Opinion paper: gynecological surgery in local anesthesia?

PURPUSE: The paracervical block (PCB) is a local anesthesia procedure that can be used to perform gynecological surgeries without the need for further anesthesia. With the PCB, surgeries can be moved from the central operating room to outpatient operating rooms, where they can be performed without the presence of an anesthesia team. METHODS: In this paper, the indications, implementation and limitations of the procedure are discussed. CONCLUSION: Especially in times of scarce staff and OR resources during the Corona pandemic, OR capacity can be expanded in this way.

Adequacy of maternal anesthesia depth with two sodium thiopental doses in elective caesarean section: a randomized clinical trial.

BACKGROUND: Administration of an optimal dose of anesthetic agent to ensure adequate depth of hypnosis with the lowest risk of adverse effects to the fetus is highly important in cesarean section. Sodium thiopental (STP) is still the first choice for induction of anesthesia in some countries for this obstetric surgery. We aimed to compare two doses of STP with regarding the depth of anesthesia and the condition of newborn infants. METHODS: In this clinical trial, parturient undergoing elective Caesarian section were randomized into two groups receiving either low-dose (5 mg/kg) or high-dose (7 mg/kg) STP. Muscle relaxation was provided with succinylcholine 2 mg/kg and anesthesia was maintained with O2/N2O and sevoflurane. The depth of anesthesia was evaluated using isolated forearm technique (IFT) and bispectral index (BIS) in various phases. Additionally, infants were assessed using Apgar score and neurobehavioral test. RESULTS: Forty parturient were evaluated in each group. BIS was significantly lower in high-dose group at skin incision to delivery and subcutaneous and skin closure. Also, significant differences were noticed in IFT over induction to incision and incision to delivery. Apgar score was significantly lower in high-dose group at 1 min after delivery. Newborn infants in low-dose group had significantly better outcomes in all three domains of the neurobehavioral test. CONCLUSION: 7 mg/kg STP is superior to 5 mg/kg in creating deeper hypnosis for mothers. However, it negatively impacts Apgar score and neurobehavioral test of neonates. STP seems to has dropped behind as an acceptable anesthetic in Cesarean section. TRIAL REGISTRATION: IRCT No: 2016082819470 N45 , 13/03/2019.

Paracervical blocks facilitate timely brachytherapy amidst COVID-19.

PURPOSE: The COVID-19 pandemic presents serious challenges for brachytherapists, and in the time-sensitive case of locally advanced cervical cancer, the need for curative brachytherapy (BT) is critical for survival. Given the high-volume of locally advanced cervical cancer in our safety-net hospital, we developed a strategy in close collaboration with our gynecology oncology and anesthesia colleagues to allow for completely clinic-based intracavitary brachytherapy (ICBT). METHODS AND MATERIALS: This technical report will highlight our experience with the use of paracervical blocks (PCBs) and oral multimodal analgesia (MMA) for appropriately selected cervical ICBT cases, allowing for completely clinic-based treatment. RESULTS: 18 of 19 (95%) screened patients were eligible for in-clinic ICBT. The excluded patient had significant vaginal fibrosis. 38 of 39 intracavitary implants were successfully transitioned for entirely in-clinic treatment utilizing PCBs and oral MMA (97% success rate). One case was aborted due to inadequate analgesia secondary to a significantly delayed case start time (PO medication effect diminished). 95% of patients reported no pain at the conclusion of the procedure. The median (IQR) D2cc for rectum and bladder were 64.8 (58.6-70.2) Gy and 84.1 (70.9-89.4) Gy, respectively. Median (IQR) CTV high-risk D90 was 88.0 (85.6-89.8) Gy. CONCLUSIONS: In a multidisciplinary effort, we have successfully transitioned many ICBT cases to the clinic with the use of PCB local anesthesia and oral multimodality therapy in direct response to the current pandemic, thereby mitigating exposure risk to patients and staff as well as reducing overall health care burden.

Gabapentin as an adjunct to paracervical block for perioperative pain management for first-trimester uterine aspiration: a randomized controlled trial.

