Local analgesia in laparoscopy: a randomized trial

OBJECTIVE: To investigate whether local infiltration of bupivacaine reduces postoperative pain at trocar sites during gynecologic laparoscopy. METHODS: This was a randomized, placebo-controlled, double-blind clinical trial, using patients as their own controls. For each patient, 2 opposite trocar sites were infiltrated. One site was randomly chosen to receive 0.5% bupivacaine, and the other received 0.9% saline. In addition, patients were randomized into 2 cohorts to receive either preincision or postsurgical infiltration. Surgeons, patients, and interviewers were blinded toward the exposure. Postoperative pain was evaluated at 1 hour, 4 hours, and 24 hours after surgery using a 100-mm visual analog scale. Patients rated their pain at each of the infiltrated trocar sites. A 20-mm difference between pain scores was considered clinically significant. A paired t test was used for analysis. RESULTS: Infiltration of bupivacaine at completion of surgery resulted in significantly decreased pain at 1 hour postoperatively (mean pain score 25.8 versus 48.6, P = .02). Mean pain scores at 4 hours and 24 hours were decreased, but not statistically different. Patients receiving bupivacaine before surgery did not have a statistically significant decrease in pain scores. CONCLUSION: Infiltration of bupivacaine at completion of gynecologic laparoscopic surgery decreases pain at trocar sites in the immediate postoperative period.     

Liposomal Bupivacaine Versus Bupivacaine Hydrochloride with Lidocaine during Midurethral Sling Placement: A Randomized Controlled Trial

Study ObjectiveTo study the effects of liposomal bupivacaine (LB) compared with bupivacaine hydrochloride with lidocaine on postoperative day 1 pain scores.DesignA randomized controlled trial (Canadian Task Force classification 1).SettingAn academic medical center within the department of female pelvic medicine and reconstructive surgery.PatientsFifty-seven patients undergoing midurethral sling placement by a fellowship-trained urogynecologic surgeon and a fellow in female pelvic medicine and reconstructive surgery.InterventionsFifty-seven patients were enrolled to participate in this study. There were 24 patients randomized to receive liposomal bupivacaine and 33 to receive a mixture of bupivacaine and lidocaine during the placement of a retropubic midurethral sling.Measurements and Main ResultsPatients were given a diary of pain scales and asked to record their level of pain using the provided visual analog scale scored on a 100-mm Likert scale. Patients recorded their pain 4 hours after hospital discharge and on the night of surgery and their most intense pain each day thereafter for 7 days postoperatively. In addition, patients recorded total opioid and nonsteroidal anti-inflammatory drug consumption daily for 1 week postoperatively. Finally, the quality of recovery was assessed using the Quality of Recovery-15 (QoR-15) questionnaire scores. The median pain score in the experimental group was 20 mm (range, 0–80 mm) versus 30 mm (range, 0–60 mm) in the comparative group (p = .046). The postoperative day 1 QoR-15 scores were significantly lower in the LB group (124 [range, 54–150] vs 144 [range, 68–150], p = .007). There were no significant differences in opioid and nonsteroidal anti-inflammatory drug consumption, the remaining pain scores, or postoperative day 7 QoR-15 scores.ConclusionThe results suggest the use of liposomal bupivacaine during retropubic midurethral sling placement does not provide a clinically significant difference in postoperative day 1 pain scores when compared with immediate-acting bupivacaine hydrochloride and lidocaine.     

Paracervical Block as a Strategy to Reduce Postoperative Pain after Laparoscopic Hysterectomy: A Randomized Controlled Trial

Study ObjectiveTo determine if performing a paracervical block with .5% bupivacaine before laparoscopic hysterectomy reduces postoperative pain.DesignDouble-blind randomized controlled trial (Canadian Task Force classification I).SettingUniversity-affiliated hospital.PatientsWomen aged between 18 and 65 years scheduled to undergo total laparoscopic hysterectomy for benign indications.InterventionsEligible patients were allocated to control or treatment groups using block randomization. Surgeon administered injection of either .9% NaCl or .5% bupivacaine into the cervical stroma at the 3 and 9 o'clock positions after general anesthesia was established. Pain was assessed using a visual analog scale with a range from 0 to 10 at 30 and 60 minutes after extubation.Measurements and Main ResultsForty-one patients met criteria for analysis. Based on randomization, 20 were allocated to the control arm and 21 to the treatment arm. We used Student t and Pearson χ² tests to ensure both groups were homogenous to age (46.5 vs 46, p = .87), body mass index (35 vs 32.7 kg/m², p = .45), minutes of operating time (132.5 vs 119.7, p = .11), specimen weight (138.8 vs 160.6 g, p = .44), and history of cesarean section (p = .58). Pain scores at 30 minutes (5.7 vs 3.2, p = .01) and 60 minutes (5.9 vs 2.3, p <.001) were significantly lower in the treatment arm. We dichotomized results depending on whether patients had successful postoperative pain control, defined as an average pain score of 4 or less. The χ² test was used for comparison. Using this definition 25% of patients had successful pain control in the placebo group versus 71.4% in the treatment group. This was statistically significant (p = .003). Mean length of hospital stay (.65 vs .86 days, p = .44) was not statistically different.ConclusionPerforming a paracervical block with .5% bupivacaine before laparoscopic hysterectomy significantly reduces immediate postoperative pain. (ClinicalTrials.gov no.: NCT03027661.)     

