UTILITY OF PREEMPTIVE LOCAL ANALGESIA IN VAGINAL HYSTERECTOMY

M. O'Neal, MD, DP Shackelford, MD

   Objective:  We seek to determine if pre-emptive administration of a long acting local anesthetic [0.5% Bupivacaine] immediately prior to vaginal hysterectomy will improve postoperative pain.

   Materials and Methods:  A randomized, double blinded, placebo controlled clinical trial of paracervical injection of 20cc 0.5% Bupivacaine with 1:200,000 epinephrine or 20 cc of normal saline placebo with 1:200,000 epinephrine was conducted following IRB approval.  Randomization and the key to the randomization scheme were managed by the hospital pharmacy.  Anesthesia was general, verbal analogue pain scores were collected at 1,2,3,4,6, 24 hours following surgery.  Morphine was used in the post anesthesia care unit on an adlib basis per nursing protocols. Pain management following discharge from the PACU was standardized to Morphine PCA. Ketorolac was use on an adlib basis for breakthrough pain.

   Results:  Twenty patients were enrolled.  Nine randomized to Bupivacaine. There was no difference between groups regarding indication for surgery, age, and length of surgery, blood loss or length of stay.  Pain scores were lower in the Bupivacaine group by ANOVA. [p=.003].  Morphine data is presented in Table 1.

Table 1

    PACU Morphine PCA Morphine Total Morphine

Saline         7.7±5    29.8±15.8  37±16

Bupivacaine 4.7±3.9  17.8±8.7            18.5±7.3

P value       0.14     .04           .01

Total morphine and that delivered by PCA was significantly less in patients who received Bupivacaine.  No difference was noted regarding supplemental ketorolac.  

   Conclusion:  Application of a paracervical block with a 0.5% Bupivacaine with 1:200,000 epinephrine prior to vaginal hysterectomy is associated with lower pain scores and a reduction in morphine requirements in the first 24 hours following surgery.

   Key Words: Bupivacaine, Vaginal Hysterectomy