BACKGROUND: Pain management approaches during uterine aspiration vary, which include local anesthetic, oral analgesics, moderate sedation, deep sedation, or a combination of approaches. For local anesthetic approaches specifically, we continue to have suboptimal pain control. Gabapentin as an adjunct to pain management has proven to be beneficial in gynecologic surgery. We sought to evaluate the impact of gabapentin on perioperative pain during surgical management of first-trimester abortion or early pregnancy loss with uterine aspiration under local anesthesia. OBJECTIVE: We hypothesized that adding gabapentin to local anesthesia will reduce perioperative and postoperative pain associated with uterine aspiration. Secondary outcomes included tolerability of gabapentin and postoperative pain, nausea, vomiting, and anxiety. STUDY DESIGN: We conducted a randomized double-blinded placebo-controlled trial of gabapentin 600 mg given 1 to 2 hours preoperatively among subjects receiving a first-trimester uterine aspiration under paracervical block in an outpatient ambulatory surgery center. There were 111 subjects randomized. The primary outcome was pain at time of uterine aspiration as measured on a 100-mm visual analog scale. Secondary outcomes included pain at other perioperative time points. To assess changes in pain measures, an intention to treat mixed effects model was fit with treatment groups (gabapentin vs control) as a between-subjects factor and time point as a within-subjects factor plus their interaction term. Because of a non-normal distribution of pain scores, the area under the curve was calculated for secondary outcomes with comparison of groups utilizing Mann-Whitney U tests. RESULTS: Among the 111 randomized, most subjects were Black or African American (69.4%), mean age was 26 years (±5.5), and mean gestational age was 61.3 days (standard deviation, 14.10). Mean pain scores at time of uterine aspiration were 66.77 (gabapentin) vs 71.06 (placebo), with a mean difference of -3.38 (P=.51). There were no significant changes in pain score preoperatively or intraoperatively. Subjects who received gabapentin had significantly lower levels of pain at 10 minutes after surgery (mean difference [standard error (SE)]=-13.0 [-5.0]; P=.01) and 30 minutes after surgery (mean difference [SE]=-10.8 [-5.1]; P=.03) compared with subjects who received placebo. Median nausea scores and incidence of emesis pre- and postoperatively did not differ between groups. Similarly, anxiety scores did not differ between groups, before or after the procedure. At 10 and 30 minutes after the procedure, most participants reported no side effects or mild side effects, and this did not differ between groups. CONCLUSION: Preoperative gabapentin did not reduce pain during uterine aspiration. However, it did reduce postoperative pain, which may prove to be a desired attribute of its use, particularly in cases where postoperative pain may be a greater challenge.

Influence of non-pharmacological obstetric interventions on adverse outcomes of childbirth under regional analgesia.

Background We examined the influence of companionship and the use of complementary therapies on adverse outcomes in parturients under regional analgesia. Methods This study is a single-center retrospective cohort of 986 term pregnant women, and it was based on data from medical records (hospitalization period: November 2012-November 2018). The women were in the active phase of labor under regional analgesia. A statistical program was used to search for an association between companionship and the use of complementary therapies with sample data. Bi- and multivariate logistic regressions based on significant associations were used to analyze the potential intervening variables in the adverse outcomes. Results Models were constructed for each of the maternal adverse outcomes. Childbirth complications were significantly associated with complementary therapies [adjusted odds ratio (AOR) = 0.42; 95% confidence interval (CI) = 0.28-0.63; P < 0.001] and companionship (AOR = 0.36; 95% CI = 0.22-0.57; P < 0.001). Prolonged maternal hospitalization was significantly associated with companionship (AOR = 0.57; 95% CI = 0.36-0.92; P < 0.05). Unplanned cesarean section showed a significant association with complementary therapies (AOR = 0.05; 95% CI = 0.01-0.47; P < 0.01). Conclusion The likelihood of childbirth complications and prolonged maternal hospitalization is reduced by companionship, whereas the likelihood of childbirth complications and cesarean section rates is reduced by the use of complementary therapies.

Auricular acupuncture as an adjunct for pain management during first trimester abortion: a randomized, double-blinded, three arm trial.