Intraperitoneal Instillation of Bupivacaine for Reduction of Postoperative Pain After Laparoscopic Hysterectomy: A Double-Blind Randomized Controlled Trial

Study ObjectiveTo evaluate the effect on postoperative pain of intraperitoneal instillation of dilute bupivacaine at the conclusion of laparoscopic hysterectomy.DesignProspective, randomized, double-blind, placebo-controlled trial (Canadian Task Force classification I).SettingTertiary care, urban, academic teaching hospital.PatientsWomen aged 18 to 65 years undergoing total or supracervical laparoscopic hysterectomy with or without salpingo-oophorectomy.InterventionRandomization to intraperitoneal instillation of bupivacaine vs normal saline solution at the conclusion of laparoscopic hysterectomy performed because of benign indications.Measurements and Main ResultsA total of 160 patients consented to participate in the study and were randomized to receive either intraperitoneal instillation of 100 mg bupivacaine in 100 mL normal saline solution or 100 mL normal saline solution alone, at the conclusion of laparoscopic hysterectomy. Sixty seven of 77 patients (87%) in the treatment group and 73 of 80 patients (91%) in the placebo group completed the study. There were no significant differences in demographic profile, indication for hysterectomy, or number of previous surgeries between the two groups. All patients were prescribed a standardized routine postoperative analgesic regimen. Pain was measured by patient self-report using a 10-cm visual analog scale (VAS) at 1, 2, 4, 6, 12, and 24 hours postoperatively. Mean VAS scores at all time points were between 2.0 and 4.3 and were highest in the first postoperative hour. VAS scores were not significantly different between the two groups at any time point. None of the measured secondary outcomes were significantly different between the bupivacaine and placebo groups, including total postoperative opioid analgesic use in morphine equivalents (23.2 mg vs 27.5 mg; p = .09), length of hospital stay in hours (23.3 vs 23.0; p = .49), patient satisfaction on a 10-cm VAS (9.0 vs 8.2; p = .12), and complication rates (9% vs 15%; p = .35).ConclusionIntraperitoneal instillation of bupivacaine at the conclusion of laparoscopic hysterectomy does not reduce postoperative pain. Opioid analgesic use, length of hospital stay, overall patient satisfaction, and complication rates are also unchanged. Self-reported postoperative pain was low in both groups after this major gynecologic surgery performed laparoscopically.     

A Randomized,Double-Blind,Placebo-Controlled Trial of Oral Pregabalin for Relief of Shoulder Pain after Laparoscopic Gynecologic Surgery

Study ObjectiveTo investigate the efficacy of pregabalin for the relief of postoperative shoulder pain after laparoscopic gynecologic surgery.DesignProspective, randomized, double-blind, placebo-controlled trial (Canadian Task Force classification I).SettingTertiary referral center, university hospital.PatientsFifty-six women undergoing elective laparoscopic gynecologic surgery between June 2012 and March 2013.InterventionsWomen in the study group received 75 mg pregabalin 2 hours before surgery and then every 12 hours for 2 doses, and women in the control group received an identical capsule and the same dosage of placebo.Measurements and Main ResultsVisual analog scale (VAS) scores for shoulder pain and surgical pain at 24 and 48 hours after surgery were evaluated as primary outcome. Postoperative analgesics used and drug-related adverse events were also monitored. Patients in the pregabalin group had significantly lower postoperative VAS scores for shoulder pain at 24 hours, compared with the placebo group (median, 23.14 [range, 13.67–32.61] vs 37.22 [27.75–46.64]; p = .04), and required less analgesic (p = .01). There were no significant differences in VAS scores for surgical pain and adverse events between the 2 groups (p = .56).ConclusionsPerioperative administration of 75 mg pregabalin significantly reduced postoperative laparoscopic shoulder pain and amount of analgesic used.     

