operation is required for proper stone localization and for adequate stone fragmentation during the procedure[4].

Eutectic mixture of local anesthetics (EMLA) containing 5% lidocaine and 5% prilocaine in a cream was found to give effective topical analgesia in normal and diseased skin, making it useful for superficial surgery and various other clinical procedures. To be effective, an adequate amount must be applied under occlusion and at the right time before the intervention[5].

In the present study, we aimed to assess the safety and efficacy of local anesthetic EMLA cream compared with nalufin for pain control during SWL.


  Patients and Methods Top


This was a prospective randomized study of patients diagnosed with renal or ureteric stones and should receive SWL as treatment for this stones by using Dornier Gemini electromagnetic SWL device made in Germany.

The study protocol was approved by the local ethics committee of the Faculty of Medicine, Menoufia University. All participants gave written informed consent before inclusion in the study.

The study included 80 patients divided into two groups; each group is formed of 40 patients: group A (EMLA group) received EMLA cream as local anesthetic for pain control and received nalufin intravenous injection on demand if intolerable pain is felt, and group B (nalufin group) received nalufin intravenous injection before SWL for pain control and received more doses of nalufin injection on demand if intolerable pain is felt.

Inclusion criteria were patients with renal and upper ureteric stones indicated for SWL as first choice in proximal ureteric stones especially 10 mm or less and renal stones 20 mm or less especially upper and middle calyceal stones in adult patients between 18 and 75 years of age.

Exclusion criteria were patients with skin disease or hypersensitivity to EMLA, patients with elevated serum creatinine level more than 2 mg/dl, patients with bleeding disorders, patients more than 120 kg body weight, patients with incisional lumbar hernia, patients with active UTI (urinary tract infection) or urosepsis, and pediatric patients.

All patients were subjected to clinical assessment including a full history and clinical examination, and also laboratory and radiological investigations was done.

Local anesthetic EMLA 5 g 5% cream is applied to the skin 60 min before the procedure to the lower thoracic and lumbar region for renal stones and lumbar region only for upper ureteric stones according to localization of the stone and site of coupling and entry of shock waves for group A And intravenous nalufin injection of 6 mg as starting dose 10–20 min before the procedure for group B.

During the procedure, the following data are evaluated and recorded: procedure duration, procedure complications, number of shock waves, average voltage of shock waves, dose of nalufin received, and pain evaluation using visual analog scale (VAS) (Wong Baker face scale) [Figure 1].
Figure 1: Wong Baker face scale for pain (1983 Wong Baker FACES Foundation).

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Postprocedure data, including numerical pain rating from 1 to 10 by asking the patient, hospital stay, complications, and patient satisfaction, were evaluated.

Follow-up of all patients was done after 2 weeks post each SWL session with plain KUB, (Kidneys, ureters and bladder) pelvi-abdominal ultrasound for radiolucent stones, or may be noncontrast CTUT (Computed tomography urinary tract) if any of them is not conclusive.

Data were collected, revised, coded, and entered to the International Business Machines Company for Statistical Package for Social Science (IBM, SPSS, SPSS Inc., Chicago, Illinois, USA), version 23. The quantitative data were presented as mean, SDs, and ranges when parametric and median with interquartile range when nonparametric. Moreover, qualitative variables were presented as number and percentages. The comparison between groups regarding qualitative data was done by using χ2 test and/or Fisher exact test when the expected count in any cell was found less than 5. The comparison between two independent groups with quantitative data and parametric distribution was done by using independent t test. The comparison between two independent groups with quantitative data and nonparametric distribution was done by using Mann–Whitney test. The confidence interval was set to 95%, and the margin of error accepted was set to 5%. So, the P value was considered significant as follows: P value more than 0.05, nonsignificant; P value less than 0.05, significant; and P value less than 0.01, highly significant.


  Results Top


It shows that there was a statistically significant difference found between the two studied groups regarding maximal intensity tolerated by the patient; it showed that group A can tolerate more intense pain than group B (max kV) (P = 0.027). The data are summarized in [Table 1].
Table 1: Comparison between eutectic mixture of local anesthetics group A and nalufin group B regarding shock wave lithotripsy session data

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There was a statistically highly significant difference found between the two studied groups regarding dose of analgesic needed during SWL session, as group B received more doses of nalufin (P < 0.001). Moreover, there was a statistically significant difference found between the two studied groups regarding pain evaluation by face scale, as patients of group B expressed more intense feeling of pain than group A (P = 0.011).

There was a statistically highly significant difference found between the two studied groups regarding numerical pain score, which was more for group B (P = 0.004).

There was a statistically significant difference found between the two studied groups regarding patient satisfaction, as group A patients were more satisfied. (P = 0.030). The data are summarized in [Table 2].
Table 2: Comparison between eutectic mixture of local anesthetics group A and nalufin group B regarding dose of analgesic, patient evaluation, and complications during shock wave lithotripsy session

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There was a statistically highly significant difference found between the two studied groups regarding hospital stay, as group A had less hospital stay time than group B (P < 0.001).

There was a statistically highly significant difference found between the two studied groups regarding complications after SWL session, as group B experienced more percentage of complications than group A (P < 0.001). The data are summarized in [Table 3].
Table 3: Comparison between eutectic mixture of local anesthetics group A and nalufin group B regarding patient evaluation after shock wave lithotripsy session and stone-free rate

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  Discussion Top


Extracorporeal SWL is an attractive treatment modality offering a minimally invasive and convenient treatment option, delivered in an outpatient setting and resulting in low complication rates. Several factors determining the success of SWL treatment of urinary stones have been studied. These include the stone site, size, crystal type, degree of obstruction, stone impaction, and function of the renal unit[6]. One of the most important adverse effects related to SWL is the shock wave-related pain that occurs during the procedure mainly owing to the entry of shock waves at the level of skin, as proper management of pain related to shock wave to ensure patient relaxation, co-operation, and satisfaction, as patient relaxation and co-operation is required for proper stone localization and for adequate stone fragmentation during the procedure[4].

