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

STUDY OBJECTIVE: To assess the efficacy of a superior hypogastric plexus nerve block in reducing opioid requirements in the first 24 hours after minimally invasive gynecologic surgery. DESIGN: Patient-blinded randomized controlled trial. SETTING: Single-center academic institution (Sydney Women's Endosurgery Centre). Two surgeons administering the blocks in their own surgeries. PATIENTS: Patients undergoing either laparoscopic or robot-assisted laparoscopic hysterectomy or myomectomy for benign indications. INTERVENTIONS: Ropivacaine 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 RESULTS: The 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. CONCLUSION: A 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.

Perimortem caesarean section: Two cases performed in New Zealand hospitals.

Perimortem caesarean section is a term many obstetricians are familiar with despite few encountering it first-hand. It is estimated the intervention will be needed every 53 000 maternities. Despite this rarity it is vital clinicians are trained in detecting and intervening where perimortem caesarean is required. In New Zealand eight perimortem caesareans were performed from 2006 to 2013. Here we discuss two perimortem caesarean sections performed in two New Zealand hospitals alongside current guidance and recommendations.

Use of implantable cardioverter defibrillators in the New Zealand context from 2000 to 2007.

BACKGROUND: Implantable Cardioverter Defibrillator (ICD) therapy is now standard of care for prevention of sudden cardiac death in high-risk patient groups. In order to determine if the potential benefit of ICD therapy is being realised, ongoing monitoring of ICD therapy is required. This study was conducted to examine ICD therapy in two New Zealand tertiary hospitals. METHODS: We retrospectively audited patient notes for all patients receiving a first ICD between 2000 and 2007 at two tertiary referral hospitals in New Zealand. RESULTS: 702 patients received their first ICD within the study period, 73% male, mean age 53 years (range 1 to 83), with 73% of devices for secondary prevention. The implant rate increased from 15/million in 2000 to a peak of 44/million in 2004. Antitachycardia pacing was delivered to 21% of patients, appropriate defibrillation to 26% and inappropriate defibrillation to 16% of patients, with frequency of all types of therapy increasing with time since implantation. All cause mortality was 8.6%, and only 7 (1%) died as a consequence of sudden cardiac arrest. CONCLUSIONS: While increasing across the study period, the ICD implant rate remains low, with a high therapy rate and low mortality rate. This suggests that those receiving ICD therapy are benefiting, but may also imply that the group of patients receiving ICDs is too restricted.