IV Hydromorphone Superior to IV Lidocaine for Abdominal Pain in the ED

Intravenous (IV) administration of hydromorphone may be more effective than IV lidocaine in alleviating abdominal pain in the emergency department (ED), according to a study published in the Annals of Emergency Medicine.

Adults weighing between 60 and 120 kg who presented to one of 2 EDs in the Bronx, New York, for acute abdominal pain, were randomly assigned to receive 120 mg IV lidocaine (n=77) or 1 mg IV hydromorphone (n=77). Patients were stratified based on clinical suspicion of nephrolithiasis and were asked whether they required a second dose of medication approximately 30 minutes after the initial dose. Improvement from baseline in pain intensity — evaluated using a 0 to 10 scale — at 90 minutes was the study’s primary outcome. The need for “off-protocol” parenteral analgesics (eg, opioids and nonsteroidal anti-inflammatory drugs) was the secondary outcome.

Patients who received hydromorphone vs lidocaine reported greater improvements in pain intensity at 90 minutes (5.0 points vs 3.8 points, respectively; mean difference, 1.2; 95% CI, 0.3-2.2). A greater percentage of patients who received lidocaine vs hydromorphone required off-protocol rescue medications (51% vs 26%, respectively; difference, 25%; 95% CI, 10%-40%). Patients with nephrolithiasis who received hydromorphone vs lidocaine also indicated greater improvements in pain levels (6.4 points vs 3.4 points, respectively; mean difference, 3.0; 95% CI, 0.5-5.5). No differences were observed between the 2 groups in terms of adverse events.

Study limitations of the study include a possible underdosing of the initial lidocaine bolus.

“Our data do not provide any compelling reasons to choose [IV] lidocaine as a first-line analgesic over hydromorphone for abdominal pain,” the researchers concluded. “Placebo-controlled studies are needed to determine whether [IV] lidocaine should play any role in the management of ED patients with pain.”

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Reference

Chinn E, Friedman BW, Naeem F, et al. Randomized trial of intravenous lidocaine versus hydromorphone for acute abdominal pain in the emergency department [published online February 25, 2019]. Ann Emerg Med. doi:10.1016/j.annemergmed.2019.01.021