Original Articles: Clinical Sciences

Transcription

1 Medical Journal of the Islamic Reublic of! ran Volume 19 Number4 Winter 1384 February 2006 Original Articles: Clinical Sciences ASSESSMENT OF THE EFFICACY OF PARA CERVICAL BLOCK IN CONJUNCTION WITH COCIOUS SEDATION ON PAIN CONTROL DURING OUTPATIENT HYSTEROSCOPY S. ATASHKHOII, M.D.,* S. NEGARGAR, M.D.,** AND S. TAGAVI, M.D.*** From the Deartment of Anesthesiology, Alzahra Hosital, Tabriz University of Medical Sciences, Tabriz, Iran. ABSTRACT Background and Objective: Hysteroscoy is considered as very imortant in the investigation of abnormal uterine bleeding. It is usually erformed as an outatient rocedure under either local or no anesthesia. This study was designed to comare the combination ofaracervical block (PCB) and conscious sedation with aracervical block or conscious sedation alone for outatient hysteroscoy in terms of ain control and atient satisfaction. Methods: A total of 60 women with abnormal uterine bleeding were considered eligible for the study. Patients were randomized into three grous. Grou A (20 atients) underwent diagnostic hysteroscoy with conscious sedation, in grou B (20 atients) aracervical block was erformed, and grou C (20 atients) received both conscious sedation and aracervical block. Main outcome measures were ain control during the rocedure, the ostoerative ain score at 15 min, 60 min, and 24 h after the rocedure, and atient's satisfaction rate. Results: There were significant differences between combination theray with other grous in terms of ain control during the rocedure (aracervical block lus sedation versus the other two grous:<0.001 ), and in ostoerative ain at different intervals (grou C versus A and B grous,<o.oo 1 ). Satisfaction rate in grou C atients was higher than the other atients (aracervical block +sedation versus grou AandB,<O.OOl ). Conclusion: Both aracervical block and conscious sedation anesthesia can be used for diagnostic hysteroscoy, but their combination resulted in imroved analgesia both during the rocedure and ostoerative ain and atient satisfaction comared with monotheray. MJIRI, Vol. 19, No.4, , Keywords: Hysteroscoy, Paracervical Block, Conscious Sedation, Anesthesia. *Corresonding Author: Dr. Simin Atashkhoii, Iran, Tabriz, Deartment of Anesthesiology, Alzahra Hosital, Artesh Jonoobi Ave, e mail :siminatashkhoii@yahoo. com, Tel: Fax: ** Dr. Sohrab Negargar, Assistant rofessor of Anesthesiology. ***Dr. Simin Tagavi, Assistant rofessor of Obstetrics and Gynecology. I 281

