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Evaluation of peridural anesthesia in outpatient culdoscopy
Evaluation of peridural anesthesia in outpatient culdoscopy TURHAN
S. DOG-U,
JERRY
A.
DORSCH,
Pittsburgh,
Pennsylvania
M.D. M.D.
Ninety-one outpatients had culdoscopy under peridural anesthesia during the period from Oct. 1, 1967 to April 1, 1969 at Magee-Womens Hospital. Seventy-four per cent of these patients were pleased with the peridural technique, and it was demonstrated to be a safe anesthetic technique for outpatients. The incidence of major complications due to anesthesia or culdoscopy was rare. The selection of suitable patients is essential to reduce this incidence. The patient (or the insurance company) saves money by this procedure; it frees hospital beds for inpatients or for emergency cases; and the patient spends less time in the hospital, which may be important to her and to her family.
C u L D o s c o P Y has been useful in establishing diagnoses of unruptured ectopic endometriosis, Stein-Leventhal prqvncy, syndrome, pelvic tuberculosis, salpingooophoritis, tubal occlusion, pelvic adhesions, and ovarian tumor. Many unnecessary explorative laparotomies may be prevented by this diagnostic procedure. Most gynecologists favor the patients’ staying in the hospital for a 24 or 48 hour period after culdoscopy. Decker, Decker, and Milowskyl point out that the culdoscopic examination is a short procedure and may be done on ambulatory patients. Shneidman’ states that it is a safe and easily accomplished Peretz and Sharf3 report office procedure. that most of their patients were discharged on the same day following examination. This prospective study was designed to evaIuate the efficacy of extradural technique for outpatient culdoscopy. Material and methods All outpatients having culdoscopy 1967 and 1969 at MageeWomens
between Hospital
From the Department of Anesthesiology, University of Pittsburgh School of Medicine, Magee-Womens Hospital.
were included in this study. The patients consisted of 87 white and 4 nonwhite females. They ranged in age from 20 to 41 and were all private patients. All patients were ASA physical status 1, except one whose physical status was 3. The patients were given preoperative instructions by their physicians before entering the hospital. Routine laboratory work was done in the hospital after admission, and the cases were scheduled between 9: 00 A.M. and 12: 00 noon. All patients were interviewed by the staff anesthesiologist or the anesthesia resident; and the type of anesthesia as well as the position, onset, and duration were discussed. Problems relating to culdoscopy such as the position for the examination and the shoulder, chest, or upper abdominal pain caused by pneumoperitoneum were also explained. Written consent was obtained. The patients were premeditated with a narcotic, belladonna, barbiturate, or phenothiazine, or combination thereof in a quantity judged necessary for the patients’ emotional status. Stable patients received no premeditation. Most blocks were performed by anesthesia residents under the direct supervision of a
Peridural
Table I. Peridural
blocks
in outpatient
culdoscopy Technique
1 No.
of patients 66 1
Caudal Single dose Continuous
23 1 91
staff anesthesiologist. Anesthetic technique, the management of the knee-chest position, and postoperative care of the patient were done as previously reported.” Following culdoscopic examination, patients were taken to the recovery room; and after the anesthesia had worn off they were returned to the four-bed outpatient surgical suite. Several months later a questionnaire was sent to each patient to determine any discomfort and the patient’s reaction to the extradural technique and culdoscopic examination. Patients not responding to the questionnaire were telephoned by physicians. Results Lumbar epidural blocks were performed in 66 patients, a continuous technique being used on one. There were 23 single injection caudals and one continuous caudal (Table
far
culdoscopy
469
Table II. Supplemental analgesia required in 18 of 91 patients receiving peridurtl anesthesia Agents
Lumbar epidural Single dose Continuous
Total
anesthesia
No.
of jmtients
Intravenous narcotic Intravenous narcotic and barbiturate or tranquilizer Intravenous tranquilizer Intravenous barbiturate Lumbar epidural Caudal and local and intravenous narcotic Caudal Local and methoxyflurane N,O - 0, lfi
Total
Table III. 80 patients
Complications (In response
Complication
or discomfort
Chest or shoulder pain Backache Nausea Nausea and vomiting Fainting Stomach discomfort Headache Weakness Nausea and lethargy Nausea and sweating Nausea and shoulder pain Hip pain
or discomfort in to the questions) No.
of cases 1 :‘.
