By Thomas G. Ciccone
Interview with Alexis LaPietra, DO
Renal colic (RC), or kidney stone pain, is a common pain condition seen in emergency departments (ED), with some 1.2 million patients hospitalized every year for the condition.1
Lidocaine, a local anesthetic, can be an effective intravenous (IV) agent for the treatment of both acute and chronic pain conditions,2-5 but it could be especially effective for RC patients.
“In people who fail the standard of care, you can add (lidocaine) on, and in people who have issues with opiates, you can use this in lieu of opiates,” said Alexis LaPietra, DO, from the department of emergency medicine at St. Joseph’s Healthcare System in Patterson, New Jersey.
Avoiding many of the complications posed by opioids, lidocaine could be a useful option for RC patients, noted Dr. LaPietra during her presentation.6 Many patients may benefit from incorporating or even substituting opioid analgesia with intravenous lidocaine. Some research even suggests the drug could help patients with stone passage, as well.
Renal Colic Pain Management in the ED
Renal colic is considered one of the most painful conditions to present to the emergency department.Lidocaine augments opioid analgesia and promotes opioid-sparing due to the way it interacts with κ and μ opioid receptors.7 Because of this, lidocaine as an adjuvant to morphine not only can reduce the need for systemic opioid use but also may help patients achieve a pain-free state more quickly, perhaps by about 13 minutes.
Some research even suggests opioids may not be the most effective option for RC pain, considering non-steroidal anti-inflammatory drugs (NSAID) like ketorolac8,9 can reduce renal blood flow and ureter pressure during obstruction.10
Dr. LaPietra mentioned one clinic in Iran which did not have access to IV NSAIDs, and so chose to compare lidocaine to morphine for treatment of RC pain. The researchers found a higher percentage of patients had a successful response to lidocaine compared to morphine.11
Lidocaine Infusion in the ED
Lidocaine benefits from being a relatively cheap medication for clinicians to incorporate into EDs. It’s also safe at low doses, with mild adverse side effects, like perioral numbness, dizziness, and confusion, which are a less prevalent issue than what typically is encountered with opioid analgesia, noted Dr. LaPietra.
Given the drug’s low half-life of 1.5 to 2 hours, toxicity symptoms are also highly reversible, making it a friendly tool for ED clinicians to work with. However, patient monitoring during the first few minutes of infusion still is recommended, she added.
“We know that IV lidocaine was used as an anti-arrhythmic liberally, but in some patients, it can also induce arrhythmia.” So patients should be kept on a cardiac monitor to make sure there are no issues hemodynamically, said Dr. LaPietra.
Allergic reactions to the medication are known to induce cardiac arrhythmia and dyspnea in patients, and patients with a history of seizure should be contraindicated for IV lidocaine. “Even if it’s an alcohol withdrawal seizure, the lidocaine does reduce the seizure threshold, and we want to avoid that complication,” Dr. LaPietra added. Patients with advanced age and/or cardiac or hepatic dysfunction should be under continuous monitoring with lidocaine.12
Also, IV lidocaine should not be “pushed,” but rather put in a 50 mL or 100 mL bag. “In our practice, we put 200 mg (lidocaine) in a 100 mL’s of NS (normal saline).” Nurses then use the patient’s weight to infuse a weight-based dose over 10 minutes, said Dr. LaPietra. Maximum bolus dose of lidocaine for adults is 300 mg.13
So far, Dr. LaPietra and her colleagues have not found any issues with arrhythmia in patients administered the drug, and typically, patients only need to be monitored about 15 minutes post-infusion. Granted, not every RC patient is ideal for intravenous lidocaine infusion, but it is an alternative form of therapy clinicians in the ED should consider, especially since it may enable patients to pass their stones more quickly by paralyzing the ureter and reducing muscle spasm, Dr. LaPietra noted.
- Hosseininejad SM, Emami Zeydi A. Can intracutaneous sterile water injection be used as a possible treatment for acute renal colic pain in the emergency department? A short literature review.Urol Ann. 2015;7:130-132.
- Finnerup NB, Biering-Sørensen F, Johannesen IL, et al. Intravenous lidocaine relieves spinal cord injury pain: a randomized controlled trial.Anesthesiology. 2005;102(5):1023-1030.
- de Souza MF, Kraychete DC. The analgesic effect of intravenous lidocaine in the treatment of chronic pain: a literature review.Rev Bras Reumatol. 2014;54(5):386-392.
- Baranowski AP, De Courcey J, Bonello E. A trial of intravenous lidocaine on the pain and allodynia of postherpetic neuralgia.J Pain Symptom Manage. 1999;17(6):429-433.
- Rosen N, Marmura M, Abbas M, et al. Intravenous lidocaine in the treatment of refractory headache: A retrospective case series.Headache. 2009;49:286-291.
- LaPietra A. New Treatment Options for Managing Pain. Presentation at: PAINWeek 2016; September 6-10; Las Vegas, Nevada.
- Cohen SP, Mao J. Is the analgesic effect of systemic lidocaine mediated through opioid receptors?Acta Anaesthesiol Scand. 2003;47;910-911.
- Firouzian A, Alipour A, Dezfouli HR, et al. Does lidocaine as an adjuvant to morphine improve pain relief in patients presenting to the ED with acute renal colic? A double-blind, randomized controlled trial.The American Journal of Emergency Medicine. 2016;34(3):443-448.
- Labrecque M, Dostaler L, Rousselle R, et al. Efficacy of nonsteroidal anti-inflammatory drugs in the treatment of acute renal colic. A meta- analysis.Arch Intern Med. 1994;154:1381-1387.
- Perlmutter AL, Miller Trimble L, Marion D. Toradol, an NSAID used for renal colic, decreases renal perfusion and ureteral pressure in caine model of unilateral ureteral obstruction.J Urol. 1993;149:926-930.
- Soleimanpour H, Hassanzedeh K, Vaezi H, et al. Effectiveness of intravenous lidocaine versus intravenous morphine for patients with renal colic in the emergency department.BMC Urol. 2012;12:13.
- Bursell B, Ratzan RM, Smally AJ. Lidocaine toxicity misinterpreted as a stroke.West J Emerg Med. 2009;10(4):292-294.
- Lauretti GR. Mechanisms of analgesia of intravenous lidocaine.Rev Bras Anestesiol. 2008;58:280-286.