Opioid Use After Laparoscopic Surgery for Endometriosis and Pelvic Pain

Study ObjectiveThe primary objective was to quantify postoperative opioid use after laparoscopic surgery for endometriosis or pelvic pain. The secondary objective was to identify patient characteristics associated with greater postoperative opioid requirements.DesignProspective, survey-based study in which subjects completed 1 preoperative and 7 postoperative surveys within 28 days of surgery regarding medication usage and pain control.SettingTertiary care, academic center.PatientsA total of 100 women with endometriosis or pelvic pain.InterventionsLaparoscopic same-day discharge surgery by fellowship-trained minimally invasive gynecologists.Measurements and Main ResultsA total of 100 patients were recruited and 8 excluded, for a final sample size of 92 patients. All patients completed the preoperative survey. Postoperative response rates ranged from 70.7% to 80%. The mean number of pills (5 mg oxycodone tablets) taken by day 28 was 6.8. The average number of pills prescribed was 10.2, with a minimum of 4 (n = 1) and maximum of 20 (n = 3). Previous laparoscopy for pelvic pain was associated with a significant increase in postoperative narcotic use (8.2 vs 5.6; p = .044). Hysterectomy was the only surgical procedure associated with a significant increase in postoperative narcotic use (9.7 vs 5.4; p = .013). There were no difference in number of pills taken by presence of deep endometriosis or pathology-confirmed endometriosis (all p >.36). There was a trend of greater opioid use in patients with diagnoses of self-reported chronic pelvic pain, anxiety, and depression (7.9 vs 5.7, p = .051; 7.7 vs 5.2, p = .155; 8.1 vs 5.6, p = .118).ConclusionMost patients undergoing laparoscopic surgery for endometriosis and pelvic pain had a lower postoperative opioid requirement than prescribed, suggesting surgeons can prescribe fewer postoperative narcotics in this population. Patients with a previous surgery for pelvic pain, self-reported chronic pelvic pain syndrome, anxiety, and depression may represent a subset of patients with increased postoperative opioid requirements.     

The effect of preemptive pudendal nerve blockade on pain after transvaginal pelvic reconstructive surgery

OBJECTIVE: To assess the effect of preemptive pudendal nerve blockade on pain and consumption of narcotic analgesia following transvaginal pelvic reconstructive surgery. METHODS: This was a randomized, double-blind, placebo-controlled trial. Patients undergoing transvaginal pelvic reconstructive surgery under general anesthesia were randomized to receive pudendal block with either bupivacaine 0.25% or placebo (normal saline 0.9%) immediately before surgery. All patients received postoperative intravenous hydromorphone patient-controlled analgesia. Patients were asked to report on their pain intensity 1, 3, 5, 7, 18, and 24 hours postoperatively, using a validated visual analog pain scale from 0-10. Main outcome measures included postoperative pain intensity and hydromorphone consumption. RESULTS: One hundred ten patients enrolled in the study, of whom 106 underwent randomization, and 102 received pudendal nerve blockade, 51 with bupivacaine and 51 with saline. Demographic and baseline clinical characteristics were not significantly different between the 2 patients groups. There were no significant differences in postoperative pain intensity (median scores: 1 hour, 4.0 versus 5.0; 3 hours, 3.0 versus 4.0; 7 hours, 2.0 versus 3.0; 18 hours, 3.0 versus 4.0), the consumption of hydromorphone (0-3 hours, 1.84 mg versus 1.77 mg; 4-7 hours, 1.19 mg versus 1.20 mg; 8-18 hours, 2.89 mg versus 2.35 mg), or mean hospital stay (39.6 versus 37.3 hours) between the bupivacaine and saline groups. CONCLUSION: Preemptive pudendal nerve blockade does not affect postoperative pain intensity or the consumption of narcotic analgesia after transvaginal pelvic reconstructive surgery.     

Pelvic Pain and Patient Satisfaction After Laparoscopic Supracervical Hysterectomy: Prospective Trial

