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PCA better for pain relief after vaginal reconstructive surgery

NEW YORK (Reuters Health) – Women having vaginal reconstructive surgery have less pain the day afterward if they receive patient-controlled analgesia (PCA), according to a report from Good Samaritan Hospital in Cincinnati.

The research was led by Dr. Catrina Crisp, who told Reuters Health by phone that now all women having vaginal reconstructive surgery at her center receive hydromorphone PCA for postoperative pain control.

She and her colleagues enrolled 59 women undergoing vaginal reconstruction procedures, with or without vaginal hysterectomy. All received locally infiltrated lidocaine and epinephrine for portions of the dissection, three doses of ketorolac on the day of surgery and then ibuprofen every eight hours until discharge.

In addition, patients had access to hydromorphone, either via PCA (a 0.2 mg demand dose, with a lockout interval of eight minutes and a four-hour maximum of 5 mg) or as an optional 0.5 mg dose offered by nurses every two hours. All patients could receive narcotics for breakthrough pain.

Pain and patient satisfaction were measured using standard 100-mm visual analog scales (VAS).

Of the 54 patients who completed the study, 30 received PCA and 24 had nurse-administered analgesia (NAA). The two groups were similar in demographics, BMI and operative parameters.

Initial pain scores on arrival to the nursing unit were also equivalent. But at 8 a.m. on the first postoperative day (POD), PCA patients had significantly less pain than those receiving NAA (25 vs 39 mm, p=0.007).

Eighty percent of patients went home on POD1. By POD2, the remaining patients were no longer on intravenous hydromorphone and pain scores were not significantly different, nor was there a difference between the groups at POD14.

Patients in both groups were equally satisfied with their pain control at all intervals.

The PCA patients used significantly more hydromorphone than the NAA group on both the day of surgery (1.8 mg vs. 0.79 mg, respectively, p=0.003) and on POD1 (1.77 mg vs. 0.68 mg, p<0.001).

Dr. Crisp said, “While the patients in the PCA group had lower pain scores, they used twice as much narcotic without increased adverse effects. There was no difference in satisfaction with pain control between groups, which could be related to the autonomy that patients feel while using a PCA, although overall, no patient reported severe pain.”

The cumulative dose of hydromorphone over two days was less than 4 mg for patients in both groups.

Dr. Derek Rosner, who’s on the anesthesia faculty at the New England University College of Osteopathic Medicine and was not a participant in the study, told Reuters Health in an email, “Peak VAS scores in both groups were below 5 which correlates with ‘tolerable pain,’ and total hydromorphone consumption was meager, meaning this operation isn’t particularly painful. This notion is additionally supported by the lack of rescue doses required for either arm of the study. It is not surprising that PCA narcotic consumption was higher given the patient control aspect of PCA.”

In summary, Dr. Rosner said, “PCA hydromorphone seems to provide superior analgesia after urogynecologic surgery compared with standard nurse administered opioids and was equally well tolerated. Given the unique nature of vaginal reconstructive surgery, these data cannot be extrapolated to all urogynecologic procedures.”

Dr. Crisp agreed. She added, “I feel that this reiterates what most urogynecologists and gynecologists already know. The vaginal approach is the primary route for minimally invasive gynecologic surgery.”

SOURCE: http://bit.ly/N1CAU5

Am J Obstet Gynecol 2012.