ANNALS OF EMERGENCY MEDICINE
JULY 2013
Systematic Review Snapshot
TAKE-HOME MESSAGE
High-volume intravenous fluid therapy has not been shown to improve ureteral
stone passage, pain control, or need for surgical stone removal.
METHODS
DATA SOURCES
The authors searched the Cochrane Renal Group’s Specialised
Register (January 2012), which
includes the Cochrane Central
Register of Controlled Trials, and
also searched MEDLINE, EMBASE,
and the International Clinical Trials Registry and ClinicalTrials.gov
and conducted hand-searches of
journals and major conferences.
Letters seeking information about
unpublished or incomplete trials
were sent to investigators known
to be involved in previous studies
to identify unpublished data.
STUDY SELECTION
Two independent reviewers identified randomized controlled trials
and quasi randomized controlled
trials that examined high-volume
(⬍10 mL/kg) intravenous fluids,
oral fluids, or diuretics versus
maintenance fluids, no fluids, or
no diuretics for the treatment of
adult patients presenting to the
emergency department with an
initial episode of acute ureteral
colic. The presence of ureteral
stones had to be confirmed by
computed tomography (CT), intravenous pyelogram, or Doppler
ultrasonography. No primary outcome was defined; however, 4
short-term outcomes (length of
stay, duration of pain, length of
time to documented stone elimination, and hospital admission)
36 Annals of Emergency Medicine
Do Fluids Facilitate Stone Passage in Acute
Ureteral Colic?
EBEM Commentators
Jonathan Kirschner, MD
Lee Wilbur, MD
Department of Emergency Medicine
Indiana University School of Medicine
Indianapolis, IN
Results
Effect of high-volume intravenous fluids compared with minimal or no fluids in acute
ureteral colic.
Edna, 1983 (nⴝ60)
Outcome
Springhart, 2006 (nⴝ43)
RR (95% CI)
Outcome
SMD
Pain at 6 h
1.06 (0.71–1.57)
Surgical
removal
Cystoscopic
manipulation
1.20 (0.41–3.51)
Change in pain score
at 4 h
Analgesic use
Intervention⫽6.5
Control⫽7.0 (P⫽.54)
Intervention⫽16.4 ME
Control⫽15.4 ME (P⫽.72)
RR (95% CI)
1.38 (0.5–3.84)
0.67 (0.21–2.13)
Outcome
Stone passage
RR, Relative risk; CI, confidence interval; SMD, standard mean difference; ME, morphine equivalents.
The search identified 23 potential
studies, but only 2 met the inclusion
criteria. Different outcomes were reported in each study, precluding
pooling of data. Edna and Hesselberg1
randomized 60 patients to either 3 L
of intravenous fluids during 6 hours
or no fluids; all patients received meperidine. The risk of bias was unclear
because of inadequate reporting of
the methods of randomization, allocation concealment, and blinding.
Springhart et al2 randomized 58 patients to receive either 2 L of normal
saline solution during 4 hours or minimal hydration of 20 mL of normal
saline solution per hour; all patients
received ketorolac and morphine as
needed. Of the 58 patients randomized, 26% were excluded postrandomization (11 in the intervention
group and 4 in the control group; 4
patients did not receive ketorolac as
per study protocol, 9 had no stone
present on CT imaging, and 2 refused
CT imaging). The average stone passage rate was 26%, and follow-up was
obtained in 68% of patients.
Commentary
Renal colic affects approximately 1.2
million people annually in the United
States, accounts for 1% of all hospital
admissions, and is estimated to produce annual medical costs of $2.1 billion.3 Although nearly 98% of ureteral
calculi less than 5 mm will pass spontaneously,4 therapies aimed to accelerate stone passage may improve
patient outcomes compared with
standard therapy. Although forced hyVolume , .  : July 
Systematic Review Snapshot
DATA EXTRACTION AND
BIAS ASSESSMENT
Two authors independently extracted trial data on standardized
forms and assessed methodological quality with the Cochrane risk
of bias assessment tool. Dichotomous outcomes (surgical intervention and symptom relapse)
were expressed as relative risks
and continuous outcomes were
reported as mean differences with
95% confidence intervals.
Despite a comprehensive search strategy, the authors identified only 2
studies that met the inclusion criteria,
neither of which investigated diuretic
use. Among these 2 small studies,
high-volume fluid therapy failed to
demonstrate benefit in pain score,
use of analgesics, or stone passage
rate, but the effect size estimates
were imprecise. The risk of bias was
considerable for both studies; the
study by Springhart et al2 was particularly at risk for attrition bias, given
the disproportionate number of patients who were excluded postrandomization from the fluid therapy
group compared with the standard
therapy group. The rate of stone passage was much lower than what has
been previously reported,4 although
follow-up was not obtained for 32%
of patients and length of follow-up
was not described.
dration might expedite stone passage, the theoretical harms of urinary tract wall rupture or renal
impairment are also unclear. This
review examined the evidence for
the use of high-volume fluid therapy, diuretics, or both in facilitating
stone passage.
Although neither study included in
this review demonstrated a significant
effect, the high risk of bias and small
sample size limit the validity and applicability of the results. The benefits
and harms of high-volume fluid therapy to accelerate symptom resolution
for patients with ureteral colic remain
unknown.
and 4 long-term outcomes (length
of time to return to activities of
daily living, surgical intervention,
adverse events such as kidney
injury, and recurrence of pain or
symptoms) were specified.
This is a systematic review abstract, a
regular feature of the Annals’ EvidenceBased Emergency Medicine (EBEM)
series. Each features an abstract of a
systematic review from the Cochrane
Database of Systematic Reviews and a
commentary by an emergency physician
knowledgeable in the subject area. The
source for this systematic review abstract is: Worster AS, Bhanich Supapol
W. Fluids and diuretics for acute ureteric
colic. Cochrane Database Syst Rev. 2012;
(2):CD004926. doi:10.1002/14651858.
CD004926.pub3. (Assessed as up-todate: 3 January 2012.)
1. Edna TH, Hesselberg F. Acute ureteral
colic and fluid intake. Scand J Urol
Nephrol. 1983;17:175-178.
2. Springhart WP, Marguet CG, Sur RL, et al.
Forced versus minimal intravenous
hydration in the management of acute
renal colic: a randomized trial. J Endourol.
2006;20:713-716.
3. Pearle MS, Calhoun EA, Curhan GC.
Urologic Diseases in America project:
urolithiasis. J Urol. 2005;173:848857.
4. Segura JW, Preminger GM, Assimos DG,
et al. Ureteral Stones Clinical Guidelines
Panel summary report on the
management of ureteral calculi. The
American Urological Association. J Urol.
1997;158:1915-1921.
Michael Brown, MD, MSc, Alan Jones,
MD, and David Newman, MD, serve
as editors of the SRS series.
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Volume , .  : July 
Annals of Emergency Medicine 37