Study ObjectiveTo evaluate the occurrence and intensity of cyclic pelvic pain and patient satisfaction after laparoscopic supracervical hysterectomy and to explore the effect of the procedure on pelvic pain relief in women with perioperative detection of endometriosis and in women with histologic confirmation of adenomyosis.DesignProspective observational study with 12-month follow-up after laparoscopic supracervical hysterectomy (Canadian Task Force classification II-2).SettingUniversity teaching hospital in Norway.PatientsOne hundred thirteen premenopausal women with preoperative cyclic pelvic pain treated via laparoscopic supracervical hysterectomy.InterventionsStudy participants underwent laparoscopic supracervical hysterectomy and were followed up at the outpatient clinic at 12 months after the procedure.Measurements and Main ResultsThe main outcomes were occurrence, intensity, and reduction of cyclic pelvic pain and patient satisfaction measured using an ordinal and a visual analog scale at 12 months after the procedure. Of the 113 women included in the study, 8 were lost to follow-up. Consequently, 105 women (92.9%) were followed up at 12 months after surgery. All women had cyclic pelvic pain preoperatively, but only 34 (32.4%) experienced this pain at 12 months after the procedure. The intensity of pelvic pain was reduced from a mean (SD) of 5.5 (2.4) preoperatively to 0.7 (1.5) at 12 months after the procedure on a visual analog scale of 0 to 10 (p < .01). Endometriosis was diagnosed perioperatively in 14 women (12.4 %), and adenomyosis was confirmed at histologic analysis in 19 (18.1%). In women with perioperative detection of endometriosis or histologic confirmation of adenomyosis, there were no significant differences in main outcomes at 12 months after laparoscopic supracervical hysterectomy when compared with women without these diagnoses.ConclusionLaparoscopic supracervical hysterectomy is associated with high patient satisfaction and reduces cyclic pelvic pain to a minimum by 12 months after the procedure.     

A Systematic Review and Meta-Analysis of the Effect of Intraoperative Bupivacaine in Gynaecologic Surgery After 24 Hours or 9 Half-Lives

ObjectiveTo review all high quality available evidence regarding the effect of intraoperative bupivacaine 24 hours (or 8.9 half-lives) after intraoperative administration at time of gynaecologic surgery and to ascertain whether a second mechanism of action, beyond the initial prevention of sodium channel depolarization and blockade of nerve impulses, may be occurring.Data SourcesWe searched all major databases with an algorithm designed to include all randomized trials that used any form of local bupivacaine, regardless of dose or route of administration, at the time of any gynaecologic surgery and compared its use with saline placebo.ResultsAs expected, we found that bupivacaine showed a significant improvement for all gynaecologic surgeries with respect to pain intensity at 6 hours after surgery when compared with a saline group (mean difference [MD] –1.28; 95% CI –1.96 to –0.61], P = 0.07). We also found a significant difference at 24 hours after surgery, giving evidence to the possibility of a second mechanism of action (MD –0.57; 95% CI –1.10 to –0.05], P = 0.01). Further subgroup analysis for pain levels at 24 hours showed significant decreases in pain for the laparoscopy (MD –0.74; 95% CI –0.93 to –0.54, P < 0.01) and laparotomy (MD –2.60; 95% CI –2.93 to –2.27, P < 0.01)) subgroups but not for the vaginal hysterectomy (MD 0.20; 95% CI –0.69 to 1.09, P = 0.66) or prolapse surgery (MD –0.11; 95% CI –0.41 to 0.19, P = 0.48) subgroups. There was no significant difference with respect to the length of hospital stay (MD –0.11; 95% CI –0.59 to 0.38, P = 0.67).ConclusionAs expected, bupivacaine significantly reduced visual analog pain scores when compared with placebo at 6 hours after surgery, but also showed a significant difference at 24 hours after surgery, giving evidence of a second mechanism of action following the initial sodium channel blockade.     

Intraperitoneal bupivacaine for the reduction of postoperative pain following operative laparoscopy: a pilot study and review of the literature.

This pilot case-control study was carried out to determine the value of intraperitoneal irrigation with a long-acting local anaesthetic agent in reducing postoperative analgesic requirements following gynaecological operative laparoscopy. Twenty women undergoing gynaecological laparoscopic surgery were recruited to receive dilute bupivacaine instilled into the peritoneal cavity at the completion of surgery. Analgesic requirements were assessed during the first 10 hours, and pain scores at 4 and 24 hours. Analgesic requirements were then compared with historical controls. Our results revealed that the total parenteral opioid requirement after bupivacaine was significantly less than in the control group (0.50 mg vs. 7.17 mg, P=0.006). Oral analgesic requirements were not significantly different between the two groups. Pain scores in the bupivacaine group showed no difference at 4 and 24 hours postoperatively. Intraperitoneal irrigation with dilute bupivacaine at the end of gynaecological laparoscopic surgery appears to reduce early postoperative analgesic requirements in this pilot study.     