The most commonly used analgesics during SWL include opioids, sedatives, NSAIDS, and anesthetic topical creams[2].

In our study, regarding maximal intensity tolerated by the patient; it showed that group A can tolerate more intense pain than group B, and this was agreed by Monk et al.[7], who reported that there was a significant decrease in pain at energy levels of 18 and 20 kV in the EMLA group. In contrast, Acar et al.[8] showed that maximal energy of SWL procedure was similar between the groups, and this could be explained by the smaller sample size and narrow area of EMLA application (10 cm).

Moreover, the study showed that regarding dose of analgesic needed during SWL session in group B, there was more nalufin dose needed as shown by a study conducted by Bárcena et al.[9]. Despite higher voltages, lower pain scores were found in patients for whom EMLA cream was used, and only two patients of 20 required further analgesia versus all patients required additional fentanyl in the first session without EMLA. Moreover, Tiselius[10] defined the role of cutaneous local anesthesia and concluded that cutaneous surface anesthesia makes it possible to decrease the dose of analgesic sedative drugs and also to perform the treatment at a higher energy setting without additional analgesic sedation in many patients.

Regarding pain evaluation by face scale VAS, patients of group B expressed more intense feeling of pain than group A, by numerical pain score, it was more for group B patients, and according to patient satisfaction, group A patients are more satisfied also. This also agreed with Vilar et al.[11], who found that EMLA group has improved VAS scores than placebo.

According to hospital stay, group A had less hospital stay time than group B. Moreover, group B experienced more complications than group A regarding complications after SWL. This was supported by Nagendra and Sharma[12]. They concluded that local anesthetic is a useful, simple, safe, and economical adjuvant technique to reduce pain and complications and facilitate early discharge from the recovery room.


  Conclusion Top


Our study concluded that the use of EMLA during SWL was successful for pain control and patient comfort and significantly reduced the use of nalufin for pain control and consequently reduced systemic complications and hospital stay.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Joshi HN, Karmacharya RM, Shrestha R, Shrestha B, de Jong IJ, Shrestha RK. Outcomes of extra corporeal shock wave lithotripsy in renal and ureteral calculi. Kathmandu Univ Med J 2014; 12:51–54.  Back to cited text no. 1
    
2.
Gupta NP, Kumar A. Analgesia for pain control during extracorporeal shock wave lithotripsy: current status. Indian J Urol 2008; 24:155–158.  Back to cited text no. 2
    
3.
Tu J, Matula TJ Bailey MR, Crum LA. Evaluation of a shock wave induced cavitation activity both in vitro and in vivo. Phys Med Biol 2007; 52:5933–5944.  Back to cited text no. 3
    
4.
Kumar S, Kumar S, Ganesamoni R, Mandal AK, Prasad S, Singh SK. Dimethyl sulfoxide with lignocaine versus eutectic mixture of local anesthetics: prospective randomized study to compare the efficacy of cutaneous anesthesia in shock wave lithotripsy. Urol Res 2010; 39:181–183.  Back to cited text no. 4
    
5.
Juhlin L, Evers H. Use of local anesthetic cream to the skin during extra corporeal shock wave lithotripsy. Adv Dermatol 1990; 5:75–91.  Back to cited text no. 5
    
6.
Nabi G, Downey P, Keeley F. Extra-corporeal shock wave lithotripsy (ESWL) versus ureteroscopic management for ureteric calculi. Cochrane Database Syst Rev 2007; 1:15–21.  Back to cited text no. 6
    
7.
Monk TG, Ding Y, White PF, Albala DM, Clayman RV. Effect of topical eutectic mixture of local anesthetics on pain response and analgesic requirement during lithotripsy procedures. Anesth Analg 1994; 79:506–511.  Back to cited text no. 7
    
8.
Acar A, Erhan E, Nuri Deniz M, Uguar G. The effect of EMLA cream on patient-controlled analgesia with remifentanil in ESWl procedure: a placebo-controlled randomized study. Anesth Pain 2013; 2:110–122.  Back to cited text no. 8
    
9.
Bárcena M, Rodríguez J, Gude F, Vidal MI, Fernández S. EMLA cream for renal extracorporeal shock wave lithotripsy in ambulatory patients. Eur J Anaesthesiol 1996; 13:373–376.  Back to cited text no. 9
    
10.
Tiselius H. Cutaneous anesthesia with lidocaine-prilocaine cream: A useful adjunct during shock wave lithotripsy with analgesic sedation. J Urol 1993; 149:8–11.  Back to cited text no. 10
    
11.
Vilar GD, Garcia FG, Di Capua SC, Beltran PJ, Perez MM, De Francia JA, et al. Topical EMLA for pain control during extracorporeal shock wave lithotripsy: prospective, comparative, randomized, double-blind study. Urol Res 2012; 40:575–579.  Back to cited text no. 11
    
12.
Nagendra BK, Sharma U. Comparative study in extracorporeal shock wave lithotripsy with and without the use of local anaesthetic (lidocaine 1%) infiltration at the shock wave site. Kathmandu Univ Med J 2009; 7:92–96.  Back to cited text no. 12
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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