In the urgent care setting, pain control is another consideration when evaluating a patient with upper urinary tract obstruction. The cornerstone of pain control for patients with renal colic and upper urinary tract function has traditionally been parenteral narcotics (Gulmi et al. 2002). Nonsteroidal anti-inflammatory drugs (NSAIDs) have recently gained popularity in the urgent care setting (Larkin et al. 1999). NSAIDs provide effective analgesia in the absence of significant sedation or exacerbation of associated nausea and vomiting. In a prospective, randomized, double-blind trial, Larkin and colleagues compared efficacy of the NSAID, ketorolac, to meperidine among 70 patients evaluated for acute renal colic. They noted that ketorolac provided superior analgesia and facilitated quicker discharges from the emergency room setting (Larkin et al. 1999). Despite the analgesic benefits of NSAIDs, associated physiologic effects in the kidney can be detrimental especially for patients with renal obstruction. In fact, the use of NSAIDS in the absence of renal obstruction has led to case reports of acute renal failure (Kim et al. 1999; Simckes et al. 1999). Despite these reports, other groups have noted safety in clinical use of ketorolac (Diblasio et al. 2004; Lee et al. 2004). For patients with upper urinary tract obstruction, NSAIDS should be administered with caution. Prior to the administration of analgesics in the urgent care setting, assessment of renal function should be documented. For patients with renal insufficiency or patients with bilateral obstruction, selection of narcotic-based analgesics maybe preferred.
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