Weber A, Koehrmann K U, Denig N, Michel M S, Alken P
Department of Urology, Klinikum Mannheim of the University of Mannheim, Germany.
Eur Urol. 1998 Aug;34(2):85-92. doi: 10.1159/000019690.
Additional anesthesia is required to minimize the tolerable pain level in efficiently performed extracorporeal shockwave lithotripsy (ESWL) with electrohydraulic and electromagnetic sources. In order to assess optimum anesthesia for each patient undergoing a standardized ESWL protocol, pain measurement and scoring were carried out. We attempted to determine the individual type and amount of analgesia prior to treatment.
Patients (n = 95) with urolithiasis underwent pain measurement and scoring prior to ESWL. 'Threshold of pain' (TP) and 'maximal tolerable pain (MTP) were assessed by inducing ischemia pain with the submaximum effort tourniquet technique. Pain intensity was assessed by a verbal rating scale (VRS). The results of pain measurement and amount of analgosedation were correlated in two phases. Patients were administered an oral premedication of 0.1 mg/kg midazolam. Phase 1: 60 patients were randomized into three groups: (1) piritramide (0.1-0.3 mg/kg) and midazolam (1-3 mg) i.v. (2) Lidocaine/prilocaine cream topically (30 g) to skin and diclofenac supp. 100 mg. (3) No analgesia. Phase 2: Based on the data of phase 1, cut-off points for TP and MTP were set for female and male patients. In accordance with these results, 35 patients comprised group 1 for anesthesia with piritramide/midazolam, group 2 with lidocaine/prilocaine cream and diclofenac supp. and group 3 for no analgesia at all. The electromagnetic shockwave sources Modulith SLX and Lithostar Plus were utilized.
Phase 1: All patients randomized for group 1 (intravenous analgosedation) were treated in accordance with the protocol. 65% of group 2 (cream/suppository) tolerated treatment as planned. 35% of patients selected for ESWL without analgesia (group 3) remained within this group. Patients requiring additional analgosedation displayed lower TP and MTP. The cut-off points for females and males were TP >/=25/35 s and MTP >/=45/60 s, respectively. Phase 2: 20/35 patients were preselected for a nonintravenous protocol. Five out of these 20 violated the protocol. The rate of additionally administered analgesia was lower than in phase 1: 35:10% in group 2 (cream/supp.), 65:40% in group 3 (no analgesia).
The TP and MTP levels are lower in patients requiring stronger analgesia. The determined parameters are suitable for patient preselection and individual assessment of anesthesia prior to ESWL. It may be assumed that 50% of patients administered intravenous opioids are overtreated. Routine pain measurement for patient depends on the individual pain tolerance level. A third phase of this study recruiting a large number of patients will contribute to the confirmation of these results.
在使用液电式和电磁式源有效进行体外冲击波碎石术（ESWL）时，需要额外的麻醉以将可耐受的疼痛水平降至最低。为了评估接受标准化ESWL方案的每位患者的最佳麻醉方法，进行了疼痛测量和评分。我们试图在治疗前确定个体的镇痛类型和剂量。
95例尿石症患者在ESWL治疗前进行疼痛测量和评分。采用次最大强度止血带技术诱发缺血性疼痛，评估“疼痛阈值”（TP）和“最大可耐受疼痛”（MTP）。采用视觉模拟评分法（VRS）评估疼痛强度。疼痛测量结果和镇痛镇静剂量在两个阶段进行相关性分析。患者口服0.1mg/kg咪达唑仑进行术前用药。第一阶段：60例患者随机分为三组：（1）静脉注射匹利卡明（0.1 - 0.3mg/kg）和咪达唑仑（1 - 3mg）；（2）在皮肤局部涂抹利多卡因/丙胺卡因乳膏（30g）并直肠给予双氯芬酸栓剂100mg；（3）不进行镇痛。第二阶段：根据第一阶段的数据，为女性和男性患者设定TP和MTP的截断点。根据这些结果，35例患者分为三组，第一组采用匹利卡明/咪达唑仑麻醉，第二组采用利多卡因/丙胺卡因乳膏和双氯芬酸栓剂，第三组不进行任何镇痛。使用了电磁冲击波源Modulith SLX和Lithostar Plus。
第一阶段：所有随机分配到第一组（静脉镇痛镇静）的患者均按方案进行治疗。第二组（乳膏/栓剂）65%的患者按计划耐受治疗。选择不进行镇痛的ESWL患者（第三组）中有35%仍在该组。需要额外镇痛镇静的患者TP和MTP较低。女性和男性的截断点分别为TP≥25/35秒和MTP≥45/60秒。第二阶段：20/35例患者预先选择采用非静脉方案。这20例中有5例违反了方案。额外给予镇痛的比例低于第一阶段：第二组（乳膏/栓剂）为35:10%，第三组（不进行镇痛）为65:40%。
需要更强镇痛的患者TP和MTP水平较低。所确定的参数适用于ESWL治疗前患者的预选和个体麻醉评估。可以假设50%接受静脉注射阿片类药物的患者治疗过度。对患者进行常规疼痛测量取决于个体的疼痛耐受水平。本研究的第三阶段招募大量患者将有助于证实这些结果。
