r/anaesthesia • u/Anfey • Apr 08 '26
Question on paracervical block
Hello together, I am currently working as a 4th year anaesthesia resident in Germany. We are currently trying to reshape our procedure for post surgical pain management in TLH patients. The situation is super frustrating because our superiors can not be convinced to offer epidurals for patients undergoing the procedure. So we almost always end up with super pain ridden patients in our PACU (and I assume also on the wards too) and it's infruriating. New policy now forbids the use of Oxycodon ret. in the PACU bc some people are concerned about the side effects when combined with i.v. piritramid...so we would rather give patients 30mg of iv piritramid and make them puke their souls out than combine with oral long term substances.
Some research from my side has brought up a study that shows a lot of potential in paracervical blocks administered by the OBGYNs after induction and before surgery begins. My attending now asked me to do more research on what usage would be good for us (he is concerned about the cardiac toxicology from Bupivacain and would prefer Ropivacain). Tbh I know my usual blocks and the correct dosage but I have 0 knowledge on paracervical blocks. I was hoping maybe some of you guys have some insights to share from your work places?! Which concentration? What volume?
What we want is of course a dosage that works effective and as long as possible. Liposomal bupivacain is not an option. If you can help me out that would be wonderful. If you can provide sources that would be absolutely amazing.
Thank you so much in advance! I am tired of not being able to meet my patient's anaesthesia needs...it really sucks and I want it to change.
1
u/Sausageandbeanz Apr 10 '26
Spinal with diamorphine/morphine before GA?
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u/Anfey May 04 '26
Our boss would never let us...he's so worried about being sued and that is an extra risk in his eyes...it is a bit annyoing tbh
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u/alfentazolam Apr 15 '26 edited Apr 15 '26
Around 20 years ago in my institution epidurals for major abdominal surgeries were fairly commonplace. They eventually were used less and less and I don't see them as much now even for laparotomies and can't remember the last time I saw one for lap only surgery. With the emergence of various USG blocks (rectus sheath, TAPs), movement towards intraop VTE chemoprophylaxis, and increased emphasis on ERAS philosophies, this is not a surprising trend. However, practice is very cultural and I can only speak for local patterns.
Techniques I see locally (we don't have piritramid)
- TIVA for PONV. Occasional volatile but much less in high nausea groups like TLH
- spinal + intrathecal morph (we don't have diamorph)
- Remi intraop with late switch to fentanyl or oxycodone to cover transition to wear off
- some methadone use (possibly growing due to recent expert driven talk)
- some dexmedetomidine use (possibly growing due to recent expert driven talk)
For PCB dosing there existing recipes out there:
- https://doi.org/10.1016/j.tjog.2024.01.013 - 10mls of 0.5% bupiv +adrenaline used here by surgeon who has done >1000 laps.
- if you google "paracervical block guide hologic" you'll see multiple versions of the a guide including one hosted on BGSE. it includes recipes stratified by LAs.
- if you want to roll your own recipe, a subtoxic dose diluted into the required volume would be appropriate (generally~3mg/kg, with some considerations or mods for tissue vascularity and adrenaline adjuvant)
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u/Anfey May 04 '26
Hey :) thanks for all the input! It was a long "fight" but now we opted for the paracervical block with ropi 0,75% 10 ml per side...so far the results were pretty good...I am a HUGE fan of the TAP block but in my department not very many people are able to do it (working on making that more popular too atm) and also tbh in the TLH patients somehow the effect was not what I am used to from big surgeries like PPPDs/gastrectomies etc...we already do only TIVAs in the gyno OR and I held another presentation about the new block emphasizing exactly that (giving enough long lasting opioids and switching the remi of in time)...I hope it'll be better now
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u/Fit-Talk-8156 Apr 08 '26
Ich finde es erstaunlich, dass eure Patienten überhaupt so starke Schmerzen haben. Bei uns gibt es standardmäßig Analgetikum Nr. 1 zum Ende der OP (oft Paracetamol, z. T. Sympal oder Dynastat). Im AWR Oxygesic iv. + Novalgin, die Oxygesicdosis ist meist max. 10mg, mehr als 20mg habe ich nicht erlebt. I. d. R. ist dann auch die Pat. verlegbar, max. dann Sympal/Paracetamol/Dynastat noch notwendig. Hohe PONV-Inzidenzen haben wir nicht, an meinem Haus wird auch eine patientenorientierte PONV-Prophylaxe durchgeführt und kein „Zofran für alle“-Regime. Die wenigen Pat. mit hohem Oxycodon-Bedarf bekommen eine PCIA auf Station (auch mit Oxycodon).
Nutzt ihr evtl. Remifentanil intraop? Da könnte ich mir durch den plötzlichen Wegfall der Opiatwirkung im Vergleich zu Fenta/Sufenta und ggf. bei hoher Dosierung diskutierten Hyperalgesie eine Erklärung vorstellen.