_’
Total
Ij. In 18 patients, supplemental analgesia was needed (Table II). Seventy-three patients required no supplementation. There was no anesthetic complication in 82 cases. A decreased blood pressure of 25 per cent or more from the base-line reading was observed in 2 patients. This was corrected with intravenous fluid in one, and with the addition of a vasopressor in the other. Dural puncture occurred in 2. Shivering was noted in 3 and nausea in one. One patient who experienced hypotension and loss of consciousness for a very short period was hospitalized overnight. One rectal perforation occurred without further complication. The response to the questionnaire indi-
cated that out of 80 responses there were 9 ( 11.2 per cent) who felt there was. undue discomfort during the procedure. Five of the patients had inadequate epidural anesthesia and were supplemented with inhalation or intravenous analgesia. One patient experienced cramps. Another feIt some pain at the beginning of the procedure and noted pressure of the instruments. Two patients experienced nonspecific discomfort. Fifteen of the 80 patients (18.7 per cent) noted discomfort during the administration of the block. Three of these patients experienced shivering, and one was generally apprehensive. The other 11 experienced pain on insertion of the epidural needle. In 5 of
470
DO$J
and
Dorsch
these, multiple attempts to enter the epidural space were necessary. In response to the questions concerning complications or discomfort postoperatively, 30 of the 80 (38.7 per cent) answered that they had had discomfort (Table III). The most frequent complaint was that of chest or shoulder pain which was attributed to pneumoperitoneum or shoulder braces. One patient complained of headache for 5 days, although no dural puncture had occurred. Those who had a dural puncture had no postoperative complications from it. When asked if they preferred epidural anesthesia or general anesthesia, 57 (74 per cent) of our patients preferred the epidural anesthesia. Comment The value of epidural anesthesia for culdoscopy has already been demonstrated? Our investigation was designed to show the value of this technique as an outpatient anesthesia in the face of rising hospital costs and shortage of hospital beds. In the case of our 91 patients, it meant a bed was available for 182 nights for emergency admissions. During the 19 months of our study, the patients or the insurance companies saved approximately $4,600. In terms of time savings
Amer.
October J. Obstet.
1, 1970 Gynec.
to the patient, it is not necessary that she be absent from her family or occupation for part or all of the day before and after culdoscopy. Cohen and Dillon” reported that only 2 of 676 patients (0.28 per cent) stayed overnight in the hospital for anesthetic reasons. Our most frequent complaint of chest and shoulder pain was probably due to pneumoperitoneum and shoulder braces. This was readily accepted by the patients if it was discussed with them in the preanesthetic visit. The persistence of pain should certainly suggest the possibility of a complication. Shneidman recommends that the woman who is extremely nervous and highly sensitive with low sensory thresholds should be admitted to the hospital for culdoscopy. Also, it is believed that in the culdoscopic hypersensiexamination of apprehensive, tive, and emotionally unstable individuals discomfort may be a prominent feature.lv 4 Our study points out that peridural anesthesia is readily accepted by patients. This experience leads us to believe that if the patient is seen by an anesthesiologist and the peridural block is performed by the same anesthesiologist, the success rate and patient acceptance of the anesthetic will be high and the incidence of complications low.
REFERENCES
1. Decker, A., Decker, W., and Milowsky, J.: AMER. J. OBSTET. GYNEC. 59: 455, 1950. 2. Shneidman, A. P.: J. Amer. Osteopath. Ass. 57: 652, 1958. 3. Peretz, A., and Sharf, M.: AMER. J. OBSTET. GYNEC. 82: 582, 1961.
4. 5.
DOELI, T. S., and Cook, D. R.: Anesth. Analg. 48: 237, 1969. Cohen, D. D., and Dillon, J. B.: J. A. M. A. 196: 1114, 1966.