OBJECTIVES: To assess pain-management using auricular acupuncture as an adjunct to ibuprofen and paracervical block during first trimester uterine aspiration, and to assess auricular acupuncture's effect on anxiety. STUDY DESIGN: This randomized, double-blinded, three-arm trial enrolled women undergoing uterine aspiration for spontaneous or induced abortion. Study participants were randomized 1:1:1 to receive auricular acupuncture, placebo, or usual care alone. Participants in all groups received ibuprofen and paracervical block (usual care). The main outcome was maximum pain reported at the end of the procedure measured using a Visual Analog Scale; we compared those receiving auricular acupuncture to those receiving usual care alone. We also compared auricular acupuncture to placebo and placebo to usual care alone. Finally, we compared the maximum anxiety scores between participants randomized to auricular acupuncture, placebo, and usual care alone. RESULTS: We randomized 153 women over 9 months, and analyzed 52 participants in the auricular acupuncture group, 49 in the placebo group, and 49 in the usual care group. The groups had similar baseline characteristics. After uterine aspiration, participants reported median maximum pain scores as follows: auricular acupuncture 39.5 (interquartile range (IQR) 11, 64.5), placebo 70.0 (IQR 40.5, 84), and usual care alone 71.0 (IQR 32, 91.5) (p<0.01). In pairwise comparisons, the median maximum pain score after auricular acupuncture was lower than placebo and usual-care groups (p<0.01 for both). Post-procedure median anxiety scores were 11.5, 31.0 and 44.0, respectively (p=.01). CONCLUSIONS: Women undergoing first trimester uterine aspiration assigned to auricular acupuncture reported substantially less pain and anxiety than women assigned to placebo or usual care. IMPLICATIONS: Auricular acupuncture may be a useful adjunct to ibuprofen and paracervical block during first trimester uterine aspiration. This approach to managing pain and anxiety could avoid the operational complexities and expenses of sedation and opioid use.

Acupuncture for reducing pruritus induced by intrathecal morphine at elective cesarean delivery: a placebo-controlled, randomized, double-blind trial.

BACKGROUND: Intrathecal morphine is a standard postoperative analgesic administered after cesarean delivery, but frequently causes pruritus. Acupuncture reportedly resolves refractory pruritus in certain patients. The aim of the study was to investigate the effectiveness of acupuncture in preventing pruritus induced by intrathecal morphine. METHODS: Thirty parturients received intrathecal hyperbaric bupivacaine (12 mg), fentanyl (10 µg), and morphine (150 µg) for spinal anesthesia at elective cesarean delivery at term. Patients were randomly divided into the acupuncture group (n=15) and the control group (n=15). In the acupuncture and control groups, certified acupuncturists inserted either indwelling press needles or sham needles, into Hegu (LI4), Neiguan (PC6), Quchi (LI11), and Zhigou (SJ6) on both arms the day before surgery. Needles were removed 48 hours postoperatively. The primary outcome was the incidence of postoperative pruritus. Adverse effects including nausea and vomiting were also investigated. RESULTS: There were no significant differences between the acupuncture group and the control group in the incidence of pruritus (67% vs. 67%, P=1.000, RR 1.0 [95% CI 0.60 to 1.66]) or the requirement for antipruritic therapy (6.7% vs. 20.0%, P=0.283, RR 0.33 [95% CI 0.04 to 2.85]). The incidence of postoperative nausea in the acupuncture group versus control group was 40.0% vs. 13.3%, P=0.099, RR 3.0 [95% CI 0.72 to 12.6]). The postoperative analgesic effect was comparable. CONCLUSION: Preoperatively administered acupuncture using press needles did not decrease intrathecal morphine-induced pruritus or the requirement for treatment.

Effect of magnesium sulfate on anesthesia depth, awareness incidence, and postoperative pain scores in obstetric patients. A double-blind randomized controlled trial.

OBJECTIVES: To assess the effects of magnesium on the depth of anesthesia and to determine the effects of magnesium on incidence of awareness and postoperative pain after caesarean section.  Methods: The study was designed as a double-blind, controlled, randomized study and conducted in Hacettepe University Hospital, Ankara, Turkey  between January 2015 and March 2016. A total of 100 pregnant healthy women who were between 17 and 41 years old, ASA II, and scheduled for an elective cesarean section with general anesthesia were included in the study. After induction, sevoflurane was used for maintenance in Group S and desflurane in Group D (control groups). At Group S-M and Group D-M (study groups), magnesium infusion was started with sevoflurane and desflurane anesthesia respectively. Minimum alveolar concentration of sevoflurane and desflurane were kept constant. Bispectral index scores (BIS), fentanyl consumption and postoperative visual analogue scale (VAS) values were recorded. All of the patients had been followed-up for awareness until the postoperative first year. Results: Demographic variables of the patients were similar. BIS values were significantly higher in control groups throughout the operation (p less than 0.001). No significant difference was detected for intraoperative fentanyl consumption and awareness incidence. VAS values were significantly lower in study groups (p less than 0.05). Conclusion: Magnesium infusion provided significantly lower intraoperative BIS values and lower postoperative VAS scores. We believe that magnesium can be useful as an adjuvant to general anesthesia.

