COCHRANE NURSING CARE REVIEW

Pain Management for Tubal Sterilization by Hysteroscopy Daphne Stannard, PhD, RN, CCRN, CCNS, FCCM QUESTION: WHAT IS THE EFFICACY of different types of interventions for pain management in patients undergoing tubal sterilization by hysteroscopy?

Significance to Nursing Sterilization is a permanent form of birth control, and sterilization procedures for women are called tubal sterilization.1 Hysteroscopic sterilization is a procedure whereby small implants are placed into both fallopian tubes. The implants stimulate tissue growth, and the lumens close over time. The advantages of tubal sterilization by hysteroscopy include no surgical incision and the convenience of having the procedure performed in an office-based setting. Pain, however, remains a concern.

Study Description and Results This summary is based on two randomized controlled trials, which included a total of 167 participants. One trial, conducted in the United States, compared paracervical block with lidocaine to paracervical block with normal saline at the time of sterilization. The second trial, conducted in Canada, evaluated conscious sedation administered intravenously to oral analgesia. Validated pain scales, Daphne Stannard, PhD, RN, CCRN, CCNS, FCCM is the Director and Chief Nurse Researcher, Department of Nursing, Institute for Nursing Excellence, UCSF Medical Center, San Francisco, CA and a member of the Cochrane Nursing Care Field. Conflict of interest: None to report. This is a summary of a Cochrane Review. The full citation and the names of the researchers who conducted the Review are listed in the Reference section below. Address correspondence to Daphne Stannard, Department of Nursing, Institute for Nursing Excellence, UCSF Medical Center, 855 Folsom Street, #923, San Francisco, CA 94107; e-mail address: [email protected]. Ó 2013 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00 http://dx.doi.org/10.1016/j.jopan.2013.09.005

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such as the visual analog scale (VAS) or the McGill Pain Score, were considered acceptable measures of treatment effect. If a study reported pain on more than one occasion, the primary treatment effect was considered for the overall patientreported pain score for the entire procedure. In the absence of that report, a summation of all pain scores for the procedure was considered to be a primary treatment effect. Other primary outcomes included pain during each portion of the procedure and pain postprocedure. Secondary outcomes included:  Frequency of completion of the procedure  Adverse effects and complications  Procedure time measured in minutes Both trials had a low risk of bias owing to sequence generation and allocation. Correspondence with both sets of study authors was required, however, to address ambiguities related to risk of bias. Blinding of the participant, investigator, and study staff who had direct subject contact was reported in both studies. In the Canadian study, three randomized subjects were removed from the analysis. Two patients withdrew after randomization because they requested intravenous sedation. Excluding these subjects from analysis introduces a low risk of bias to the study. However, one patient was excluded from the study because only unilateral placement of the implant was achieved. Excluding this patient from the analysis introduces a high risk of bias, as pain (primary outcome) can be a determining factor as to whether or not the patient wants to continue with the procedure. However, because only 1 of the 84 subjects was excluded for this reason, it was determined that the exclusion had little impact on the overall results. For continuous outcomes, the mean difference was computed with a 95% confidence interval (CI) using a fixed-effect model. For dichotomous outcomes, the Mantel-Haenszel odds ratio (OR) with 95% CI was calculated using a fixed-effect model. All statistical analyses were performed in

Journal of PeriAnesthesia Nursing, Vol 28, No 6 (December), 2013: pp 402-403

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RevMan 5 (Cochrane software, London, UK). Owing to differences in the interventions, no trials were combined in a meta-analysis.

women who received intravenous conscious sedation versus oral analgesia (mean difference: 223.00; 95% CI: 262.02 to 16.02). Using a 100-point VAS, no significant difference emerged during any of the six portions of the procedure. Procedure time (mean difference: 20.2 minutes; 95% CI: 22.0 to 1.6 minutes) and time in the recovery area (mean difference: 3.6 minutes; 95% CI: 211.3 to 18.5 minutes) was not different among the groups. Women who received intravenous conscious sedation, however, had lower pain scores at the time of insertion of the second tubal implant compared with women who received oral analgesia (mean difference: 212.60; 95% CI: 223.98 to 21.22).

Summary of the main results:  Using a 10-cm VAS to measure pain, no significant difference in overall pain was found for the entire procedure among women who received a paracervical block with lidocaine versus normal saline (mean difference: 20.77; 95% CI: 22.67 to 1.13). No significant difference in pain score was noted at the time of injection of study solution (mean difference: 20.6; 95% CI: 21.3 to 0.1), placement of the implants in the fallopian tubes (mean difference: 20.60; 95% CI: 21.8 to 0.7), and postprocedure pain (mean difference: 0.2; 95% CI: 20.8 to 1.2). Procedure time (mean difference: 20.2 minutes; 95% CI: 22.2 to 1.8 minutes) and successful bilateral placement (OR: 1.0; 95% CI: 0.19 to 5.28) was not significantly different among the groups. During certain portions of the procedure, including but not limited to administration of the paracervical block (mean difference: 21.92; 95% CI: 22.84 to 21.00), the use of the lidocaine block resulted in lower pain scores.  Using a 600-point scale calculated by adding 100-point VAS scores from six different portions of the procedure, no significant difference was found in overall pain between

Nursing Implications The available literature is insufficient to determine the appropriate pain management strategy for sterilization by hysteroscopy. Compared with paracervical block with normal saline, paracervical block with lidocaine reduced pain during some portions of the procedure. Likewise, intravenous sedation resulted in lower pain scores during insertion of the second tubal implant. However, neither paracervical block with lidocaine nor conscious sedation significantly reduced overall pain scores for sterilization by hysteroscopy.2

References 1. The American College of Obstetricians and Gynecologists. Hysteroscopic sterilization. FAQ #180. 2013. Available at: http://www.acog.org//media/For%20Patients/faq 180pdf. Accessed August 18, 2013.

2. Kaneshiro B, Grimes DA, Lopez LM. Pain management for tubal sterilization by hysteroscopy. Cochrane Database Syst Rev 2012;(8):CD009251, http://dx.doi.org/10.1002/14651858. CD009251.pub2; 2012.

Pain management for tubal sterilization by hysteroscopy.

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