TOTAL ABDOMINAL HYSTERECTOMY WITH BILATERAL SALPINGO-OOPHORECTOMY

Transcription

1 TOTAL ABDOMINAL HYSTERECTOMY WITH BILATERAL SALPINGO-OOPHORECTOMY Review of evidence Eight studies have assessed the postoperative analgesic efficacy of surgical site infusion following total abdominal hysterectomy with bilateral salpingo-oophorectomy (BSO). Four were randomized, double-blind and placebo-controlled (Gupta et al. 2004, Kristensen et al. 1999, Leong et al. 2002, Zohar et al. 2001), and four were randomized and double-blind, but not placebocontrolled (Gupta et al. 2005, Hafizoglu et al. 2008, Perniola et al. 2009, Zohar et al. 2004). In three studies, local anaesthetic surgical site infusion was associated with a significant decrease in postoperative pain and analgesic requirements (Gupta et al. 2004, Gupta et al. 2005, Zohar et al. 2001). In one study, surgical site infusion was not associated with improved pain scores when compared with placebo (Leong et al. 2002). No difference in analgesic efficacy was seen between ropivacaine 0.1% and 0.2% (Zohar et al. 2004), or between levobupivacaine 7.5 mg/h, 12.5 mg/h and 17.5 mg/h (Perniola et al. 2009). In one study, catheter placement above the fascia appeared to be more effective than below the fascia (Hafizoglu et al. 2008). Overall, surgical site infusion was not associated with clinically significant complications or side effects. There was no evidence of systemic or local surgical site infection (Gupta et al. 2004, Kristensen et al. 1999, Leong et al. 2002, Zohar et al. 2001, Zohar et al. 2004), and the incidence of nausea or vomiting was either decreased or unchanged when compared with controls (Gupta et al. 2004, Zohar et al. 2001, Zohar et al. 2004)

2 Publication Gupta et al. Anesth Analg 2004 Gupta et al. Middle East J Anesth 2005 Hafizoglu et al. Anesth Analg 2008 Grade* (1 13) Number of patients Catheter type and location 8 40 Multiholed Supravaginal Multiholed (converted from epidural) Above the fascia 5 62 Multiholed 20G epidural Above vs below the fascia Preclosure bolus 20 ml (50 mg) levobupivacaine Postoperative administration Levobupivacaine 0.25% continuous infusion Not used Bupivacaine 0.25% continuous infusion Not used PCSSA bupivacaine 0.25%, 9 ml, 60 min lockout for 24 h Outcomes Pain Rescue medication Nausea Nausea and vomiting VAS pain scores Above fascia: Bupivacaine Rescue medication VAS pain scores Satisfaction Chapter 3 Gynaecological surgery Kristensen et al. Reg Anesth Pain Med Multiholed between the peritoneum and muscle layer Not used Intermittent bupivacaine 0.25% No difference Table 19. Summary of literature for total abdominal hysterectomy with bilateral salpingo-oophorectomy.

3 Publication Grade* (1 13) Number of patients Catheter type and location Preclosure bolus Postoperative administration Outcomes Leong et al. Aust NZJ Obstet Gynaecol Epidural Above the fascia Not used Bupivacaine 0.5% continuous infusion No difference Perniola et al. Eur J Anaesth Multiholed Supravaginal 20 ml of study solution subcutaneously, + 20 ml via catheter Levobupivacaine: 7.5 mg/h (1) 12.5 mg/h (2) or 17.5 mg/h (3) continuous infusion for 48 h No difference between groups Zohar et al. Anesth Analg Epidural Above the fascia Not used PCSSA bupivacaine 0.25% Opioid medication Nausea Satisfaction Zohar et al. J Clin Anesth Epidural Above the fascia Not used PCSSA ropivacaine 0.1% or 0.2% No difference Table 19 cont. Summary of literature for total abdominal hysterectomy with bilateral salpingo-oophorectomy. *see page 15 for grading of publications