Pain Management for First-Trimester Uterine Aspiration.

IMPORTANCE: First-trimester uterine aspiration can easily be performed in the office setting if adequate pain management for the patient is achieved. It is important for clinicians to understand evidence-based approaches for pain control to ensure a safe and efficient procedure. OBJECTIVE: This article reviews the literature regarding pharmacologic and nonpharmacologic pain control options for first-trimester abortion performed in the clinical setting. Preoperative, procedural, and postoperative pain control are all reviewed. EVIDENCE ACQUISITION: Authors searched the online database PubMed for relevant published literature through January 2018. To identify possible publications for review, the key word "abortion" was paired with the following key words: "pain," "pain-control," "pain management," "aspiration," "paracervical block," "sedation, "non-pharmacologic," and "post-operative." RESULTS: Optimizing pain control for first-trimester uterine aspiration may involve interventions before, during, and after the surgery. Evidence shows patients benefit from premedication with nonsteroidal anti-inflammatory drugs, a defined paracervical block technique, and an option to use one of several nonpharmacologic interventions. CONCLUSIONS AND RELEVANCE: Pain management for first-trimester uterine aspiration should be individualized for optimal patient satisfaction. Evidence supports multiple approaches to support this individualization. Targeted interventions before, during, and after the procedure should be offered to improve procedure experience and satisfaction.

Society of Family Planning clinical guidelines pain control in surgical abortion part 1 - local anesthesia and minimal sedation.

Satisfactory pain control for women undergoing surgical abortion is important for patient comfort and satisfaction. Clinicians ought to be aware of the safety and efficacy of different pain control regimens. This document will focus on nonpharmacologic modalities to reduce pain and pharmacologic interventions up to the level of minimal sedation. For surgical abortion without intravenous medications, a multimodal approach to pain control may combine a dedicated emotional-support person, visual or auditory distraction, administration of local anesthesia to the cervix with buffered lidocaine and a preoperative nonsteroidal anti-inflammatory drug. Oral opioids do not decrease procedural pain. Oral anxiolytics decrease anxiety but not the experience of pain. Further research is needed on alternative options to control pain short of moderate or deep sedation.

Lidocaine Spray Versus Paracervical Block During Loop Electrosurgical Excision Procedure: A Randomized Trial.

OBJECTIVE: The aim of the study was to compare the effectiveness of pain control between lidocaine spray (LS) and paracervical block (PB) with lidocaine during the loop electrosurgical excision procedure (LEEP). MATERIALS AND METHODS: A single-blinded randomized controlled trial was conducted on 132 women who underwent LEEP of the cervix. The participants were randomly allocated to either a PB group or a LS group. The PB group participants were anesthetized by PB using 10 mL of 2% lidocaine with 1:100,000 of epinephrine. The LS group participants were locally anesthetized with four puffs (40 mg) of 10% LS, which was applied thoroughly to the cervix. Pain scores, using 10-cm visual analog scales, were obtained and compared for participants in both groups during anesthesia, during excision and 30 minutes after excision. RESULTS: A total of 132 LEEPs were performed with 66 in LS group and 66 in PB group. The mean (SD) pain scores during excision were 5.2 (2.4) in the LS group and 4.2 (3.3) in the PB group (mean difference = 1.1, 95% CI = 0.8 to 2.1, p = .033), which was within the nonclinically significant margin of this study. The baseline pain score after speculum examination was not significantly different in both groups. There was no adverse effect in the LS group compared with eight cases in the PB group (tinnitus, numbness, palpitation or tachycardia, and hypertension). CONCLUSIONS: The local 40 mg of 10% LS can be used to substitute for PB for pain control during LEEP of the cervix. It also resulted in fewer adverse effects.

