The American Society of Regional Anesthesia has announced it will be hosting a novel video guided session moderated by Dr Brian Harrington with presenters Eugene Viscusi MD, Edward Mariano MD, and Santhanam Suresh MD. It will feature submitted videos by ASRA members and a Panel Discussion and an Open Forum.
Pain Relief for Women Undergoing Oocyte Retrieval for Assisted Reproduction (review)
Published: January 2013
In: The Cochrane Collaboration
From: EPPI-Centre, University of London
Authors: Kwan I, Bhattacharya S, Knox F, McNeil A.
In investigating if spinal anesthesia might be the best anesthetic and analgesic approach for oocyte retrieval, I found a recent and complete review on anesthesia and oocyte retrieval. The main result of this review was that use of more than one pain relief modality improved patient comfort. My informal on-line survey of patient information provided for patients by fertility clinics suggests propofol infusion as procedural sedation/general anesthesia is likely the most common method employed for oocyte retrieval in the US.
Various methods of conscious sedation and analgesia have been used for pain relief during oocyte recovery in in vitro fertilisation (IVF) and intra-cytoplasmic sperm injection (ICSI) procedures. The choice of agent has also been influenced by the quality of sedation and analgesia as well as by concerns about possible detrimental effects on reproductive outcomes.
To assess the effectiveness and safety of different methods of conscious sedation and analgesia on pain relief and pregnancy outcomes in women undergoing transvaginal oocyte retrieval.
With this update, nine new studies were identified resulting in a total of 21 trials including 2974 women undergoing oocyte retrieval. These trials compared five different categories of conscious sedation and analgesia: 1) conscious sedation and analgesia versus placebo; 2) conscious sedation and analgesia versus other active interventions such as general and acupuncture anaesthesia; 3) conscious sedation and analgesia plus paracervical block versus other active interventions such as general, spinal and acupuncture anaesthesia; 4) patient-controlled conscious sedation and analgesia versus physician-administered conscious sedation and analgesia; and 5) conscious sedation and analgesia with different agents or dosage. Evidence was generally of low quality, mainly due to poor reporting of methods, small sample sizes and inconsistency between the trials. Conflicting results were shown for women’s experience of pain. Compared to conscious sedation alone, more effective pain relief was reported when conscious sedation was combined with electro-acupuncture: intra-operative pain mean difference (MD) on 1 to 10 visual analogue scale (VAS) of 3.00 (95% CI 2.23 to 3.77); post-operative pain MD in VAS units of 2.10 (95% CI 1.40 to 2.80; N = 61, one trial, low quality evidence); or paracervical block (MD not calculable).The pooled data of four trials showed a significantly lower intra-operative pain score with conscious sedation plus paracervical block than with electro-acupuncture plus paracervical block (MD on 10-point VAS of -0.66; 95% CI -0.93 to -0.39; N = 781, 4 trials, low quality evidence) with significant statistical heterogeneity (I(2) = 76%). Patient-controlled sedation and analgesia was associated with more intra-operative pain than physician-administered sedation and analgesia (MD on 10-point VAS of 0.60; 95% CI 0.16 to 1.03; N = 379, 4 trials, low quality evidence) with high statistical heterogeneity (I(2) = 83%). Post-operative pain was reported in only nine studies. As different types and dosages of sedative and analgesic agents, as well as administrative protocols and assessment tools, were used in these trials the data should be interpreted with caution. There was no evidence of a significant difference in pregnancy rate in the 12 studies which assessed this outcome, and pooled data of four trials comparing electro-acupuncture combined with paracervical block with conscious sedation and analgesia plus paracervical block showed an odds ratio (OR) of 0.96 (95% CI 0.72 to 1.29; N = 783, 4 trials) for pregnancy. High levels of women’s satisfaction were reported for all modalities of conscious sedation and analgesia as assessed in 12 studies. Meta-analysis of all the studies was not attempted due to considerable heterogeneity.For the rest of the trials a descriptive summary of the outcomes was presented.
The evidence from this review of 21 randomised controlled trials did not support one particular method or technique over another in providing effective conscious sedation and analgesia for pain relief during and after oocyte recovery. The simultaneous use of more than one method of sedation and pain relief resulted in better pain relief than one modality alone. The various approaches and techniques reviewed appeared to be acceptable and were associated with a high degree of satisfaction in women. As women vary in their experience of pain and in coping strategies, the optimal method may be individualized depending on the preferences of both the women and the clinicians and resource availability.
Pub Med has access available to this review of Upper Extremity Regional Anesthesia, authored by Joseph M. Neal, MD, J.C. Gerancher, MD, Quinn H. Hogan, MD et al. It is wonderfully illustrated by Jennifer Gentry and provided on the web by US National Library of Medicine and the National Institutes of Health.
A former professor at the departments of anesthesiology at Wake Forest School of Medicine and Stanford University School of Medicine, Dr. John Charles “JC” Gerancher has extensive experience promoting evidence-based solutions that anesthesiologists can use to improve patient care.
Recently, anesthesiologists have begun utilizing multimodal approaches to the administration of analgesic treatments, a method of pain management that prioritizes the use of specific combinations of drugs rather than prioritizing a single treatment. This approach has generally resulted in better patient outcomes by reducing the negative side effects of traditional analgesic regimens and better controlling pain before and after surgery.
Most anesthesiologists have prioritized the use of opioids like morphine in managing pain, but these drugs have well known adverse effects. The multimodal approach to analgesia involves introducing other drug treatments, including nonsteroidal antiinflammatory drugs (NSAIDs), paracetamol, local anesthetics, and adjuvants. Research has found that by using multiple drugs, ideally three or more, in the treatment of pain, analgesia is improved markedly in both perioperative and postoperative settings. While this approach has not become fully mainstream, with fewer than 25 percent of physicians providing multimodal treatments prior to surgery, pain specialists throughout the country are striving to ensure that anesthesiologists are informed about the benefits of combining analgesic treatments.
Previously, John Charles Gerancher worked as a professor of anesthesiology at Wake Forest School of Medicine in Winston-Salem, North Carolina. J.C. Gerancher has received such honors as the Golden Apple Award, the H. Barrie Farley Excellence in Teaching Award, and the Best Doctors in America designation.
A French study recently discovered that many reusable medical items house contaminants. When researchers examined samples taken from pulse oximeters and electrocardiogram cables, researchers found that more than 50 percent of the analyzed materials tested positive for microbial contamination. Though the analysis identified no drug-resistant pathogens among the microbes uncovered, the study highlights the potential need to improve decontamination procedures.
Researchers from New York conducted a similar study published in the journal Anesthesia & Analgesia. This study found contamination rates roughly equal to those reported in the French study, but the New York researchers documented lower contamination rates when medical personnel were conscious of being monitored.