ABC for D&E: Addition of Buprenorphine to Paracervical Block for Pain Control During Osmotic Dilator Insertion
Study Details
Study Description
Brief Summary
Cervical preparation with osmotic dilators is commonly used prior to dilation and evacuation (D&E) procedures to decrease the risk of complications. Women have described the pain of osmotic dilator insertion as moderate to severe yet there have been few studies aimed at addressing pain during and after osmotic dilator insertion. In addition to the discomfort during insertion, pain after osmotic dilator insertion peaks at 2 hours post-insertion with use of a lidocaine paracervical block. One randomized trial found that use of a paracervical block with 1% buffered lidocaine decreased pain with osmotic dilator insertion compared to a sham block. There are adjunct treatments to optimize analgesia with local anesthetics at a variety of anatomic locations. Buprenorphine, a partial mu-opioid receptor agonist, has been found to increase the quality of the anesthetic at the time of administration and increase the duration of nerve block analgesia at several anatomic sites, though has never been studied as an adjunct in a paracervical block. This has been used extensively in orthopedic surgery with significant prolongation of the local anesthetic effect by almost threefold in some studies.
Primary Aim: To compare the mean pain score at the time of osmotic dilator insertion among women randomized to a 1% lidocaine and buprenorphine paracervical block compared to a 1% lidocaine paracervical block alone.
Secondary Aim: To compare the mean pain score 2 hours after osmotic dilator insertion among women randomized to a lidocaine and buprenorphine paracervical block compared to a lidocaine paracervical block alone.
The investigators hypothesize that in patients undergoing osmotic dilator insertion in preparation for dilation and evacuation, the addition of buprenorphine 0.15mg to a 1% lidocaine paracervical block will be associated with lower mean pain scores at time of osmotic dilator insertion compared to women who receive a 1% lidocaine paracervical block alone.
Condition or Disease | Intervention/Treatment | Phase |
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Phase 4 |
Detailed Description
Dilation and evacuation (D&E) is the most common method of second trimester abortion in the United States. Cervical preparation prior to the procedure is essential in order to allow passage of operative instruments and pregnancy tissue safely through the cervix and to decrease the risk of complications. In the second trimester, cervical preparation is typically achieved with placement of osmotic dilators prior to the procedure. Women have described the pain of osmotic dilator insertion as moderate to severe yet there have been few studies aimed at addressing pain during osmotic dilator insertion. A lidocaine paracervical block is commonly used for pain control during other gynecologic procedures including procedures involving cervical dilation like dilation and curettage. One randomized controlled trial found that use of a paracervical block with 1% lidocaine decreased pain with osmotic dilator insertion compared to a sham block. Because the dilators slowly expand after insertion, there is continued discomfort for several hours after placement. Research has shown that pain after osmotic dilator insertion peaks at 2 hours post-insertion with use of a lidocaine paracervical block and a local anesthetic is not sufficient to provide lasting pain relief. Systemic medications, such as gabapentin and narcotic analgesics have been studied to treat post-insertional dilator pain, however these treatments have not been shown to be effective.
There are many adjunct treatments to optimize the duration of local analgesia from a peripheral nerve block. Buprenorphine, a partial mu-opioid receptor agonist, is a high potency, lipophilic opioid and has a high binding capacity for the mu-opioid receptor. Because of the high binding capacity, buprenorphine has the longest duration of action of all opioids. When administered perineurally in combination with a local anesthetic, buprenorphine has been found to drastically increase the duration of analgesia at several anatomic sites, including axillary and subclavian brachial plexus blocks and infragluteal sciatic nerve blocks. With the addition of buprenorphine at doses of 0.15 - 0.3mg, there is significant prolongation of the anesthetic sensory blockade up to three times the duration of the local anesthetic alone. The use of perineural buprenorphine is well established for postoperative analgesia. Buprenorphine itself also has local anesthetic properties. Buprenorphine blocks voltage gated sodium channels and inhibits C-fiber action potentials, thereby contributing to an analgesic effect. Buprenorphine not only prolongs the duration of local anesthetic effect but also improves the analgesic properties when administered in a perineural block.
