Extracorporeal Shockwave Lithotripsy

Anesthesia Implications

Position: Supine, one arm extended
Time: 30-60 min (short)
Blood Loss: Zero
Post-op Pain: Moderate (3-6)
Maintenance Paralytic: No

Hearing Protection – The machine utilized to fracture the stones is loud – so hearing protection may be utilized for both staff and patient.

High Stimulation – The process of breaking up the stones is very painful, so make sure the patient is deep enough prior to starting the machine.

Extensions – Sometimes there is a long distance between the machine and the ventilator – so you may need an extension.

Dysrhythmia Risk – Shock wave can cause dysrhythmias. Specifically, R on T phenomenon and mechanical disruption.

Injury Risk – Any organ between the shock wave and the stone can be damaged. Skin irritation/petechiae/bruising are all possibilities. Hematuria is also a common postoperative side effect. Consider preparing the patient by disclosing these risks preoperatively.

Conscious Sedation – for the sicker patients and/or anesthesia fearing, it has been suggested that minimal versed/fentanyl combined with EMLA cream over the effective site (which is previously found on X-ray and/or ultrasound) is extremely effective.

Initially, the C-arm will be used to locate the kidney stones.

The patient is placed on the ESWL table and either gel or water is placed between the patient and the machine. The machine is then utilized to fracture the stones.

If the stones are large, the surgeon may elect to insert a stent prior to pulverizing the stones.

This method is the preferred method to “break up” proximal and midureteral kidney stones.

If this procedure doesn’t work to adequately break up the stones, the patient may need to have a laser lithotripsy or percutaneous nephrolithotomy.

Absolute contraindications: Pregnancy, high bleeding risk
Relative contraindications: Pacemaker/ICD, renal artery or aortic calcification, untreated UTI, distal obstruction (patient won’t be able to pass the stone fragments), morbid obesity.