4 Practical details for total abdominal hysterectomy with BSO Catheter type Three studies used a standard epidural catheter (Leong et al. 2002, Zohar et al. 2001, Zohar et al. 2004), one converted a standard epidural catheter into a multiholed catheter by piercing the catheter wall with a 26G needle (Gupta et al. 2005), and four used a multiholed catheter (Gupta et al. 2004, Hafizoglu et al. 2008, Kristensen et al. 1999, Perniola et al. 2009). Both epidural and multiholed catheters were associated with improved postoperative analgesia. Expert opinion A multiholed catheter placed along the entire length of the wound is suggested, because intuitively this seems likely to produce better results than a standard epidural catheter. However, there are no double-blind, randomized studies comparing the efficacy of different catheter types. Evidence grade: Moderate Catheter placement In four studies, the catheter was placed above the fascia (Gupta et al. 2005, Leong et al. 2002, Zohar et al. 2001, Zohar et al. 2004). In two studies the catheter was placed supravaginally (Gupta et al. 2004; Perniola et al. 2009) and in another between the peritoneum and muscle layer (Kristensen et al. 1999). Catheter placements above the fascia and supravaginally were both associated with improved postoperative analgesia (Gupta et al. 2004, Zohar et al. 2001), but placement between the peritoneum and muscle layer (with bupivacaine 15 ml, 2.5 mg/ml) was not associated with improved pain scores, compared with placebo (Kristensen et al. 1999). In the study comparing catheter placements, catheters placed above the fascia were associated with reduced postoperative pain, decreased opioid requirement, and increased patient satisfaction compared with catheters placed below the fascia (Hafizoglu et al. 2008). Chapter 3 Gynaecological surgery

5 Expert opinion Catheter placement above the fascia is suggested, although further studies are needed to confirm optimal catheter placement. Evidence grade: Moderate Preclosure bolus administration In two studies, 20 ml levobupivacaine was infiltrated subcutaneously before skin closure (Gupta et al. 2004; Perniola et al. 2009). Expert opinion Surgical site infiltration with levobupivacaine prior to wound closure is suggested, although further studies are needed to confirm the benefit of preclosure bolus infiltration. Since all patients received surgical site infiltration (levobupivacaine) prior to local anaesthetic administration, it is not possible to determine the relative contribution of the infiltration process to the overall outcomes. There are no double-blind, randomized studies assessing the efficacy of preclosure bolus infiltration. Grading of evidence: Moderate Drug and dosing regimen Bupivacaine 0.25% (Gupta et al. 2005, Hafizoglu et al. 2008, Kristensen et al. 1999, Zohar et al. 2001), bupivacaine 0.5% (Leong et al. 2002), ropivacaine 0.1% or 0.2% (Zohar et al. 2004), levobupivacaine 0.25% (Gupta et al. 2004) and levobupivacaine up to 17.5 mg/h (Perniola et al. 2009) have all been used. Four studies used an intermittent technique for surgical site instillation (Hafizoglu et al. 2008, Kristensen et al. 1999, Zohar et al. 2001, Zohar et al. 2004) and four used a continuous infusion technique (Gupta et al. 2004, Gupta et al. 2005, Leong et al. 2002, Perniola et al. 2009). For total abdominal hysterectomy with BSO, ropivacaine 0.1% was associated with similar postoperative analgesia to ropivacaine 0.2% (Zohar et al. 2004). In a similar study, levobupivacaine 7.5 mg/h was associated with similar analgesia to levobupivacaine 12.5 mg/h and 17.5 mg/h (Perniola et al. 2009). These results suggest that there are no additive analgesic effects when higher dosages of local anaesthesia are administered