Superior Hypogastric Plexus Nerve Block in Minimally Invasive Gynecology: A Randomized Controlled Trial

Study ObjectiveTo assess the efficacy of a superior hypogastric plexus nerve block in reducing opioid requirements in the first 24 hours after minimally invasive gynecologic surgery.DesignPatient-blinded randomized controlled trial.SettingSingle-center academic institution (Sydney Women's Endosurgery Centre). Two surgeons administering the blocks in their own surgeries.PatientsPatients undergoing either laparoscopic or robot-assisted laparoscopic hysterectomy or myomectomy for benign indications.InterventionsRopivacaine 10 mL (0.75%) infiltrated into the retroperitoneal space overlying the superior hypogastric plexus vs control of no block given at the completion of surgery.Measurements and Main ResultsThe primary outcome was the total opioid use in the first 24 hours after surgery, measured in morphine milligram equivalents (MME). Standardized fentanyl patient-controlled analgesia was given to all patients in the trial. The secondary outcome was pain measured on a visual analog scale (1 to 10) at 1, 2, 6, 12, and 24 hours after surgery. Fifty patients out of 56 approached for the study participated in, and completed, the study (89.2%). The patients were randomized over a 5-month period, March 2020 to July 2020. A total of 27 patients were randomized to receive a nerve block, and 23 were randomized to the control. There was a difference of –21.8 MME in the block group compared with the no-block group (95% confidence interval [CI], –38.2 to –5.5; p = .008). This correlated to a 38% reduction in opioid use in the block group. The mean opioid use in the patients in the block group was 33.1 MME (95% CI, 24.2–41.9) and in those in the no-block group 54.9 MME (95% CI, 40.7–69.1). For the block group, opioid use ranged from 1.0 to 76.5 MME, with an interquartile range of 37 (14–51). For the control group, the range was 7.5 to 113.5 MME, with a higher interquartile range of 60 (28–88). Pairwise comparisons of the mean pain scores over the 24 hours showed a lower pain score with a nerve block of 1.8 (95% CI, 1.5–2.1) compared with a no-block score of 2.6 (95% CI, 2.3–2.9) No adverse effects of local anesthetic toxicity, nerve injury, or bowel/vascular injury were noted in any patient.ConclusionA superior hypogastric plexus nerve block is a simple technique for reducing postoperative opioid requirements and pain in the first 24 hours after minimally invasive gynecologic surgery.     

The Effect of Preoperative Cannabis Use on Postoperative Pain Following Gynaecologic Oncology Surgery

ObjectiveTo determine whether cannabis users have different pain scores after gynaecologic oncology surgery than non-cannabis users.MethodsA retrospective chart review was completed for 654 patients who underwent gynaecologic oncology surgery during a 2-year period. The primary outcome was postoperative pain at 12 and 36 hours after surgery using an 11-point pain scale. Secondary outcomes included opioid consumption, length of hospital stay, opioid side effects, and sleep disturbance.ResultsOf all patients included in this study, 64 used cannabis and 590 did not. Propensity score matching and list-wise deletion identified 57 matched pairs. Pain scores were significantly higher at 12 hours (P < 0.001) and 36 hours (P =0.002) after surgery in cannabis users (median pain scores 6 [IQR 5–7]) and 5 [IQR 4–7], respectively) than non-users (median pain scores 4 [IQR 3–6] and 4 ([IQR 2–5], respectively). Median opioid consumption was significantly higher at 12 hours (P = 0.039) and 36 hours (P = 0.044) after surgery in cannabis users (oral morphine equivalent [OME] 20 [IQR 10–40] mg and OME 40 [IQR 10–100] mg, respectively) than non-users (OME 10 [IQR 5–20] mg and OME 30 mg [IQR 7.5–50] mg, respectively]. Sleep disturbance was significantly higher in cannabis users (odds ratio 3.31; P = 0.009).ConclusionsAfter gynaecologic oncology surgery, patients who used cannabis preoperatively had higher postoperative pain scores, higher opioid use, and more sleep disturbance than non-users. This suggests that preoperative cannabis use is a risk factor for postoperative pain.     

Effects of Low Intraperitoneal Pressure on Quality of Postoperative Recovery after Laparoscopic Surgery for Genital Prolapse in Elderly Patients Aged 75 Years or Older