2 Paracervical Block Plus Conscious Sedation for Hysteroscoic Pain Control INTRODUCTION Outatient hysteroscoy is now regarded as the investigation of choice for abnormal uterine bleeding 1 as there is no longer any doubt that hysteroscoy is more effective than conventional curettage at identifying intrauterine athology as it allows direct insection of the uterine cavity, direct biosy, and aroriate theraeutic management. 2 Aroriate investigation of abnormal uterine bleeding can be carried out in an outatient setting. 3 Another imortant advantage of hysteroscoy is that it can be erformed without general anesthesia for reduced cost and time. 3.4 Although some authors 5 7 have reorted that intracervical or aracervical nerve block (PCB) failed to reduce ain during outatient hysteroscoy, others have 11 shown that local anesthesia8 (PCB or toical anesthesia) and conscious sedation 9 12 can be used for this rocedure. The aim of this rosective randomized double blind study is to comare aracervical block or conscious sedation with their combination in terms of ain control and atient satisfaction during diagnostic hysteroscoy. PATIENTS AND METHODS Sixty atients aged years in ASA class I or II were studied at the Alzahra hosital. Exclusion criteria were regnant women, menorrhagia at the time of the rocedure, and a history of anesthetic or surgical comlications. These atients were randomized into three equal grous (20 atients each), using a comuter generated randomization: grou A (conscious sedation), grou B (PCB), and grou C (PCB in conjunction with conscious sedation). Each atient signed an informed consent form for the rocedure and anesthesia. All atients were laced in the lithotomy osition. After the vaginal examination, a bivalve seculum was inserted, and the cervix was exosed, and cervix, fornix, and vagina were cleaned with Povidone Iodine 10% solution and then swabbed dry. Conscious sedation (grou A) was erformed immediately before surgery with the i.v. administration of0.5 mg (0.02 mg/kg) atroine and )lg ( 1-2)lg/kg) fentanyl, followed by an i.v. slow injection of2.0 mg (0.03mg/ kg) midazolam. Paracervical block (grou B) was erformed 5 minutes before the rocedure with 10 ml 0.5% buivacaine hydrochloride solution injected with a 22 gauge sinal needle on four sites (at 3, 5, 7 and 9 o'clock ositions) at the junction of the cervix and vagina. Grou C received first PCB and then conscious sedation with the above method. All atients maintained control of their airways, and additional analgesia was rovided on request. All atients underwent diagnostic hysteroscoy using a standard 5.5 mm hysteroscoe. Normal saline was used as the distending medium. A comlete insection of the uterine cavity was made, and endometrial samling was done. During and after the rocedure, atients were asked to record their degree of ain by means of a visual analogue scale (VAS) from 1-5, indicating: l=no ain; 2=slight ain; 3=tolerable ain; 4= severe ain; 5=intolerable ain. 9 Postoerative ain score was evaluated immediately after surgery, 15 min, 60 min, and 24h after the rocedure. Postoeratively, analgesics (Tramadol100 mg) were administered when requested by the atient. Satisfaction rate was assessed before the atient's discharge. Women had to choose between three different assessments of satisfaction: high satisfaction, moderate satisfaction and no satisfaction. 8 Patients were discharged once they had no discomfort. Statistical analysis was erformed with the use of the two-tailed Student's t-test. Satisfaction rate was comared with the X 2 test. <0.05 was considered as statistically significant. RESULTS The demograhic data of the three grous of atients are resented in Table I. There were no statistically significant differences between the grous with regard to mean age, arity, and indications for hysteroscoy. Oerative data are shown in Table II. The amount of saline used varied from ml. All rocedures finished within 15 min. No differences were noted between the grous in terms of oerative and discharge times (Table II). No significant comlications occurred during surgery. The main comlication was related to vagal reaction and associated symtoms (e.g. allor, nausea and vomiting) (Table II). Pain control during and after hysteroscoy are reorted in Table III. There were no significant differences in the ain exerienced during the rocedure between grousa( ) andb ( ) (>0.05), but women in grou C ( ) had significantly less ain during the rocedure (grou C versus A and B grous;<o.oo 1 ). Postoerative ain score didn't differ between grous A and B, at 15, 60 min, and 24 h. Mean of ostoerative ain score of grou C was significantly less than A and B grous at the same times (grou C versus A and B grous;<0.001) (Table III). Only ten atients ( 4, 5 and 1 atient in grous A, B and C, resectively) required ostoerative analgesics (grou C versus A and B grous; <O.O 1) (Table III). 282 \ MJ1RI, Vol. 19, No.4, , 2006

3 S. Atashkhoii, et al. Table I. Clinical characteristics and indications of 60 atients undergoing diagnostic hysteroscoy. Variables A: Conscious Sedation B:PCBGrou C: Sedation + PCB grou grou No of atients Age (years) 43.5 ± ± ± 3.7 Parity ± ± ± 1.5 Indications(%) Postmenoausal bleeding 4 (20) 6 (30) Menorrhagia 3 (15) 4 (20) 5 (25) Irregular eriod 9 (45) 10 (50) 8 (40) Others 1(5) 2 (10) 1(5) Values are resented as mean ± SD Table II. Oerative data and comlications data of 60 atients undergoing diagnostic hysteroscoy. Variables A: Sedation Grou B:PCBGrou C: Sedation + PCB grou Oerative time (min) 12.2 ± ± ±3.1 Volume of normal saline (ml) Discharge time (min) Comlications Uterine erforation (n) Fluid overload (n) Hemorrhage (n) Hyotension (n) Nausea-vomiting (n) 400 ± ± ± ± ± 22 Values are resented as mean ± SD Table III. Pain control and satisfaction rate of 60 atients undergoing diagnostic hysteroscoy. Variables A: Sedation grou B:PCBGrou C: sedation+ PCB grou Pain during the rocedure 3.90 ± ± ± 0.9 <0.001 Postoerative ain at 15 min 3.00 ± ± ± 0.2 <0.001 at 1 h 2.50 ± ± ± 0 <0.001 at 24 h 1.30 ± ± ± 0 <0.001 Requirements for ostoerative analgesics (atients=n) 4 5 <0.001 Satisfaction rate (%) Very satisfied 4 (20) 4 (20) 12 (60) Moderately satisfied 6 (30) 5 (25) 6 (30) Not satisfied 10 (50) 11 (55) 2 (10) Values are resented as mean ± SD MJIRI, Vol. 19, No.4, , 2006 I 283