S. DOG-U,
JERRY
A.
DORSCH,
Pittsburgh,
Pennsylvania
M.D. M.D.
Ninety-one outpatients had culdoscopy under peridural anesthesia during the period from Oct. 1, 1967 to April 1, 1969 at Magee-Womens Hospital. Seventy-four per cent of these patients were pleased with the peridural technique, and it was demonstrated to be a safe anesthetic technique for outpatients. The incidence of major complications due to anesthesia or culdoscopy was rare. The selection of suitable patients is essential to reduce this incidence. The patient (or the insurance company) saves money by this procedure; it frees hospital beds for inpatients or for emergency cases; and the patient spends less time in the hospital, which may be important to her and to her family.
C u L D o s c o P Y has been useful in establishing diagnoses of unruptured ectopic endometriosis, Stein-Leventhal prqvncy, syndrome, pelvic tuberculosis, salpingooophoritis, tubal occlusion, pelvic adhesions, and ovarian tumor. Many unnecessary explorative laparotomies may be prevented by this diagnostic procedure. Most gynecologists favor the patients’ staying in the hospital for a 24 or 48 hour period after culdoscopy. Decker, Decker, and Milowskyl point out that the culdoscopic examination is a short procedure and may be done on ambulatory patients. Shneidman’ states that it is a safe and easily accomplished Peretz and Sharf3 report office procedure. that most of their patients were discharged on the same day following examination. This prospective study was designed to evaIuate the efficacy of extradural technique for outpatient culdoscopy. Material and methods All outpatients having culdoscopy 1967 and 1969 at MageeWomens
between Hospital
From the Department of Anesthesiology, University of Pittsburgh School of Medicine, Magee-Womens Hospital.
were included in this study. The patients consisted of 87 white and 4 nonwhite females. They ranged in age from 20 to 41 and were all private patients. All patients were ASA physical status 1, except one whose physical status was 3. The patients were given preoperative instructions by their physicians before entering the hospital. Routine laboratory work was done in the hospital after admission, and the cases were scheduled between 9: 00 A.M. and 12: 00 noon. All patients were interviewed by the staff anesthesiologist or the anesthesia resident; and the type of anesthesia as well as the position, onset, and duration were discussed. Problems relating to culdoscopy such as the position for the examination and the shoulder, chest, or upper abdominal pain caused by pneumoperitoneum were also explained. Written consent was obtained. The patients were premeditated with a narcotic, belladonna, barbiturate, or phenothiazine, or combination thereof in a quantity judged necessary for the patients’ emotional status. Stable patients received no premeditation. Most blocks were performed by anesthesia residents under the direct supervision of a
Peridural
Table I. Peridural
blocks
in outpatient
culdoscopy Technique
1 No.
of patients 66 1
Caudal Single dose Continuous
23 1 91
staff anesthesiologist. Anesthetic technique, the management of the knee-chest position, and postoperative care of the patient were done as previously reported.” Following culdoscopic examination, patients were taken to the recovery room; and after the anesthesia had worn off they were returned to the four-bed outpatient surgical suite. Several months later a questionnaire was sent to each patient to determine any discomfort and the patient’s reaction to the extradural technique and culdoscopic examination. Patients not responding to the questionnaire were telephoned by physicians. Results Lumbar epidural blocks were performed in 66 patients, a continuous technique being used on one. There were 23 single injection caudals and one continuous caudal (Table
far
culdoscopy
469
Table II. Supplemental analgesia required in 18 of 91 patients receiving peridurtl anesthesia Agents
Lumbar epidural Single dose Continuous
Total
anesthesia
No.
of jmtients
Intravenous narcotic Intravenous narcotic and barbiturate or tranquilizer Intravenous tranquilizer Intravenous barbiturate Lumbar epidural Caudal and local and intravenous narcotic Caudal Local and methoxyflurane N,O - 0, lfi
Total
Table III. 80 patients
Complications (In response
Complication
or discomfort
Chest or shoulder pain Backache Nausea Nausea and vomiting Fainting Stomach discomfort Headache Weakness Nausea and lethargy Nausea and sweating Nausea and shoulder pain Hip pain
or discomfort in to the questions) No.
of cases 1 :‘.