Study ObjectivePrevious clinical trials for laparoscopic surgery have included few elderly patients aged ≥75 years. We aimed to evaluate the quality of postoperative recovery after laparoscopic surgery using low intraperitoneal pressure (IPP) (6 mm Hg) and warmed, humidified carbon dioxide gas for genital prolapse in elderly patients aged ≥75 years.DesignProspective consecutive case series.SettingUniversity hospital.PatientsConsecutive patients (n = 30) aged ≥75 years planning to undergo laparoscopic surgery for genital prolapse by the same surgeon were recruited from October 2016 through December 2019.InterventionsLaparoscopic promontofixation for the treatment of genital prolapse was performed using low IPP and warmed, humidified carbon dioxide gas. When a promontory could not be easily identified, laparoscopic pectopexy was alternatively performed.Measurements and Main ResultsThe primary outcome was the Quality of Recovery–40 (QoR-40) score at 24 hours postoperatively. The secondary outcomes were postoperative pain using a 100-mm visual analog scale and the length of hospital stay after surgery (LHSS). For the global QoR-40 score and for 4 dimensions of the QoR-40, “emotional state,” “physical comfort,” “psychologic support,” and “pain,” no differences were observed between the baseline score and the score at 24 hours. The score for the “physical independence” dimension at 24 hours was significantly lower than the baseline score (p <.001). No patient had visual analog scale pain scores >30 out of 100 at 12 hours or later. LHSS was <48 hours in 22 patients (73.3%) and <72 hours in 8 patients (26.7%). Multivariable analysis showed that the odds of an LHSS >48 hours were more than 8 times higher in patients who were discharged from the operating room in the afternoon compared with those with a morning discharge.ConclusionThe use of a low IPP is feasible, safe, and has clinical benefits for elderly patients aged ≥75 years who undergo laparoscopic surgery for genital prolapse.     

Perioperative Duloxetine for Pain Management After Laparoscopic Hysterectomy: A Randomized Placebo-Controlled Trial

Study ObjectiveTo evaluate the effect of perioperative duloxetine on pain management in patients recovering from laparoscopic hysterectomy.DesignA randomized placebo-controlled trial.SettingA university hospital.PatientsOf 100 patients enrolled, 80 were randomized 1:1 to receive perioperative duloxetine (n = 40) or placebo (n = 40).InterventionsPatients undergoing laparoscopic hysterectomy for benign conditions from November 2017 through March 2018 received 2 doses of 60 mg duloxetine or placebo 2 hours before and 24 hours after surgery.Measurements and Main ResultsThe Quality of Recovery (QoR)-40 questionnaire was completed by participants after discharge. Study and control groups were compared in terms of questionnaire scores, opioid analgesic use, and hospital length of stay. The baseline characteristics of the groups were comparable; median total QoR-40 scores were 111 of 200 and 112 of 200 for duloxetine and the placebo group, respectively; the difference did not reach statistical significance (p = .91). Although the physical independence subcomponent of the recovery questionnaire was improved in favor of duloxetine, none of the subcomponents reached statistical difference between groups. The groups did not differ in terms of postoperative narcotic analgesic use and hospital length of stay (p >.05).ConclusionPerioperative duloxetine did not reduce pain, need for narcotic analgesia, or hospital length of stay following laparoscopic hysterectomy.     

Continuous local bupivacaine wound infusion with neuraxial morphine reduces opioid consumption after cesarean delivery

Abstract

Background: As a part of a quality improvement program, maternal postoperative opioid use and pain scores were compared between those receiving continuous infusion of bupivacaine for local incisional pain control with multimodal pain management and neuraxial morphine versus multimodal pain management with neuraxial morphine alone.

Objective: We compared postoperative opioid use and pain scores between the multimodal pain management group with neuraxial morphine and the group receiving multimodal pain management, neuraxial morphine, and continuous infusion of bupivacaine for local incisional pain control.

Study design: A retrospective cohort analysis of cesarean deliveries from January of 2015 through March of 2016 was undertaken. Deliveries were grouped by utilization of continuous infusion of bupivacaine for local incisional pain control. For each postoperative day, the average daily opioid use, antiemetic use and pain scores were determined. Patients received 1–2 tablets oxycodone–acetaminophen (5–325?mg) every 4?h as needed with oxycodone 5–10?mg immediate release tablets every 4?h as needed for breakthrough pain in addition to acetaminophen and ibuprofen. Total dose of narcotic, antiemetic use, and pain scores was compared between groups utilizing t-test for continuous variables and chi square for categorical data. A linear mixed model with unstructured covariance was utilized to analyze the daily dose of narcotic and pain scores from postoperative day 1 through day 4.

Results: Patients in the standard multimodal group with neuraxial morphine used more opioids versus those receiving continuous wound infusion of bupivacaine in total postoperative dosing (122.79?±?61.92?mg versus 89.88?±?51.38?mg, p?=?.0063). There was a statistically significant difference between the standard group and local infusion of bupivacaine group on postoperative days 1 and 2 (32.79?±?15.56?mg versus 22.13?±?15.73?mg, p?=?.0011 and 40.25?±?19.84?mg versus 29.13?±?14.58?mg, p?=?.0018, respectively). There was no difference in narcotic use for postoperative days 3 and 4. There was a higher mean number of antiemetic doses in the standard group (0.31?±?0.70 versus 0.10?±?0.30, p?=?.0396). Pain scores did not differ between groups, although there was a correlation between opioid dosing and pain scores. The standard group received more IV ketorolac (87.72?±?42.01?mg versus 64.50?±?53.3?mg, p?=?.0165) and more IV acetaminophen (634.89?±?706.42?mg versus 375.0?±?490.29?mg, p =?.0315) within the first 24?h postoperatively. In addition, the standard group received more oral acetaminophen (6969.67?±?3230.14?mg versus 5248.75?±?2711.71?mg, p?=?.0064). No difference was seen in regard to ibuprofen between groups. These results remained constant when adjusted for differences in gestational age, variation in intraoperative opioid dosing, as well as differences in uterine incision type.