Análisis y evaluación de la efectividad de la analgesia epidural y su relación con el parto eutócico o distócico / Analysis and evaluation of the effectiveness of epidural analgesia and its relationship with eutocic or dystocic delivery

Objetivo. Numerosos estudios han demostrado mayor puntuación en la escala verbal nominal del dolor en relación con el parto distócico y la inducción médica del parto, de manera que el parto distócico y la macrosomía fetal se han relacionado con una mayor sensación de dolor durante el parto, sobre todo en el primer estadio. Incluso la analgesia epidural se ha vinculado al parto instrumentado y a la cesárea. El objetivo del estudio fue analizar y evaluar la efectividad de la analgesia epidural en el parto distócico frente al parto eutócico. Pacientes y métodos. Se diseñó un estudio observacional, analítico, longitudinal y prospectivo, en el Área Obstétrica del Hospital Universitario Dexeus. Se incluyeron 180 gestantes. Fueron incluidas todas las nulíparas o multíparas con edad gestacional superior a 36 semanas, más allá de 3cm de dilatación cervical y en trabajo de parto espontáneo o inducido. Todas las pacientes recibieron la analgesia epidural según protocolo. Resultados. Para el análisis estadístico univariante de la muestra se emplearon los métodos descriptivos básicos y para la comparación de medias entre 2 grupos, el test U de Mann-Whitney. Las correlaciones entre variables se estudiaron mediante el coeficiente de correlación de Spearman. Las diferencias consideradas estadísticamente significativas fueron aquellas cuya p<0,05. Conclusión. En nuestra población, no hubo diferencias estadísticamente significativas en la efectividad de la analgesia epidural en el parto eutócico frente al distócico. Las pacientes que recibieron la epidural que tuvieron partos distócicos presentaron la misma puntuación en la escala verbal nominal del dolor que aquellas que presentaron parto eutócico (p>0,05) (AU)

Objective. Numerous studies have demonstrated the difference in the verbal rating scale with regard to obstructed labour and induced labour, so that obstructed labour and foetal macrosomia have been related to a greater sensation of pain during labour, particularly in the first stage. Even the epidural analgesia is linked to the need for instrumented or caesarean section due to foetal obstruction. The goal of the study is to analyze and evaluate the effectiveness of epidural analgesia in normal versus obstructed labour. Patients and methods. One hundred and eighty pregnant women were included in an observational, analytical, longitudinal and prospective study, that was performed in the Obstetrics Department of the Hospital Universitario Dexeus. All the nulliparous or multiparous over 36 weeks of pregnancy, after 3cm of cervical dilatation in spontaneous or induced labor were included. All the patients were given epidural analgesia according to protocol. Results. The basic descriptive methods were used for the univariate statistical analysis of the sample and the Mann-Whitney U test was used for the comparison of means between both groups. The correlations between variables were studied by means of the Spearman coefficient of correlation. The differences regarded as statistically significant are those whose P<.05. Conclusion. In our population there were no statistically significant differences in the effectiveness of epidural analgesia in normal versus obstructed labour. Patients who got epidural analgesia and had obstructed labors have the same degree of verbal rating scale as patients that do not had obstructed labors (P>.05) (AU)

Strategies to reduce blood product utilization in obstetric practice.

PURPOSE OF REVIEW: Patient blood management (PBM) aims to improve patient outcome and safety by reducing the number of unnecessary RBC transfusions and vitalizing patient-specific anemia reserves. Although PBM is increasingly recognized as best clinical practice in elective surgery, implementation of PBM is restrained in the setting of obstetrics. This review summarizes recent findings to reduce blood product utilization in obstetric practice. RECENT FINDINGS: PBM-related evidence-based benefits should be urgently adopted in the field of obstetric medicine. Intravenous iron can be considered a safe, effective strategy to replenish iron stores and to correct both pregnancy-related and hemorrhage-related iron deficiency anemia. In addition to surgical techniques and the use of uterotonics, recent findings support early administration of tranexamic acid, fibrinogen and a coagulation factor concentrate-based, viscoelastically guided practice in case of peripartum hemorrhage to manage coagulopathy. In patients with cesarean section, autologous red cell blood salvage may reduce blood product utilization, although its use in this setting is controversial. SUMMARY: Implementation of PBM in obstetric practice offers large potential to reduce blood loss and transfusion requirements of allogeneic blood products, even though large clinical trials are lacking in this specific field. Intravenous iron supplementation may be suggested to increase peripartum hemoglobin levels. Additionally, tranexamic acid and point-of-care-guided supplementation of coagulation factors are potent methods to reduce unnecessary blood loss and blood transfusions in obstetrics.