6 Expert opinion Bupivacaine %, ropivacaine % or levobupivacaine 0.25% or 7.5 mg/h are suggested. There are no comparative studies designed to determine the ideal drug, drug concentration or dosing regimen. Although not examined using a rigorous investigational technique, continuous infusion is likely to provide improved baseline analgesia and prevent breakthrough pain. Grading of evidence: Moderate Duration of infusion Durations of infusion of 24 h (Gupta et al. 2004, Gupta et al. 2005, Zohar et al. 2001, Zohar et al. 2004), 48 h (Leong et al. 2002, Perniola et al. 2009) and 52 h (Kristensen et al. 1999) have all been used. Expert opinion Up to 52 h infusion duration is suggested, but duration should be tailored to the patient s needs. Grading of evidence: Moderate Key messages for total abdominal hysterectomy with BSO Surgical site infusion decreases postoperative pain and opioid requirements. Surgical site infusion is a useful alternative to patientcontrolled, intravenous morphine. References For a list of additional references and suggestions for further reading, see Appendix 4. Fredman B, Shapiro A, Zohar E, et al. The analgesic efficacy of patient controlled ropivacaine instillation following cesarean section. Anesth Analg 2000;91: Givens VA, Lipscomb GH, Meyer NL. A randomized trial of postoperative wound irrigation with local anesthetic for pain after cesarean delivery. Am J Obstet Gynecol 2002;186: Gupta S, Maheshwari R, Dulara SC. Wound instillation with 0.25% bupivacaine as continuous infusion following hysterectomy. Middle East J Anesth 2005;18: Chapter 3 Gynaecological surgery

7 Gupta A, Perniola A, Axelson K, et al. Postoperative pain after abdominal hysterectomy: A double-blind comparison between placebo and local anesthetic infused intraperitoneally. Anesth Analg 2004;99: Hafizoglu MC, Katircioglu K, Ozkalkanli MY, Savaci S. Bupivacaine infusion above or below the fascia for postoperative pain treatment after abdominal hysterectomy. Anesth Analg 2008;107(6): Kristensen BB, Christensen DS, Ostergaard M, et al. Lack of postoperative pain relief after hysterectomy using preperitoneally administered bupivacaine. Reg Anesth Pain Med 1999;24: Lavand'homme PM, Roelants F, Waterloos H, De Kock MF. Postoperative analgesic effects of continuous wound infiltration with diclofenac after elective Cesarean delivery. Anesthesiology 2007;106: Leong WM, Lo WK, Chiu JW. Analgesic efficacy of continuous delivery of bupivacaine by an elastomeric balloon infusor after abdominal hysterectomy: a prospective randomized controlled trial. Aust N Z J Obstet Gynaecol 2002;42: Mecklem DW, Humphrey MD, Hicks RW. Efficacy of bupivacaine delivered by wound catheter for post-caesarean section analgesia. Aust N Z J Obstet Gynaecol 1995;35: O'Neill P, Duarte F, Ribeiro I, et al. Ropivacaine continuous wound infusion versus epidural morphine for postoperative analgesia after Cesarean delivery: A randomized controlled trial. Anesth Analg 2012;114: Perniola A, Gupta A, Crafoord K, et al. Intraabdominal local anaesthetics for postoperative pain relief following abdominal hysterectomy: a randomized, double-blind, dose-finding study. Eur J Anaesthesiol 2009;26: Rackelboom T, Le Strat S, Silvera S, et al. Improving continuous wound infusion effectiveness for postoperative analgesia after Cesarean delivery: a randomized controlled trial. Obstet Gynecol 2010;116(4): Ranta PO, Ala-Kokko TI, Kukkonen JE, et al. Incisional and epidural analgesia after caesarean delivery: a prospective, placebocontrolled, randomized clinical study. Int J Obstetric Anesthesia 2006;15:

8 Zohar E, Fredman B, Phillipov A, et al. The analgesic efficacy of patient controlled bupivacaine wound instillation following total abdominal hysterectomy with bilateral salpingo-oophorectomy Anesth Analg 2001;93: Zohar E, Fredman B, Phillipov A, et al. The postoperative analgesic efficacy of wound instillation with ropivacaine 0.1% versus ropivacaine 0.2%. J Clin Anesth 2004;16: Zohar E, Luban I, Zunser I, et al. Patient controlled bupivacaine wound instillation following cesarean section: The lack of efficacy of adjuvant ketamine. J Clin Anesth 2002;14: Zohar E, Shapiro A, Eidenov A, et al. Post Cesarean analgesia: the efficacy of bupivacaine wound instillation with and without supplemental diclofenac. J Clin Anesth 2006;18: Chapter 3 Gynaecological surgery