Advertisement

Pain relief and functional status after vaginal hysterectomy: intrathecalversus general anesthesia

  • Juraj Sprung
  • Malcolm S. Sanders
  • Mary Ellen Warner
  • John B. Gebhart
  • C. Robert Stanhope
  • Christopher J. Jankowski
  • Lavonne Liedl
  • Darrell R. Schroeder
  • Daniel R. Brown
  • David O. Warner
Regional Anesthesia and Pain

Abstract

Purpose

We tested the hypothesis that the use of subarachnoid block (SAB) for vaginal hysterectomy produces superior postoperative analgesia and improves functional status at 12 weeks postoperatively.

Methods

In this randomized controlled trial 89 patients received either standardized general anesthesia vs SAB with bupivacaine, clonidine, and morphine. Postoperatively, patients in both groups received multimodal pain management. Primary outcomes included evaluation of pain and functional status (SF-36 Health Survey) over the 12 postoperative weeks.

Results

Pain was well controlled throughout the study, as judged from the average pain numerical scale scores of ≤ 3 in both groups, at all times studied. Intrathecal analgesia lessened pain and decreased the use of morphine both in the postanesthesia care unit (PACU) and over the first 12 hr after discharge from the PACU (P < 0.001). Although patients who received SAB had a lower frequency of postoperative nausea in the PACU than the patients in the general anesthesia group (P = 0.021), this effect was not extended beyond the PACU stay. Subarachnoid block did not affect the length of hospitalization. At the two-week follow-up 69% of patients in the SAB group and 48% patients in the general anesthesia group were pain free (P = 0.044). At all evaluation intervals patients’ functional status was comparable between the SAB and general anesthesia group.

Conclusions

A significantly better immediate postoperative analgesia was present in the SAB group, and the duration was consistent with the expected action of intrathecally administered drugs. Tw o weeks after surgery a higher percentage of the patients in the SAB group reported no pain. However, SAB had no effect on either length of hospitalization or patients’ postoperative functional status.

Keywords

Morphine Bupivacaine Epidural Analgesia Regional Anesthesia Vaginal Hysterectomy 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Le contrôle de la douleur et l’état fonctionnel après l’hystérectomie vaginale: l’anesthésie intrathécale versus l’anesthésie générale

Résumé

Objectif

Nous avons vérifié l’hypothèse voulant que l’usage d’un block sous-arachnoïdien (BSA) pour l’hystérectomie vaginale produise une analgésie postopératoire supérieure et améliore l’état fonctionnel jusqu’à 12 semaines après l’opération.

Méthode

Ľétude randomisée et contrôlée a porté sur 89 patientes qui ont reçu une anesthésie générale normalisée ou un BSA avec de la bupivacaïne, de la clonidine et de la morphine. Après l’opération, toutes les patientes ont reçu un traitement de la douleur multimodal. La douleur et l’état fonctionnel (SF-36 Health Survey) ont été notés pendant 12 semaines postopératoires.

Résultats

La douleur a été bien contrôlée tout au long de l’étude, si l’on en juge par les scores moyens à l’échelle de douleur numérique ≤ 3 dans les deux groupes pour toutes les mesures prises. Ľanalgésie intrathécale a réduit la douleur et diminué l’usage de morphine à la salle de réveil (SDR) et pendant les 12 premières heures après le départ de la SDR (P < 0,001). Les patientes du groupe BSA ont eu moins de nausées postopératoires en SDR que les patientes sous anesthésie générale (AG), (P = 0,021), mais cet effet ne s’est pas prolongé au delà du séjour en SDR. Le BSA n’a pas permis d’écourter l’hospitalisation. Lors de l’examen de contrôle à la deuxième semaine, 69% des patientes du groupe BSA et 48% du groupe d’AG n’avaient plus de douleur (P= 0,044). Pendant toute l’étude, l’état fonctionnel a été comparable entre les groupes.

Conclusion

Une analgésie postopératoire immédiate significativement meilleure a été notée avec le BSA et de durée conforme à l’action attendue des médicaments intrathécaux administrés. Deux semaines après l’opération, un plus fort pourcentage de patientes du groupe BSA était sans douleur. Le BSA n’a cependant pas modifié la durée de l’hospitalisation ou l’état fonctionnel postopératoire des patientes.

