Page 299 Acute Pain Management

Pethidine has commonly been used in the treatment of renal colic in the belief that it causes
less smooth muscle spasm. However, there was no difference in analgesia when IV morphine
and pethidine were compared in the treatment of renal colic (O'Connor et al, 2000 Level II).
The smooth muscle relaxant buscopan failed to improve analgesia when combined with
nsNSAIDs (Jones et al, 2001 Level II), opioids (Holdgate & Oh, 2005 Level II) or metamizole (Edwards,
Meseguer et al, 2002 Level I). Papaverine was as effective as IV diclofenac in the initial treatment
of renal colic, but required increased use of rescue analgesia (Snir et al, 2008 Level II). However,
as a rescue analgesic, papaverine was of similar efficacy to pethidine and superior to hyoscine
in patients who failed to respond to initial treatment with a diclofenac‐hyoscine combination
(Yencilek et al, 2008 Level II).
IV ondansetron produced analgesia in 42% of patients with renal colic but was less effective
than IM diclofenac (Ergene et al, 2001 Level II). IN desmopressin was also an effective analgesic,
either alone, or in combination with IM diclofenac (Lopes et al, 2001 Level II).
Renal calculus expulsive therapy using the specific alpha‐blocker tamsulosin was superior
to comparative smooth muscle relaxants such as phloroglucinol or nifedipine in terms of
increased stone expulsion and a reduction in analgesia requirements, surgical interventions,
duration of hospital stay and days off work (Dellabella et al, 2005 Level II).
TENS applied over the painful flank during prehospital transport, reduced pain scores, anxiety
and nausea in patients with renal colic (Mora et al, 2006 Level II).
IV fluid therapy had no effect on pain outcomes or stone transition in renal colic (Worster &
Richards, 2005 Level I).
Biliary colic and acute pancreatitis
All opioids increase sphincter of Oddi tone and bile duct pressures in animal and human
experimental models (Thompson, 2001). Morphine increased sphincter of Oddi contractions
more than pethidine during cholecystectomy (Thune et al, 1990 Level IV).
There are no clinical studies comparing opioids in the treatment of pain associated with biliary
spasm or acute pancreatitis (Thompson, 2001). Butorphanol, which is presumed to cause less
biliary spasm than other opioids, and ketorolac produced a clinically significant and similar
reduction in acute biliary colic within 30 minutes in patients in the emergency department
(Olsen et al, 2008 Level II).
Parenteral nsNSAIDs such as ketorolac, tenoxicam or diclofenac were at least as effective as
parenteral opioids and more effective than buscopan in providing analgesia for biliary colic CHAPTER 9
(Goldman et al, 1989 Level II; Al‐Waili & Saloom, 1998 Level II; Dula et al, 2001 Level II; Henderson et al,
2002 Level II; Kumar, Deed et al, 2004 Level II) and may also prevent progression to cholecystitis
(Goldman et al, 1989 Level II; Akriviadis et al, 1997 Level II; Al‐Waili & Saloom, 1998 Level II; Kumar,
Deed et al, 2004 Level II).
IM atropine was no more effective than saline in the treatment of acute biliary colic (Rothrock
et al, 1993 Level II).
Irritable bowel syndrome and colic
There was weak evidence that antispasmodics (smooth muscle relaxants) reduced pain in
irritable bowel syndrome, but no evidence of an analgesic effect with antidepressants or
bulking agents (Quartero et al, 2005 Level I). Peppermint oil may also reduce pain (Pittler & Ernst,
1998 Level I) and was as effective as buscopan in reducing upper (Hiki et al, 2003 Level II) and
lower GI spasm (Asao et al, 2003 Level II).

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