- Email: [email protected]
The Relief of Renal Colic and Renal Suppression: A Preliminary Report
THE RELIEF OF RENAL COLIC AND RENAL SUPPRESSION: A
PRELIMINARY REPORT I. RIDGEWAY TRIMBLE, LT. CoL. (MC)
A:\fD
MARSHALL C. SAXFORD, CAPT. (]VIC)
The relationship of renal colic and renal suppression to the spasm of smooth muscle caused by overactivity of the sympathetic nervous system is illustrated by two patients who were obrnrved at a general hospital in an overseas area. The first case is that of a patient in whom bilateral renal colic and anuria developed during sulfadiazine therapy. His colic was relieved within 10 minutes after novocain injection of the lumbar sympathetic nerve trunk; the anuria of 48 hours' duration was terminated 2 hours follmYing the first injection. In the second case reported, a patient with a ureteral calculus was relieved of renal colic within 3 minutes after novocain injection of this trunk, with the relief of pain lasting only 30 minutes. Again the next day a similar injection gave complete but temporary relief. The calculus had disappeared on x-ray examination several days later. CASE REPORTS
Case 1. A. B., a white Sergeant, Engineers Corps, aged 25 years, was admitted to the hospital March, 27, 1944 ,vith a chronic ulcer of the left lower leg. The ulcer was excised and a split thickness graft applied, the wound healing promptly. However, an area of acute cellulitis with lymphangitis later developed about the grafted area, which was treated with bed rest, elevation of the leg, hot saline compresses, and sulfadiazine by mouth (4 gm. being the initial dorn and 1 gm. every 4 hours thereafter). Instructions ,vere given to force fluids but a record of fluid intake and output was not kept. On the morning of the fourth day of treatment, and after a total of 27 gm. of sulfadiazine had been given, he had typical renal colic on the left, pain radiating from the left costovertebral angle to the groin and penis. Discontinuance of the sulfadiazine, large doses of morphine, hot tubs, hot packs to the side, and fluids forced to 4000 cc failed to give relief. The urine was loaded with red blood cells but contained no crystals, and the sulfadiazine blood level was 6.4 mg. per cent. He became lethargic and nauseated, vomited several times, and continued to complain of severe pain in the abdomen, then in the left flank and then in both flanks. He became anuric and, at this time, the non-protein nitrogen rose to 57.7 mg. per cent. A flat x-ray film of the abdomen, June 22, 1944, showed no urinary calculi. The intravenous pyelogram showed no excretion of dye by either kidney (fig. 1, a). After 48 hours of anuria and continued colic, a bilateral injection with novocain of the sympathetic nerve trunk at the level of T 12 and L 1 was performed. Within 10 minutes all pain had ceased and 2 hours later the patient began to void in large quantities. An intravenous pyelogram, (28 hours after injection) revealed subnormal excretion of dye from the right kidney but none from the left kidney. The non-protein nitrogen had fallen to 40.8 mg. per cent. Eighteen hours after the first injection pain returned to the left flank but was less severe than before, and there was no return of pain on the right side. On June 26, 4
RELIEF OF RE:',."'-L COLIC AND RENAL SUPPRESSION
5
1944 (48 hours after the first injection), a second novocain block ,ms performed, this tin,e in the left side only, and again all pain disappeared within 10 minutes,
Frn. l. a, (Upper left) Case l. Intravenous pyelogram (June 23, 1944) shows no dye from either kidney. b, (Upper right) June 27, 1944. Normal excretion of dye from right kidney, beginning excretion from left, 24 hours after second injection. (X-ray 28 hours after first injection showed some function of right kidney only, but photograph of x-ray was not clear enough for reporoduction. c, (Lower left) June 30, 1944. Excretion from right kidney is normal, and is increasing from left kidney. d, (Lower right) July 3, 1944. K ormal excretion from both kidneys.