References

  1. 1.
    Rodgers A, Walker N, Schug S, et al. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. BMJ 2000; 321: 1493.PubMedCrossRefGoogle Scholar
  2. 2.
    Wu CL, Hurley RW, Anderson GF, Herbert R, Rowlingson AJ, Fleisher LA. Effect of postoperative epidural analgesia on morbidity and mortality following surgery in medicare patients. Reg Anesth Pain Med 2004; 29: 525–33; discussion 515-9.PubMedCrossRefGoogle Scholar
  3. 3.
    Liu S, Carpenter RL, Neal JM. Epidural anesthesia and analgesia. Their role in postoperative outcome. Anesthesiology 1995; 82: 1474–506.PubMedCrossRefGoogle Scholar
  4. 4.
    Wu CL, Fleisher LA. Outcomes research in regional anesthesia and analgesia. Anesth Analg 2000; 91: 1232–42.PubMedCrossRefGoogle Scholar
  5. 5.
    Wong CS, Lu CC, Cherng CH, Ho ST. Pre-emptive analgesia with ketamine, morphine and epidural lidocaine prior to total knee replacement. Can J Anaesth 1997; 44: 31–7.PubMedCrossRefGoogle Scholar
  6. 6.
    Nakamura T, Yokoo H, Hamakawa T, Takasaki M. Preemptive analgesia produced with epidural analgesia administered prior to surgery (Japanese). Masui 1994; 43: 1024–8.PubMedGoogle Scholar
  7. 7.
    Dakin MJ, Osinubi OY, Carli F. Preoperative spinal bupivacaine does not reduce postoperative morphine requirement in women undergoing total abdominal hysterectomy. Reg Anesth 1996; 21: 99–102.PubMedGoogle Scholar
  8. 8.
    Brown DR, Hofer RE, Patterson DE, et al. Intrathecal anesthesia and recovery from radical prostatectomy. A prospective, randomized, controlled trial. Anesthesiology 2004; 100: 926–34.PubMedCrossRefGoogle Scholar
  9. 9.
    Ong CK, Lirk P, Seymour RA, Jenkins BJ. The efficacy of preemptive analgesia for acute postoperative pain management: a meta-analysis. Anesth Analg 2005; 100: 757–73.PubMedCrossRefGoogle Scholar
  10. 10.
    Block BM, Liu SS, Rowlingson AJ, Cowan AR, Cowan JA, Wu CL. Efficacy of postoperative epidural analgesia. A meta-analysis. JAMA 2003; 290: 2455–63.PubMedCrossRefGoogle Scholar
  11. 11.
    Carli F, Mayo N, Klubien K, Schricker T, Trudel J, Belliveau P. Epidural analgesia enhances functional exercise capacity and health-related quality of life after colonic surgery. Results of a randomized trial. Anesthesiology 2002; 97: 540–9.PubMedCrossRefGoogle Scholar
  12. 12.
    Gottschalk A, Smith DS, Jobes DR, et al. Preemptive epidural analgesia and recovery from radical prostatectomy. A randomized controlled trial. JAMA 1998; 279: 1076–82.PubMedCrossRefGoogle Scholar
  13. 13.
    Ware JE, Kosinski M, Keller SD. SF-36 Physical and Mental Health Summary Scales: A User’s Manual. Boston, MA, The Health Institute, New England Medical Center; 1994: 1–4: 6.Google Scholar
  14. 14.
    Ware JE, Snow KK, Kosinski M, Gandek B. SF-36 Health Survey. Manual and Interpretation Guide. Boston, MA, The Health Institute, New England Medical Center; 1993: 1–3: 9.Google Scholar
  15. 15.
    Collins SL, Moore RA, McQuay HJ. The visual analogue pain intensity scale: what is moderate pain in millimetres? Pain 1997; 72: 95–7.PubMedCrossRefGoogle Scholar
  16. 16.
    Downie WW, Leatham PA, Rhind VM, Wright V, Branco JA, Anderson JA. Studies with pain rating scales. Ann Rheum Dis 1978; 37: 378–81.PubMedCrossRefGoogle Scholar
  17. 17.
    Jensen MP, Karoly P, Braver S. The measurement of clinical pain intensity: a comparison of six methods. Pain 1986; 27: 117–26.PubMedCrossRefGoogle Scholar