Conclusion: We found a significant reduction in postoperative opioid use when continuous infusion of bupivacaine for local incisional pain control was added to our standard pain management with neuraxial morphine after cesarean delivery. As a result of this quality improvement initiative, we have implemented this intervention universally as a part of our multimodal postoperative pain management strategy.     

Utility of preemptive local analgesia in vaginal hysterectomy

OBJECTIVE: Our purpose was to determine whether preemptive administration of long-acting local anesthetics before vaginal hysterectomy will improve postoperative pain. STUDY DESIGN: A blinded, randomized, trial of paracervical injection of 0.5% bupivacaine with epinephrine or normal saline solution placebo with epinephrine was conducted. Verbal analog pain scores were collected at 1, 2, 3, 4, 6, and 24 hours after surgery. Morphine use in the postanesthesia care unit and by patient-controlled morphine analgesia was recorded. RESULTS: Twenty patients were enrolled. Nine were randomized to bupivacaine. There was no difference between groups regarding age, length of surgery, blood loss, or length of stay. Pain scores were lower in the bupivacaine group by analysis of variance (P=.03). Total morphine and patient-controlled analgesia morphine was significantly less in patients receiving bupivacaine (P=.01 and.04). CONCLUSION: Paracervical block with a 0.5% bupivacaine with 1:200,000 epinephrine before vaginal hysterectomy is associated with lower pain scores and a reduction in morphine requirements after surgery.     

Magnesium-Based Trigger Point Infiltrations Versus Local Anaesthetic Infiltrations in Chronic Pelvic Myofascial Pain: A Randomized,Double-Blind,Controlled Study

ObjectiveTo determine if a novel, magnesium-based trigger point infiltration formulation is more effective in treating chronic myofascial pelvic pain than lidocaine-only infiltration.MethodsThis was a single-centre, double-blind, randomized controlled trial of women diagnosed with chronic pelvic myofascial pain associated with trigger points. We compared a novel magnesium-based infiltration formulation with lidocaine infiltration of trigger points and with a control group of participants who were waitlisted for a chronic pain clinic. Treatment groups completed a 12-week program that included 8 trigger point injection treatments and 9 visits during which pain scores were recorded and questionnaires administered. The primary outcome measure was change in mean pain score between baseline and the final visit. Secondary outcomes included pain with function scores, scores on the World Health Organization Quality of Life questionnaire, procedural pain, concomitant medication use, and complications.ResultsWe assigned 44 women diagnosed with chronic myofascial pelvic pain associated with trigger points to either the magnesium-based infiltrate (n = 15), lidocaine infiltrate (n = 17), or waitlist (n = 12) group. In the intent-to-treat analysis, a clinically relevant decrease in mean pain score out of 10 was observed in the magnesium-based (–2.6 ± 3.2) and lidocaine (–2.9 ± 3.1) infiltration groups, but not in the waitlist group (–0.5 ± 2.3). The per protocol analysis post-hoc tests, adjusted for multiple comparisons, found a significant difference in the average change in pain score between the magnesium-based infiltrate and the waitlist groups (P = 0.045), while differences between the lidocaine infiltrate and waitlist groups approached statistical significance (P = 0.052). Both treatment groups saw improvements in pain with function and quality of life scores.ConclusionWhile this study is underpowered, it does not support the use of a magnesium-based trigger point infiltrate in the treatment of chronic myofascial pelvic pain over lidocaine-only infiltration. Nonetheless, these results are consistent with current management recommendations and suggest improvements in pain, pain with function, and quality of life scores with either magnesium-based or lidocaine-only infiltration. We outline an approach to assessment and treatment that can be adopted by general gynaecologists.     

