Re: Analgesia for Vag Hysts
From: Dr. Ainsworth (ainsron@sbcglobal.net)
Wed Sep 10 10:48:50 2003
I also inject the incisions before laparoscopic surgery. Gives me
something to do as the scrub nurse is setting up the instruments!
>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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