Local anaesthesia during endometrial ablation: a systematic review.

BACKGROUND: Endometrial ablation has been widely implemented in the outpatient setting. Many different protocols of local anaesthesia during endometrial ablation are used and described. However, prospective studies to assess and evaluate these protocols appear to be scarce. OBJECTIVES: To evaluate systematically the different local anaesthesia techniques in relation to pain perception during endometrial ablation. SEARCH STRATEGY: Medline and Embase were systematically searched and reference lists of selected articles were checked for missed publications. SELECTION CRITERIA: All types of studies reporting the performance of endometrial ablation under local anaesthesia in ten or more women were included. DATA COLLECTION AND ANALYSIS: Data about the procedure, the protocol of local anaesthesia, the acceptability and side-effects were extracted. MAIN RESULTS: Twenty-five studies, involving 2013 women, were included. Applied anaesthesia techniques included intracervical, paracervical and intrauterine anaesthesia or a combination of these techniques. Women who received a combination of either intra- or paracervical anaesthesia and intrauterine injections reported significantly lower pain scores than those who received no local anaesthesia or intra- or paracervical anaesthesia alone (P = 0.000), but the quality of evidence is low. The acceptability of endometrial ablation under local anaesthesia was high (77-94%). CONCLUSION: Endometrial ablation under local anaesthesia is a safe, feasible and acceptable procedure. The combination of either intra- or paracervical anaesthesia with intrauterine injections seems to be promising, but has to be investigated more thoroughly. TWEETABLE ABSTRACT: Systematic review of local anaesthesia techniques during endometrial ablation.

Hyperbaric oxygen therapy in sudden sensorineural hearing loss following spinal anesthesia: case reports.

The management of sudden sensorineural hearing loss following spinal anesthesia is currently an open problem. Several strategies have been used with variable results and, to the best of our knowledge, there are no prior accounts in the literature on the use of hyperbaric oxygen therapy in the treatment of this complication. We report two cases of acute onset of unilateral hearing loss after spinal anesthesia, with significantly improved results after hyperbaric oxygen therapy. A hypothesis on the possible mechanism behind this complication is discussed. A relation is established between hyperbaric oxygen therapy and this hypothetical mechanism, in order to explain successful results in the reported cases.

Low-Dose or High-Dose Rocuronium Reversed with Neostigmine or Sugammadex for Cesarean Delivery Anesthesia: A Randomized Controlled Noninferiority Trial of Time to Tracheal Intubation and Extubation.

BACKGROUND: Rocuronium for cesarean delivery under general anesthesia is an alternative to succinylcholine for rapid-sequence induction of anesthesia because of the availability of sugammadex for reversal of neuromuscular blockade. However, there are no large well-controlled studies in women undergoing general anesthesia for cesarean delivery. The aim of this noninferiority trial was to determine whether rocuronium and sugammadex confer benefit in time to tracheal intubation (primary outcome) and other neuromuscular blockade outcomes compared with succinylcholine, rocuronium, and neostigmine in women undergoing general anesthesia for cesarean delivery. METHODS: We aimed to enroll all women undergoing general anesthesia for cesarean delivery in the 2 participating university hospitals (Brno, Olomouc, Czech Republic) in this single-blinded, randomized, controlled study. Women were randomly assigned to the ROC group (muscle relaxation induced with rocuronium 1 mg/kg and reversed with sugammadex 2-4 mg/kg) or the SUX group (succinylcholine 1 mg/kg for induction, rocuronium 0.3 mg/kg for maintenance, and neostigmine 0.03 mg/kg for reversal of the neuromuscular blockade). The interval from the end of propofol administration to tracheal intubation was the primary end point with a noninferiority margin of 20 seconds. We recorded intubating conditions (modified Viby-Mogensen score), neonatal outcome (Apgar score <7; umbilical artery pH), anesthesia complications, and subjective patient complaints 24 hours after surgery. RESULTS: We enrolled 240 parturients. The mean time to tracheal intubation was 2.9 seconds longer in the ROC group (95% confidence interval, -5.3 to 11.2 seconds), noninferior compared with the SUX group. Absence of laryngoscopy resistance was greater in the ROC than in the SUX groups (ROC, 87.5%; SUX, 74.2%; P = 0.019), but there were no differences in vocal cord position (P = 0.45) or intubation response (P = 0.31) between groups. No statistically significant differences in incidence of anesthesia complications or in neonatal outcome were found (10-minute Apgar score <7, P = 0.07; umbilical artery pH, P = 0.43). The incidence of postpartum myalgia was greater in the SUX group (ROC 0%; SUX 6.7%; P = 0.007). The incidence of subjective complaints was lower in the ROC group (ROC, 21.4%; SUX, 37.5%; P = 0.007). CONCLUSIONS: We conclude that rocuronium for rapid-sequence induction is noninferior for time to tracheal intubation and is accompanied by more frequent absence of laryngoscopy resistance and lower incidence of myalgia in comparison with succinylcholine for cesarean delivery under general anesthesia.