4 Paracervical Block Plus Conscious Sedation for Hysteroscoic Pain Control Satisfaction rates are also reorted in Table III. No significant difference in the satisfaction rate was observed between women treated with local anesthesia (45%) and conscious sedation (50%), but 90% of grou C atients were satisfied with the rocedure. DISCUSSION Although diagnostic hysteroscoy with endometrial biosy can be erformed in the outatient setting under either local or no anesthesia, ain and vasovagal reaction are a concern to women and their gynecologists. 1 2 No anesthesia during hysteroscoy can cause unnecessary atient discomfort, although it has been demonstrated that % of these rocedures can be erformed with no anesthesia and atients tolerate this welj.3.4 Vercellini et aj.s reorted that aracervical anesthesia could only reduce ain during insertion of the hysteroscoe but failed to suress ain during uterine distention and asiration of the endometrium, robably this is related to the different innervations of the uterine body and the cervix, and these atients required additional intravenous sedation during the rocedure. Also local anesthesia rotocols are not effective in reducing ain during hysteroscoy, 6 7 although a study by Soriano et a!. 8 showed that lidocaine aerosol sray on the cervix reduced ain and discomfort in the majority of atients during the rocedure. Conscious sedation is widely used for ain relief during hysteroscoy. 9 Guida et al. 9 comared the efficacy of intravenous midazo1am-fentanyl (conscious sedation) or aracervical block in terms of satisfaction, intra- and ostoerative ain in 166 atients during hysteroscoy. Both grous of women had significantly less ain. Our study suggests that there is no difference between PCB and conscious sedation in terms of ain control and atient satisfaction. Our results showed that ain levels during hysteroscoy were significantly lower in the conscious sedation and PCB grous than those atients who received sedation or PCB alone. PCB alone might not reduce the ain stimuli arising from the fundal region,s and using sedation alone may be required to level IV or V on the sedation scale, and thus be associated with ostoerative side effects; nausea or vomiting, dizziness, drowsiness, and delayed recovery and atient discharge (our study atients were at level I or II on the sedation scale). The exlanation for lower ain levels in grou C may be the amnesia and analgesia caused by the use of sedative, and the small size of the hysteroscoe (5.5 mm diameter) that requires minimal cervical dilatation In summary, atients receiving only PCB or sedation during diagnostic hysteroscoy exerienced 3 times higher ain levels, comared with those receiving both PCB and sedation. Both PCB and conscious sedation alone can be used for hysteroscoy, but these may be considered for selected atients. REFERENCES I. Donnes J, Nisolle M: An atlas of oerative laaroscoy and hysteroscoy. 2nd ed., New York: The Parthenon Publishing Grou, , JaffRA, Samuels SI: Anesthesiologist's Manual of Surgical Procedures. 2"d ed., Philadelhia: Liincott Williams and Wilkins, , Kremer Ch, Barik S, Duffy S: Flexible outatient hysteroscoy without anesthesia: a safe, successful and well-tolerated rocedure. Br J Obstet Gynecol 105(6): 672-6, Bettocchi S, Ceci 0, Nai, L, Di Venere R, Masciointo V, Pansini V, et a!: Oerative office hysteroscoy without anesthesia: analysis of 4863 cases erformed with mechanical instruments. JAm Assoc Gynecol Laarosc 11(1): 59-61, Vercellini P, Colombo A, Mauro F, Oldani S, Bramante T, Crosignani PG: Paracervical anesthesia for outatient hysteroscoy. Fertil Steril 62(5): I 083-5, Wong AYK, Wong KS, Tang LCH: Stewise ain score analysis of the effect oflocallignocaine on outatient hysteroscoy: a randomized, double blind, lacebo controlled trial. Fertil Steril73(6): , Lau WC, Tam WH, Lo WK, Yuen PM: A randomized doubleblind lacebo-controlled trial of transcervical intrauterine local anesthesia in outatient hysteros~oy. Br Obstet Gynecoll07(5): 610-3, Soriano D, Ajaj S, Chuong T, Deval B, Fauconnier A, Darai E: Lidocaine sray and outatient hysteroscoy: randomized lacebo-controlled trial. Obstet Gynecol 96(5): 661-4, Guida M, Pellicano M, Zullo F, Acunzo G, Lavitola G, Palomba S, et al: Outatient oerative hysterescoy with biolar electrode: a rosective randomized study between local anesthesia and conscious sedation. Hum Rerod 18( 4 ): 840-3, Readman E, Maher PJ: Pain relief and outatient hysteroscoy: a literature review. JAm As soc Gynecol Laarosc 11 (3):3 15-9, Zullo F, Pellicano M, Stigliano CM, Di Carlo C, Fabrizio A, Nai C: Toical anesthesia for office hysteroscoy. A rosective, randomized study comaring two modalities. J Rerod Med 44(10): 865-9, Wiener-Kronish JP, Groer MA: Conscious sedation. I st ed., Philadelhia: Hanley & Belfus,. 60-1,143-4, \MJJRI, Vol. 19, No. 4, , 2006

5 S. Atashkhoii, et al. 13. Ng EHY, Chi Chui DK, Tang OS, Ho PC: Paracervical block with and without conscious sedation: a comarison of the ain levels during egg collection and the ostoerative side effects. Fertil and Steri1 75(4): 711-7, Hitchings S: Paracervical anesthesia in outatient hysteroscoy: a randomized double-blind lacebo controlled trial. BJOG 1 07(1 ): 143-4, MJIRJ, Vol. 19, No.4, , 2006 I 285