Anesthesia and pain relief for procedures performed to manage urolithiasis

Anesthetic considerations for extracorporeal shock wave lithotripsy (ESWL), percutaneous nephrolithotomy (PCNL), and concepts of pain management are discussed in this chapter. The pain associated with ESWL has cutaneous, somatic, and visceral origins. General anesthesia, regional anesthesia, and several others miscellaneous techniques (e.g., monitored anesthesia care [MAC]) have been used successfully. The continuous monitoring of hemodynamics and oxygenation is of paramount importance in patients undergoing ESWL regardless of anesthesia technique. Currently the patient undergoing lithotripsy with a ­new-generation device usually requires MAC with conscious sedation only. For patients undergoing PCNL, general anesthesia is a preferred technique. Hemodynamic parameters in prone patients need to be closely monitored as pressure on vena cava and iliac veins may cause impaired venous return and decreased cardiac preload. A multimodal analgesia and combined spinal-epidural anesthesia are alternative techniques to general anesthesia. No matter what anesthesia technique is used, the anesthetist must plan the postoperative pain management for PCNL.Effective postoperative pain management is essential for early rehabilitation, improved recovery, and better patient satisfaction. Regular pain assessment is essential for effective pain management. Several scales have been defined for this purpose, for example, verbal rating scale, visual analogue scale, and numeric rating scale. It is essential to have a basic knowledge of the pharmacology of the commonly used analgesic medications to use them safely and effectively.An individualized approach to management is important for effective postoperative pain management. A multimodal pain management regime should be employed whenever possible since it helps to increase efficacy while minimizing adverse effects. Analgesics should be given on demand after extracorporeal shock wave lithotripsy, and analgesics with a spasmolytic effect may be useful. Postoperative pain associated with percutaneous nephrolithotomy is much worse and requires stronger analgesics. Titration of the opioid dose is important to achieve effective analgesia. Patient-controlled analgesia may improve patient satisfaction. Epidural analgesia provides superior postoperative analgesia and has been shown to reduce pulmonary complications.