Re: Analgesia for Vag Hysts
From: Gail Waldby (gwaldby@willinet.net)
Tue Sep 9 15:42:41 2003
Barbara, I use ropivicaine instead of Marcaine or lidocaine, longer
action than lidocaine, safer than ropivicaine. The recent literature
strongly suggests that pre-emptive analgesia is not better than
post-procedure injection. I use the ropivicaine for laparoscopy
incisions and appendectomy incisions and I do inject before not after,
the same as you. I just don't have any scientific justification for the
choice of time.
Gail Waldby, MD
Huron Clinic SD
Barbara Nicol MD wrote:
>For several years I have used lidocaine 1 percent with epinephrine
>paracervically prior to my initial incision at vaginal hysterectomy, for
>two reasons: (1) Nichols says to do so in his excellent textbook on
>vaginal surgery (although as I look at the (4th ed) chapter again I note
>that this recommendation is based largely on personal experience and
>remains unencumbered by much data). (2) I have read a few papers from
>other surgical fields about preemptive analgesia - infiltrating local in
>the incision site prior to rather than after incision -- improving pain
>control outcomes in other types of surgery, although only where there is
>general rather than conduction anesthesia. If you are generally doing
>your VHs under spinal/epidural I would imagine there would be no
>difference in pain outcomes.
>
>If one is going to use local at all, it makes more sense to me to use it
>prior to incision - preemptively - and in the paracervical tissues
>(which have most of the pain fibers) rather than in the vascular
>pedicles after they've been cut. (Perhaps the anesthesiologist didn't
>know exactly what the UW folks are infiltrating when?)
>
>For abdominal procedures, I infiltrate the incision site with marcaine
>(unless the patient has a conduction-type anesthetic) prior to starting.
>I don't feel very comfortable using marcaine in the paracervical block
>because I think that the possibility of intravascular
>injection/absorption is higher in that setting, even using a
>control-grip syringe and aspiration. If I'm going to accidentally
>inject an anesthetic intravascularly, I'd way rather have it be
>lidocaine because the cardiac side effects would be much briefer. Maybe
>I'm being overly conservative on this point, however, since the dosages
>are small and it's unlikely that anyone would put a large dose into a
>vessel without noticing.
>
> The epi really helps keep the field dry during the case, too.
>
> Barb Nicol
>
>At Fri, 5 Sep 2003, Lynn D. Montgomery, M.D. wrote:
>
>>Heh y'all,
>>Another new one on me today. I was just about to begin a vag hyst when
>>the anesthesiologist asked me if I was going to use the "new" technique
>>of injecting the pedicles, as I did my hyst, with local anesthetic. I
>>said "say what". He then told me that because of difficultly
>>encountered in controlling postoperative pain following a vaginal
>>hysterectomy "several" gynecologists were using this technique. When I
>>asked for references, he simply told me that it came from the University
>>of Washington.
>>
>
>--
>Barbara Nicol MD
>St. Luke's Health Care Center
>San Francisco CA USA
>
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