Paracervical local anaesthesia for cervical dilatation and uterine intervention.

BACKGROUND: Cervical dilatation and uterine intervention can be performed under sedation, local or general anaesthesia for obstetrics and gynaecological conditions. Many gynaecologists use paracervical local anaesthesia but its effectiveness is unclear. This review was originally published in 2009 and was updated in 2013. OBJECTIVES: The objectives of this review were to determine the effectiveness and safety of paracervical local anaesthesia for cervical dilatation and uterine intervention, versus no treatment, placebo, other methods of regional anaesthesia, sedation and systemic analgesia, and general anaesthesia. SEARCH METHODS: We reran our search to August 2013. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 8), MEDLINE (1966 to August 2013), EMBASE (1980 to August 2013), and reference lists of articles. The original search was performed in January 2006. SELECTION CRITERIA: We included randomized or controlled clinical studies involving women who underwent cervical dilatation and uterine intervention for obstetrics and gynaecological conditions. We included studies which compared paracervical anaesthesia with no treatment, placebo, other methods of regional anaesthesia, systemic sedation and analgesia, or general anaesthesia. DATA COLLECTION AND ANALYSIS: Two authors independently evaluated the studies, extracted data, and checked and entered data into Review Manager. MAIN RESULTS: This updated review includes nine new studies, in total 26 studies with 28 comparisons and involving 2790 participants. No study of local paracervical versus general anaesthesia met our criteria. Ten studies compared local anaesthetic versus placebo. Paracervical local anaesthetic (PLA) reduced pain on cervical dilatation with a standardized mean difference (SMD) of 0.37 (95% CI 0.17 to 0.58) and a relative risk (RR) of severe pain of 0.16 (95% CI 0.06 to 0.74). PLA also reduced abdominal pain during, but not after, uterine intervention (SMD 0.74, 95% CI 0.28 to 1.19); there was no evidence of any effect on postoperative back or shoulder pain. Comparisons against no treatment did not demonstrate any effect of PLA. Five studies compared paracervical block with uterosacral block, intracervical block, or intrauterine topical anaesthesia. Two of these studies showed no significant difference in pain during the procedure. Compared to intrauterine instillation, PLA slightly reduced severe pain (from 8.3 to 7.6 on a 10-point scale), which may be negligible. Six studies compared PLA with sedation. There were no statistically significant differences in pain during or after the procedure, postoperative analgesia requirement, adverse effects, patient satisfaction, and the operator's perception of analgesia. We performed risk of bias assessment using six domains and found that more than half of the included studies had low risk of bias. AUTHORS' CONCLUSIONS: We found that no technique provided reliable pain control in the 26 included studies. Some studies reported that women experienced severe pain (mean scores of 7 to 9 out of 10) during uterine intervention, irrespective of the analgesic technique used. We concluded that the available evidence fails to show whether paracervical block is inferior, equivalent, or superior to alternative analgesic techniques in terms of efficacy and safety for women undergoing cervical dilatation and uterine interventions. We suggest that woman are likely to consider the rates and severity of pain during uterine interventions when performed awake to be unacceptable in the absence of neuraxial blockade, which are unaltered by paracervical block.