and no rndation was required for sleep. He became alert, and the non-protein nitrogen 12 hours later ,ms normal. Intravenous pyelogram June 27, 1944 shmred normal excretion from the right kidney, a reduced excretion from the
6
I. RIDGEWAY TRIMBLE AND MARSHALL C. SANFORD
left kidney (fig. 1, band c) and on July 3, 1944 showed normal excretion of dye from both kidneys (fig. 1, d). The patient has been asymptomatic since the last injection. Case 2. H. H. S., a white male technician, fifth grade, aged 28 years, was previously admitted to the hospital January 30, 1944 with a history of 2 attacks of severe left sided renal colic on January 12 and 14, 1944. At the time of admission he was asymptomatic, but x-ray showed a small stone in the lowermost calyx of the left kidney with very slight dilatation of the left renal pelvis and ureter. The urine contained many white blood cells, and culture of the urine from the bladder and left kidney yielded a heavy growth of hemolytic staphylococcus aureus; a urine specimen from the right kidney was normal. 200,000 Oxford units of penicillin were given, which did not clear the infection from the urine, but the patient remained asymptomatic and was discharged to limited duty 19 May 1944. On July 26, 1944 he was seized suddenly with excruciating pain in the left flank, radiating to the left lower quadrant of the abdomen and to the left side of the scrotum. X-ray on this day showed the stone at the junction of the middle and upper thirds of the left ureter. Three hours after the on:cet of the pain the sympathetic trunk was injected with 20 cc of ½per cent novocain containing four drops of adrenalin at the level of the first lumbar ganglion. Within 3 minutes all pain had disappeared. The patient, who had come to the operating room on a stretcher, pale, sweating and in great pain, walked back to the ward in no discomfort whatever. This relief of pain lasted only about 30 minutes, and morphia was then required, which gave some relief. The next day, when the pain had almost reached its former intensity, a second lumbar sympathetic trunk injection was done, and all pain subsided completely. Again, however, the relief lasted only 30 minutes. On July 28 he had a temperature of 102° F. X-ray showed that the stone was in the same position as 48 hours previously. Sulfadiazine, 6 gr. daily, was started. On July 30, 1944, all pain had subsided and he was afebrile. August 5, 1944, the urine showed a few clumps of white blood cells but was sterile on culture for the first time. An intravenous pyelogram taken August 7 showed no stone present, the left kidney excreting contrast media normally, slight dilatation of the left kidney pelvis and ureter. Although the urine specimens had been strained no stone was recovered. DISCUSSION
In Case 1, the first consideration was, of course, to relieve the anuria. It is a well known fact that obstructions may occur during sulfadiazine therapy because of either the formation of crystals in the kidney tubules, pelvis, and in the ureters or because of s,velling of the glomeruli and tubules secondary to inflammatory and degenerative processes due to the sulfadiazine. It was hoped that by releasing spasm throughout the kidney and ureter the crystals would be more readily excreted and that, if the spasm of the blood vessels throughout the kidney could be released, the subsequent vasodilatation and local increase in blood flow would increase the urinary secretion.
RELIEF OF RENAL COLIC AND RENAL SUPPRESSION
7
The second consideration was to relieve the intense renal colic. Because of experience with the relief of the visceral pain of widespread metastatic lesions in the abdomen by alcohol injection of the lumbar sympathetic nerve trunk and with the relief of the pain of angina pectoris by resection or injection of the thoracic sympathetic trunk, it was hoped that the renal colic in this patient would be relieved by the injection of novocain into the sympathetic trunk at the level of the celiac ganglion. Therefore, the injection of this trunk was made, using 20 cc of a ½per cent novocain solution, containing 4 drops of adrenalin, at the level of both T 12 and L 1. (No reaction follows the injection of this strength novocain solution. The adrenalin has the advantage of preventing too rapid absorption and of affording a more prolonged novocain effect.) In Case 2, the immediate relief of the pain after novocain was gratifying but, in light of our recent experience, not surprising. The short duration of this relief was, however, disappointing. Some substance which has a more prolonged effect than the aqueous solution of novocain and is not so toxic to tissues as as alcohol must be sought. Whether the passage of the ureteral calculus was aided in any way by the two periods of relaxation of the musculature of the ureter following injection is a matter of conjecture. SUMMARY
Novocain injection of the sympathetic nerve trunk was followed by gratifying results in a patient with anuria and bilateral renal colic after sulfadiazine medication. In a patient with renal colic due to a ureteral stone the same procedure was followed by temporary relief of pain and by the passage of the stone . Although nothing conclusive can be drawn from these two cases, it is believed that renal colic can be completely, even though temporarily, relieved by sympathetic trunk injection, that such an accomplishment has great promise, and that a sympathetic trunk block is indicated in certain types of anuria. · Novocain injection of the sympathetic nerve trunk is not a difficult or dangerous procedure if carefully done and merits a trial in such conditions as the two described. An excellent description of the technique of lumbar sympathetic trunk injection is that of DeBakey in The Bulletin of the United States Army Medical Department, February 1944.