_’
Total
Ij. In 18 patients, supplemental analgesia was needed (Table II). Seventy-three patients required no supplementation. There was no anesthetic complication in 82 cases. A decreased blood pressure of 25 per cent or more from the base-line reading was observed in 2 patients. This was corrected with intravenous fluid in one, and with the addition of a vasopressor in the other. Dural puncture occurred in 2. Shivering was noted in 3 and nausea in one. One patient who experienced hypotension and loss of consciousness for a very short period was hospitalized overnight. One rectal perforation occurred without further complication. The response to the questionnaire indi-
cated that out of 80 responses there were 9 ( 11.2 per cent) who felt there was. undue discomfort during the procedure. Five of the patients had inadequate epidural anesthesia and were supplemented with inhalation or intravenous analgesia. One patient experienced cramps. Another feIt some pain at the beginning of the procedure and noted pressure of the instruments. Two patients experienced nonspecific discomfort. Fifteen of the 80 patients (18.7 per cent) noted discomfort during the administration of the block. Three of these patients experienced shivering, and one was generally apprehensive. The other 11 experienced pain on insertion of the epidural needle. In 5 of
470
DO$J
and
Dorsch
these, multiple attempts to enter the epidural space were necessary. In response to the questions concerning complications or discomfort postoperatively, 30 of the 80 (38.7 per cent) answered that they had had discomfort (Table III). The most frequent complaint was that of chest or shoulder pain which was attributed to pneumoperitoneum or shoulder braces. One patient complained of headache for 5 days, although no dural puncture had occurred. Those who had a dural puncture had no postoperative complications from it. When asked if they preferred epidural anesthesia or general anesthesia, 57 (74 per cent) of our patients preferred the epidural anesthesia. Comment The value of epidural anesthesia for culdoscopy has already been demonstrated? Our investigation was designed to show the value of this technique as an outpatient anesthesia in the face of rising hospital costs and shortage of hospital beds. In the case of our 91 patients, it meant a bed was available for 182 nights for emergency admissions. During the 19 months of our study, the patients or the insurance companies saved approximately $4,600. In terms of time savings
Amer.
October J. Obstet.
1, 1970 Gynec.
to the patient, it is not necessary that she be absent from her family or occupation for part or all of the day before and after culdoscopy. Cohen and Dillon” reported that only 2 of 676 patients (0.28 per cent) stayed overnight in the hospital for anesthetic reasons. Our most frequent complaint of chest and shoulder pain was probably due to pneumoperitoneum and shoulder braces. This was readily accepted by the patients if it was discussed with them in the preanesthetic visit. The persistence of pain should certainly suggest the possibility of a complication. Shneidman recommends that the woman who is extremely nervous and highly sensitive with low sensory thresholds should be admitted to the hospital for culdoscopy. Also, it is believed that in the culdoscopic hypersensiexamination of apprehensive, tive, and emotionally unstable individuals discomfort may be a prominent feature.lv 4 Our study points out that peridural anesthesia is readily accepted by patients. This experience leads us to believe that if the patient is seen by an anesthesiologist and the peridural block is performed by the same anesthesiologist, the success rate and patient acceptance of the anesthetic will be high and the incidence of complications low.
REFERENCES
1. Decker, A., Decker, W., and Milowsky, J.: AMER. J. OBSTET. GYNEC. 59: 455, 1950. 2. Shneidman, A. P.: J. Amer. Osteopath. Ass. 57: 652, 1958. 3. Peretz, A., and Sharf, M.: AMER. J. OBSTET. GYNEC. 82: 582, 1961.
4. 5.
DOELI, T. S., and Cook, D. R.: Anesth. Analg. 48: 237, 1969. Cohen, D. D., and Dillon, J. B.: J. A. M. A. 196: 1114, 1966.