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Three Part Question

In [patients with acute renal colic], do [intravenous fluids] [increase the rate of stone passage, decrease the length or severity of pain, or decrease the need for urological interventions]

Clinical Scenario

You have a patient with known acute renal colic, confirmed by imaging. You have not yet placed an IV and the patient would prefer to try oral pain medications. Although the teaching has always been to give patients with acute renal colic large volumes of IV fluids, you wonder if there is any evidence to support this practice.

Search Strategy

Medline 1950-5/07 using the OVID interface, Cochrane Library (2007), PubMed clinical queries.
[(exp ureteral obstruction/ or exp ureteral calculi) AND (exp infusion, intravenous/ or exp fluid therapy)] LIMIT to human and english language

Search Outcome

20 papers were found, of which 18 were irrelevant to the study question. A single RCT was identified (Edna et al). The second paper was a meta-analysis (2005), however it provided no additional information.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Edna et al 1983 Norway	Patients admitted to a Norweigan hospital with a diagnosis of acute pain due to a ureteral stone.	Sixty patients (30 in control group/30 in study group) were enrolled and randomized into control or study groups. Only patients with CHF were excluded from study. Group A was allowed no fluids for six hours. Group B received 2L of 5% glucose solution and 1L of Lactated Ringer's solution over 6 hours. All patients given 100mg of pethidine IM injection.	Pain at 6 hrs post treatment	RR 1.06, 95% CI 0.71 to 1.57; No intergroup differences as regards to pain was found after 6 hours of observation.	No information available regarding blinding of participants, investigators, or outcome assessors. No mention of method of randomization. No mention of any adverse effects. Only admitted patients were enrolled in study.
			Incidence of intervention for stone removal	Group A - 5 surgical/6 cystoscopy, Group B - surgical 6/cystoscopy 4, Surgical RR: 1.06, 95% CI 0.71 to 1.57, Cystoscopy RR: 0.67, 95% CI 0.21 to 2.13; No significant differences in rates of surgical stone removal or cystoscopic manipulation.

Comment(s)

In acute renal colic, there is theoretical benefit of the use of intravenous fluids to help facilitate stone passage and therefore, relieve pain. Unfortunately, there has been only one small randomized controlled trial regarding the use of intravenous fluids in renal colic. The results of this study suggest that intravenous fluids may not benefit patients with renal colic in either pain relief or decreasing the need for stone removal by surgery or cystoscopy. The risk of diuretics and/or high volume fluid therapy to the patient, specifically urinary tract wall rupture and/or irreversible renal impairment, is significant enough to outweigh the potential benefits, i.e. the reduction of the duration of symptoms, physician visits, etc. Therefore, despite no evidence for or against these therapies, it cannot be recommended.

Clinical Bottom Line

Intravenous fluids appear to provide no benefit to patients with acute renal colic in regards to pain relief or decreasing need for stone removal interventions.

References

1. Edna et al Acute ureteral colic and fluid intake Scand J Urol Nephrol 1983;17(2):175-8