The peripartum management of a patient with glutaric aciduria type 1.

The management of cesarean delivery for a parturient with placenta previa at 36 weeks' gestation and glutaric aciduria type 1 is presented. The management goal was to prevent encephalopathic crisis by ensuring adequate caloric intake with dextrose infusion and to provide carnitine supplementation and adequate anesthesia.

[Fear-driven cesarean section on request]. / Zadanie ciecia cesarskiego podyktowane strachem przed bólem porodowym.

UNLABELLED: Traditionally, women gave birth surrounded by other, experienced women. Modern women not only require continuous support during labor, but they also want to have a part in decision-taking. That is why some of them, regardless of how much or how little medical knowledge they have, want to decide about the way of birth on their own. The aim of this study was to find the underlying cause of the growing percentage of cesarean sections and cesarean sections on request and to find an answer to the question of what can be done to reduce that number. MATERIAL AND METHODS: A survey was conducted among 100 nulliparas between 38 and 40 week of pregnancy who were determined to give birth in a natural way, and among 50 nulliparas, in the same gestational age, who requested cesarean section. RESULTS: The analysis of our survey shows that request for cesarean section in 12% of cases resulted from fear of labor pain, more than before were declared 2%. After they were informed about methods of reducing labor pain and guaranteed that those methods would be available, as many as 52% of pregnant women who had previously requested cesarean section changed their mind and wanted to give birth in a natural way (this could reduce cesarean section rate about 52%, p<0.05), and 42% (of the total) wanted to have epidural anesthesia. CONCLUSIONS: Better access of pregnant women to information about pharmacological and non-pharmacological methods of reducing labor pain, coupled with the availability of those methods, can reduce the number of cesarean sections on request even by half. In the group of pregnant women determined to have cesarean section, one in four would give it up if they had access to epidural anesthesia, and one in ten if they had access to non-pharmacological methods of reducing labor pain (mainly acupuncture).

Intrauterine anesthesia for gynecologic procedures: a systematic review.

OBJECTIVE: To assess the effectiveness of intrauterine local anesthesia in reducing pain associated with outpatient gynecologic procedures. DATA SOURCES: We searched online databases PubMed or MEDLINE, Embase, Google Scholar, and Clinicaltrials.gov and hand-searched reference lists from reviews evaluating pain-control methods for gynecologic office procedures. We identified randomized controlled trials using intrauterine local anesthetic in gynecologic procedures. METHODS: Titles and abstracts were screened for 1,236 articles. We identified 45 potential articles for inclusion. We excluded 22 of these studies because: 1) they were not randomized controlled trials; 2) they did not describe a quantifiable dose of medication used in the study; 3) they did not investigate an intrauterine anesthetic; 4) they did not study a potentially awake, outpatient procedure; and 5) they did not clearly report results or represented duplicate publication. Twenty-three articles were ultimately included for review. TABULATION, INTEGRATION, AND RESULTS: Two authors independently reviewed full search results and assessed eligibility for inclusion and independently abstracted data from all articles that met criteria for inclusion. Disagreements regarding eligibility or abstraction data were adjudicated by a third independent person. Our primary end point was the reported effect of intrauterine local anesthesia on patient-reported pain scores. As a result of heterogeneity in study methods, outcome measures, and reporting of outcomes, results could not be combined in a meta-analysis. Good evidence supports use of intrauterine anesthesia in endometrial biopsy and curettage, because five good-quality studies reported reduced pain scores, whereas only one good-quality study reported negative results. We found moderate evidence to support intrauterine anesthesia in hysteroscopy, because one good-quality study and two fair or poor quality studies reported reduced pain scores, whereas two good-quality studies had negative results. Good evidence suggests that intrauterine anesthesia is not effective in hysterosalpingography; three good-quality studies reported that pain scores were not reduced, and no good quality studies showed a beneficial effect in that procedure. Evidence was insufficient concerning first-trimester abortion, saline-infusion ultrasonogram, tubal sterilization, and intrauterine device insertion. CONCLUSION: Intrauterine local anesthesia can reduce pain in several gynecologic procedures including endometrial biopsy, curettage, and hysteroscopy and may be effective in other procedures as well.