Stephen Searle

conférence:

  • close

    Why is local anaesthesia done so rarely?
    Stephen Searle, MD, Clinical Director/Consultant in Contraception & Sexual Health, UK
    The talk will cover:
    The Technique
    MVA, Evidence Worldwide
    Practical Advantages & disadvantages of LA TOP>
    Complications
    Practical Advantages of MVA:
    Effective up to 12/40 & down to 5/40; Moves TOPs out of theatre; Less frightening for
    women; One visit, short stay; Inexpensive, low-tech; Enables non-gynaecologists to
    evacuate Ut; Simple, safe & effective for ERPC; No need to undress; No need to be
    starved; Can drive home; Less risk of uterine damage - GENTLE; Often suitable when GA
    STOP or MTOP are relatively contraindicated eg gross obesity, oral steroid treatment
    Disadvantages:
    Pain: Audit indicates there is less pain with LA than with MTOP and possibly less than
    after women awake from GA STOP
    Pain more likely with Primips, teenagers, if frightened or depressed, higher gestations.
    However: 70-90% would choose LA again
    Evidence on Analgesia
    Observational studies:
    less pain with Cx block than none
    20ml better than smaller vol
    inj @ 4 and 8 o'clock
    N2 O. x2 RCTs: 

    Entonox: BPAS 1st 501
    22% used N2 O - of these:
    28% - very helpful
    58% - Moderately helpful/some help
    11% - no help
    CONCLUSION: After 1st 250, staff were reminded to routinely offer N2 O.
    Recommendation
    "..hospitals should abandon curettage.. and adopt the aspiration methods, selecting
    manual evacuation and/or electric aspiration, according to the expertise available."
    Ref: Final Report, FIGO/WHO Task Force, March 1997
    Contraindications to MVA:
    Gestation > 12/40
    Anticoagulant Rx/Prolonged bleeding time
    Haematocrit < 30%
    Active PID
    HEALTH ECONOMICS
    GA STOP £430
    MTOP £260
    LA VTOP £190 (4 on list)
    Appendix. USA Complications
    Local vs. General Anaesthetic. Grimes 1979, Am J Ob Gyn.
    36,430 LA vs 17,725 GA
    Blood Transfusion, Cervical Tears, Perforations: x3 - x4 greater with GA
    Anaesthetic deaths: a GA complication
    BPAS + MSI: 1998-2000. N = 2,026
    ERPC = 6 (0.29%) 

    Blood transfusion = 0
    Hospital admission = 2 (0.09%)
    1 confirmed ectopic
    1 pain, anxiety, continuing pregnancy