Analgesia for pain control during extracorporeal shock wave lithotripsy: Current status

PURPOSE OF REVIEW: A cooperative patient is essential in maintaining stone targeting for optimal fragmentation during extracorporeal shock wave lithotripsy (ESWL). Therefore, it is important to choose an appropriate analgesic with minimal adverse effects. The guidelines for pain management during ESWL have not been established. CURRENT STATUS: Various analgesic agents including opioids (morphine, pethidine, and fentanyl), nonsteroidal anti-inflammatory drugs (NSAIDS - diclofenac, propofol, ketorolac, and piroxicam), local anesthetic agents and a number of combinations have been used during ESWL by various techniques (general anesthesia, regional anesthesia, subcutaneous and intravenous injections, patient-controlled analgesia, and monitored anesthesia care). Cutaneous creams like eutectic mixture of local anesthesia (EMLA) whether used alone or in combination with oral NSAIDS have also been used and are able to reduce analgesic requirements. Topical application of a combination of dimethyl sulfoxide and lidocaine has also been found to be effective. CONCLUSION: The ideal analgesic, offering optimal pain control, minimal side effects, and cost-effectiveness is still elusive. Opioids administered using various techniques, provide effective analgesia, but require active monitoring of patient for potential adverse effects. Combination therapy (oral NSAID and occlusive dressing of EMLA, DMSO with lidocaine) offers an effective alternative mode for achieving analgesia with minimal morbidity. This therapy avoids the need for general anesthesia, injectable analgesics, and opioids along with their side effects.