PRELIMINARY REPORT I. RIDGEWAY TRIMBLE, LT. CoL. (MC)
A:\fD
MARSHALL C. SAXFORD, CAPT. (]VIC)
The relationship of renal colic and renal suppression to the spasm of smooth muscle caused by overactivity of the sympathetic nervous system is illustrated by two patients who were obrnrved at a general hospital in an overseas area. The first case is that of a patient in whom bilateral renal colic and anuria developed during sulfadiazine therapy. His colic was relieved within 10 minutes after novocain injection of the lumbar sympathetic nerve trunk; the anuria of 48 hours' duration was terminated 2 hours follmYing the first injection. In the second case reported, a patient with a ureteral calculus was relieved of renal colic within 3 minutes after novocain injection of this trunk, with the relief of pain lasting only 30 minutes. Again the next day a similar injection gave complete but temporary relief. The calculus had disappeared on x-ray examination several days later. CASE REPORTS
Case 1. A. B., a white Sergeant, Engineers Corps, aged 25 years, was admitted to the hospital March, 27, 1944 ,vith a chronic ulcer of the left lower leg. The ulcer was excised and a split thickness graft applied, the wound healing promptly. However, an area of acute cellulitis with lymphangitis later developed about the grafted area, which was treated with bed rest, elevation of the leg, hot saline compresses, and sulfadiazine by mouth (4 gm. being the initial dorn and 1 gm. every 4 hours thereafter). Instructions ,vere given to force fluids but a record of fluid intake and output was not kept. On the morning of the fourth day of treatment, and after a total of 27 gm. of sulfadiazine had been given, he had typical renal colic on the left, pain radiating from the left costovertebral angle to the groin and penis. Discontinuance of the sulfadiazine, large doses of morphine, hot tubs, hot packs to the side, and fluids forced to 4000 cc failed to give relief. The urine was loaded with red blood cells but contained no crystals, and the sulfadiazine blood level was 6.4 mg. per cent. He became lethargic and nauseated, vomited several times, and continued to complain of severe pain in the abdomen, then in the left flank and then in both flanks. He became anuric and, at this time, the non-protein nitrogen rose to 57.7 mg. per cent. A flat x-ray film of the abdomen, June 22, 1944, showed no urinary calculi. The intravenous pyelogram showed no excretion of dye by either kidney (fig. 1, a). After 48 hours of anuria and continued colic, a bilateral injection with novocain of the sympathetic nerve trunk at the level of T 12 and L 1 was performed. Within 10 minutes all pain had ceased and 2 hours later the patient began to void in large quantities. An intravenous pyelogram, (28 hours after injection) revealed subnormal excretion of dye from the right kidney but none from the left kidney. The non-protein nitrogen had fallen to 40.8 mg. per cent. Eighteen hours after the first injection pain returned to the left flank but was less severe than before, and there was no return of pain on the right side. On June 26, 4
RELIEF OF RE:',."'-L COLIC AND RENAL SUPPRESSION
5
1944 (48 hours after the first injection), a second novocain block ,ms performed, this tin,e in the left side only, and again all pain disappeared within 10 minutes,
Frn. l. a, (Upper left) Case l. Intravenous pyelogram (June 23, 1944) shows no dye from either kidney. b, (Upper right) June 27, 1944. Normal excretion of dye from right kidney, beginning excretion from left, 24 hours after second injection. (X-ray 28 hours after first injection showed some function of right kidney only, but photograph of x-ray was not clear enough for reporoduction. c, (Lower left) June 30, 1944. Excretion from right kidney is normal, and is increasing from left kidney. d, (Lower right) July 3, 1944. K ormal excretion from both kidneys.