To Excise or Ablate Endometriosis? A Prospective Randomized Double-Blinded Trial After 5-Year Follow-Up

Study ObjectiveTo compare reduction of pain after laparoscopy for ablation or excision of endometriosis.DesignProspective, randomized, double-blind study (Canadian Task Force classification I).SettingEndometriosis and pelvic pain clinic at a university teaching hospital.PatientsWomen of reproductive age with pelvic pain and visually proved endometriosis.InterventionsSubjects completed a questionnaire rating various kinds of pain using visual analog scales (VAS). After visual identification subjects were randomized to treatment via ablation or excision by supervised training gynecologists as primary surgeons. Follow-up questionnaires documented pain levels every 3 months for 1 year and then every 6 months for 5 years.Measurements and Main ResultsChange in pain VAS scores during 5 years after the operation and rates of pregnancy, repeat surgery, and use of hormone therapy were evaluated. There was a reduction in all pain scores over the 5-year follow-up in both treatment groups. A significantly greater reduction in dyspareunia VAS scores was observed in the excision group at 5 years (p = .03 at univariate analysis, and p = .007 at multivariate analysis). More women in the ablation group continued to receive medical treatment of endometriosis at 5 years (p = .004).ConclusionsSurgical treatment of endometriosis provides symptom reduction for up to 5 years. In some limited areas such as deep dyspareunia, excision is more effective than ablation.     

The Role of Ovarian Suspension in Endometriosis Surgery: A Randomized Controlled Trial

Study ObjectiveA very high percentage of patients with severe pelvic endometriosis develop adhesions after laparoscopic surgery. The objective of this trial was to evaluate the role of ovarian suspension performed during surgery for severe endometriosis on ovarian adhesions and postoperative pelvic pain.DesignA randomized controlled trial (Canadian Task Force classification I).SettingThe tertiary care University Hospital of Bologna, Bologna, Italy.PatientsEighty patients with ovarian and posterior deep infiltrating endometriosis were included in the study.InterventionsPatients underwent laparoscopic surgery for endometriosis and were randomized sequentially into 2 groups: transient ovarian suspension was performed in the treatment group (n = 40), whereas in the control group (n = 40) ovaries were left free in the pelvis. Symptom intensity (dysmenorrhea, chronic pelvic pain, dyspareunia, dyschezia, and dysuria) were ranked using a visual analog scale. Postsurgical ovarian adhesions were evaluated using transvaginal ultrasonographic scans performed by an ultrasound operator who was blinded to the details of the operative procedure and women's randomization allocation. Complications, lesion localization, endometrioma diameter, and surgery time were recorded.Measurements and Main ResultsAt follow-up, a significantly lower rate of ultrasound-detectable ovarian adhesions with the uterus and the bowel was observed in the treatment group, respectively (46.7% vs 77.3%, p = .003 and 26.7% vs 68.2%, p < .0005). Patients in the control group showed a higher percentage of fixed ovaries with moderate and severe adhesions than the treatment group, respectively (56.8% vs 28.9%, p = .003 and 20.5% vs 8.9%, p = .110). No differences between the 2 groups were found regarding complications and pelvic pain.ConclusionOvarian suspension seems to be an additional effective surgical procedure associated with an increased ovarian mobility in women treated for severe endometriosis. Moreover, it is feasible, safe, simple, and fast. Hence, it should be routinely used during laparoscopic surgery for endometriosis.     

Determining the Optimal Time Interval between Vaginal Dinoprostone Administration and Diagnostic Office Hysteroscopy in Nulliparous Women: A Randomized,Double-blind Trial

Study ObjectiveTo determine the optimal timing of vaginal dinoprostone administration before office hysteroscopy (OH) in nulliparous women.DesignRandomized, double-blind trial.SettingTertiary referral hospital.PatientsA total of 180 nulliparous women undergoing diagnostic OH.InterventionsWe randomly allocated the women to long-interval or short-interval dinoprostone groups: three mg dinoprostone was administered vaginally 12 hours before OH in the long-interval group and 3 hours before OH in the short-interval group.Measurements and Main ResultsThe primary outcome was pain during OH measured using a 100-mm visual analog scale (0 = no pain; 100 = worst pain imaginable). The secondary outcomes were ease of hysteroscope passage, patient satisfaction score, and drug-related adverse effects. The patients in the long-interval dinoprostone group had lower pain scores during OH (p <.001). Contrarily, pain scores 30 minutes after the procedure were similar in both groups (p = .1). The patient satisfaction score was higher and clinicians found hysteroscope passage through the cervical canal easier and quicker in the long-interval dinoprostone group than in the short-interval group (p <.001, p = .003, and p <.001, respectively). Side effects were comparable in both study groups.ConclusionVaginal dinoprostone administered 12 hours before OH was more effective than that administered 3 hours before OH in reducing pain during OH in nulliparous women, with easier hysteroscope insertion, shorter procedure duration, and higher patient satisfaction score.