  18. 18.
    Kremer E, Atkinson JH, Ignelzi RJ. Measurement of pain: patient preference does not confound pain measurement. Pain 1981; 10: 241–8.PubMedCrossRefGoogle Scholar
  19. 19.
    Hosking MP, Warner MA, Lobdell CM, Offord KP, Melton LJ III. Outcomes of surgery in patients 90 years of age and older. JAMA 1989; 261: 1909–15.PubMedCrossRefGoogle Scholar
  20. 20.
    Kissin I. Preemptive analgesia. Anesthesiology 2000; 93: 1138–43.PubMedCrossRefGoogle Scholar
  21. 21.
    Holthusen H, Eichwede F, Stevens M, Willnow U, Lipfert P. Pre-emptive analgesia: comparison of preoperative with postoperative caudal block on postoperative pain in children. Br J Anaesth 1994; 73: 440–2.PubMedCrossRefGoogle Scholar
  22. 22.
    Kundra P, Deepalakshmi K, Ravishankar M. Preemptive caudal bupivacaine and morphine for postoperative analgesia in children. Anesth Analg 1998; 87: 52–6.PubMedCrossRefGoogle Scholar
  23. 23.
    Jellish WS, Thalji Z, Stevenson K, Shea J. A prospective randomized study comparing short- and intermediate-term perioperative outcome variables after spinal or general anesthesia for lumbar disk and laminectomy surgery. Anesth Analg 1996; 83: 559–64.PubMedCrossRefGoogle Scholar
  24. 24.
    Shir Y, Raja SN, Frank SM. The effect of epidural versus general anesthesia on postoperative pain and analgesic requirements in patients undergoing radical prostatectomy. Anesthesiology 1994; 80: 49–56.PubMedCrossRefGoogle Scholar
  25. 25.
    Wang JJ, Ho ST, Liu HS, Tzeng JI, Tze TS, Liaw WJ. The effect of spinal versus general anesthesia on postoperative pain and analgesic requirements in patients undergoing lower abdominal surgery. Reg Anesth 1996; 21: 281–6.PubMedGoogle Scholar
  26. 26.
    McNeill JA, Sherwood GD, Starck PL, Thompson CJ. Assessing clinical outcomes: patient satisfaction with pain management. J Pain Symptom Manage 1998; 16: 29–40.PubMedCrossRefGoogle Scholar
  27. 27.
    Kissin I, Lee SS, Bradley EL Effect of prolonged nerve block on inflammatory hyperalgesia in rats. Prevention of late hyperalgesia. Anesthesiology 1998; 88: 224–32.PubMedCrossRefGoogle Scholar
  28. 28.
    McCarthy MM, Caba M, Komisaruk BR, Beyer C. Modulation by estrogen and progesterone of the effect of muscimol on nociception in the spinal cord. Pharmacol Biochem Behav 1990; 37: 123–8.PubMedCrossRefGoogle Scholar
  29. 29.
    Keogh E, Hatton K, Ellery D. Avoidance versus focused attention and the perception of pain: differential effects for men and women. Pain 2000; 85: 225–30.PubMedCrossRefGoogle Scholar
  30. 30.
    Aubrun F, Salvi N, Coriat P, Riou B. Sex- and age-related differences in morphine requirements for postoperative pain relief. Anesthesiology 2005; 103: 156–60.PubMedCrossRefGoogle Scholar

Copyright information

© Canadian Anesthesiologists 2006

Authors and Affiliations

  • Juraj Sprung
    • 1
  • Malcolm S. Sanders
    • 1
  • Mary Ellen Warner
    • 1
  • John B. Gebhart
    • 1
  • C. Robert Stanhope
    • 1
  • Christopher J. Jankowski
    • 1
  • Lavonne Liedl
    • 1
  • Darrell R. Schroeder
    • 1
  • Daniel R. Brown
    • 1
  • David O. Warner
    • 1
  1. 1.Department of AnesthesiologyMayo Clinic College of Medicine, Anesthesia Clinical Research Unit, Mayo ClinicRochesterUSA

Personalised recommendations