and no rndation was required for sleep. He became alert, and the non-protein nitrogen 12 hours later ,ms normal. Intravenous pyelogram June 27, 1944 shmred normal excretion from the right kidney, a reduced excretion from the
6
I. RIDGEWAY TRIMBLE AND MARSHALL C. SANFORD
left kidney (fig. 1, band c) and on July 3, 1944 showed normal excretion of dye from both kidneys (fig. 1, d). The patient has been asymptomatic since the last injection. Case 2. H. H. S., a white male technician, fifth grade, aged 28 years, was previously admitted to the hospital January 30, 1944 with a history of 2 attacks of severe left sided renal colic on January 12 and 14, 1944. At the time of admission he was asymptomatic, but x-ray showed a small stone in the lowermost calyx of the left kidney with very slight dilatation of the left renal pelvis and ureter. The urine contained many white blood cells, and culture of the urine from the bladder and left kidney yielded a heavy growth of hemolytic staphylococcus aureus; a urine specimen from the right kidney was normal. 200,000 Oxford units of penicillin were given, which did not clear the infection from the urine, but the patient remained asymptomatic and was discharged to limited duty 19 May 1944. On July 26, 1944 he was seized suddenly with excruciating pain in the left flank, radiating to the left lower quadrant of the abdomen and to the left side of the scrotum. X-ray on this day showed the stone at the junction of the middle and upper thirds of the left ureter. Three hours after the on:cet of the pain the sympathetic trunk was injected with 20 cc of ½per cent novocain containing four drops of adrenalin at the level of the first lumbar ganglion. Within 3 minutes all pain had disappeared. The patient, who had come to the operating room on a stretcher, pale, sweating and in great pain, walked back to the ward in no discomfort whatever. This relief of pain lasted only about 30 minutes, and morphia was then required, which gave some relief. The next day, when the pain had almost reached its former intensity, a second lumbar sympathetic trunk injection was done, and all pain subsided completely. Again, however, the relief lasted only 30 minutes. On July 28 he had a temperature of 102° F. X-ray showed that the stone was in the same position as 48 hours previously. Sulfadiazine, 6 gr. daily, was started. On July 30, 1944, all pain had subsided and he was afebrile. August 5, 1944, the urine showed a few clumps of white blood cells but was sterile on culture for the first time. An intravenous pyelogram taken August 7 showed no stone present, the left kidney excreting contrast media normally, slight dilatation of the left kidney pelvis and ureter. Although the urine specimens had been strained no stone was recovered. DISCUSSION
In Case 1, the first consideration was, of course, to relieve the anuria. It is a well known fact that obstructions may occur during sulfadiazine therapy because of either the formation of crystals in the kidney tubules, pelvis, and in the ureters or because of s,velling of the glomeruli and tubules secondary to inflammatory and degenerative processes due to the sulfadiazine. It was hoped that by releasing spasm throughout the kidney and ureter the crystals would be more readily excreted and that, if the spasm of the blood vessels throughout the kidney could be released, the subsequent vasodilatation and local increase in blood flow would increase the urinary secretion.
RELIEF OF RENAL COLIC AND RENAL SUPPRESSION
7
The second consideration was to relieve the intense renal colic. Because of experience with the relief of the visceral pain of widespread metastatic lesions in the abdomen by alcohol injection of the lumbar sympathetic nerve trunk and with the relief of the pain of angina pectoris by resection or injection of the thoracic sympathetic trunk, it was hoped that the renal colic in this patient would be relieved by the injection of novocain into the sympathetic trunk at the level of the celiac ganglion. Therefore, the injection of this trunk was made, using 20 cc of a ½per cent novocain solution, containing 4 drops of adrenalin, at the level of both T 12 and L 1. (No reaction follows the injection of this strength novocain solution. The adrenalin has the advantage of preventing too rapid absorption and of affording a more prolonged novocain effect.) In Case 2, the immediate relief of the pain after novocain was gratifying but, in light of our recent experience, not surprising. The short duration of this relief was, however, disappointing. Some substance which has a more prolonged effect than the aqueous solution of novocain and is not so toxic to tissues as as alcohol must be sought. Whether the passage of the ureteral calculus was aided in any way by the two periods of relaxation of the musculature of the ureter following injection is a matter of conjecture. SUMMARY
Novocain injection of the sympathetic nerve trunk was followed by gratifying results in a patient with anuria and bilateral renal colic after sulfadiazine medication. In a patient with renal colic due to a ureteral stone the same procedure was followed by temporary relief of pain and by the passage of the stone . Although nothing conclusive can be drawn from these two cases, it is believed that renal colic can be completely, even though temporarily, relieved by sympathetic trunk injection, that such an accomplishment has great promise, and that a sympathetic trunk block is indicated in certain types of anuria. · Novocain injection of the sympathetic nerve trunk is not a difficult or dangerous procedure if carefully done and merits a trial in such conditions as the two described. An excellent description of the technique of lumbar sympathetic trunk injection is that of DeBakey in The Bulletin of the United States Army Medical Department, February 1944.