Pain Profiles: Intravenous Lidocaine for Intractable Renal Colic Unresponsive to Standard Therapy

Written by: David Cisewski, MD (@DHCisewski – EM Resident Physician, Icahn School of Medicine at Mount Sinai) // Edited by: Manpreet Singh, MD (@MPrizzleER), Alex Koyfman, MD (@EMHighAK), and Brit Long, MD (@long_brit)

emDocs is proud to present a new series by Dr. David Cisewski evaluating pain management in the emergency department. One of our most important roles in the ED is not only resuscitation and risk stratification, but treating pain. This series is here to help! Each post will be accompanied by an infographic for further use.

Intravenous Lidocaine for Intractable Renal Colic Unresponsive to Standard Therapy

Sin B, Cao J, Yang D, Ambert K, Punnapuzha S. Intravenous Lidocaine for Intractable Renal Colic Unresponsive to Standard Therapy. Am J Ther. 2018. PMID: 29443696

One-Liner

Use of IV lidocaine for renal colic unresolved by traditional NSAID and opioid treatment suggests efficacy in short-term pain reduction.

Study Characteristics

• Clinical question – Is IV lidocaine an effective analgesic for acute renal colic pain unresponsive to the traditional treatment regimen?
• This study was a case report of a single patient presenting to Brooklyn Hospital Center, Brooklyn, NY.
• The patient was an 65 year old caucasian male with a past medical history of hypertension, hyperlipidemia, myocardial infarction, Gilbert Syndrome, and a history of previous kidney stones presenting with acute, 10/10 flank pain secondary to renal colic.
• A 5-mm mildy obstructing calculus was identified on CT-abdomen.
• Patient was unresponsive to initial administration of 30 mg IV Ketorolac as well as 4 mg IV morphine.
• Due to unremitting flank pain, decision was made to administer 120 mg Lidocaine IV in 100 cc normal saline over 10 minutes.
  • Patent reported 3-minute pain rating of 1/10, 5 min rating of 0/10.
  • Pain remitted throughout the duration of ED care and patient did not require further analgesics.
  • No adverse side effects were experienced following medication administration.
  • Unknown whether patient required surgery, was discharged, or admitted to hospital for further assessment.

Quality Assessment

• This study was a case report involving single patient at a single center, without controls or randomization.

The Upshot

• As with all case reports, little information can be garnered beyond anecdotal evidence of a particular treatment or therapy. This was a single caucasian patient with multiple comorbidities and a history of stones, limiting the generalizability of these results.  80% of stones <5 mm will pass spontaneously within 4 weeks, suggesting the stone could have passed spontaneously at a time coinciding with lidocaine administration, confounding these results.  However, this report suggesting  efficacy of IV lidocaine for renal colic and does facilitate further research and recognition of  IV lidocaine for renal colic, which is already gaining support following previous research (see further reading). Though further research is needed, particularly a large, multi-center, randomized control trial, this case report is promising in that more centers are recognizing and utilizing  lidocaine to treat  renal colic; a pathology affecting  up to 12% of the population and resulting in an approximately 20% admission rate following ED presentation. If presented with the opportunity, I would use IV lidocaine for similar renal colic presentation.

Further Reading:

• Soleimanpour H et al. Effectiveness of Intravenous Lidocaine Versus Intravenous Morphine for Patients with Renal Colic in the Emergency Department. BMC Urology 2012; 12(13): 1 – 5. PMCID: PMC3508963
• Firouzian A 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. Am J Emerg Med 2016; 34(3): 443 – 8. PMID: 26704774
• Salim Rezaie at REBELEM – IV Lidocaine for Renal Colic: Another Opioid Sparing Option?
• Alexis LaPietra, DO at ALiEM – Intravenous Lidocaine for Renal Colic
• emDocs – Nephrolithiasis: Diagnosis and Management in the ED