The addition of buprenorphine to a perineural local anesthetic has not been studied in a paracervical block. This study will be the first trial to assess the efficacy of buprenorphine to provide analgesia for a gynecologic procedure. This medication has the additional benefit of providing long lasting pain relief for procedures that cause continued discomfort after the end of the procedure. The investigators hypothesize that the addition of 0.15mg of buprenorphine to a lidocaine paracervical block will improve pain during osmotic dilator insertion and provide continued pain relief several hours after osmotic dilator insertion. If this intervention proves to provide better pain control than a lidocaine paracervical block alone, it would be an intervention for women during a painful clinic procedure.
A total of 114 women undergoing D&E who require cervical preparation with osmotic dilators will be randomized to one of two study groups: (1) paracervical block with 20mL of 1% buffered lidocaine or (2) paracervical block with 20mL of 1% buffered lidocaine plus 0.15mg of buprenorphine. Participants, clinicians performing the procedure, and study personnel administering questionnaires will be blinded to study assignment. Participants will rate their level of pain on an 11-point numeric rating scale (NRS) during the insertion of osmotic dilators and at several time points after insertion. The primary outcome is to compare the median pain score at the time of osmotic dilator insertion in women randomized to a 1% lidocaine and buprenorphine paracervical block compared to a 1% lidocaine paracervical block alone. Secondary outcomes are to compare the median pain score 2 hours after osmotic dilator insertion; to assess overall narcotic and ibuprofen use after osmotic dilator placement and before dilation and evacuation procedure; to assess opioid related side effects; and to determine patient satisfaction with pain control during and after osmotic dilator insertion.
Primary Hypothesis: The addition of buprenorphine 0.15mg to a paracervical block using 1% lidocaine will be associated with a lower median pain score on the NRS at time of osmotic dilator insertion compared to women who receive a lidocaine paracervical block alone.
Secondary Hypothesis: The addition of buprenorphine 0.15mg to a paracervical block using 1% lidocaine will be associated with a lower median pain score on the NRS 2 hours after osmotic dilator insertion compared to women who receive a lidocaine paracervical block alone.
Study Design
Arms and Interventions
Arm | Intervention/Treatment |
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Experimental: Buprenorphine 0.15mg + 1% lidocaine paracervical block Paracervical block with 18mL of 1% lidocaine buffered with 2 mL 8.4% sodium bicarbonate plus 0.15mg of buprenorphine |
Drug: Buprenorphine 0.15 MG
Buprenorphine 0.15mg solution will be added to a 20mL 1% buffered lidocaine solution (paracervical block) which will be administered in the paracervical space prior to osmotic dilator insertion.
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Placebo Comparator: 1% lidocaine paracervical block Paracervical block with 18 mL of 1% lidocaine buffered with 2 mL 8.4% sodium bicarbonate |
Drug: Lidocaine 1% Injectable Solution
20mL of 1% buffered lidocaine solution (paracervical block) will be administered in the paracervical space prior to osmotic dilator insertion.
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Outcome Measures
Primary Outcome Measures
- Pain score at the time of osmotic dilator insertion [Assessed immediately after last dilator inserted]
Median pain score on a 0 (no pain) to 10 (worst pain) numeric rating scale at the time of osmotic dilator insertion
Secondary Outcome Measures
- Pain score 2 hours after osmotic dilator insertion [2 hours after osmotic dilator insertion]
Median pain score on a 0 (no pain) to 10 (worst pain) numeric rating scale 2 hours after osmotic dilator insertion assessed via text message
- Pain score 1 hour after osmotic dilator insertion [1 hour after osmotic dilator insertion]
Median pain score on a 0 (no pain) to 10 (worst pain) numeric rating scale 1 hour after osmotic dilator insertion assessed via text message
- Pain score 6 hours after osmotic dilator insertion [6 hours after osmotic dilator insertion]
Median pain score on a 0 (no pain) to 10 (worst pain) numeric rating scale 6 hours after osmotic dilator insertion assessed via text message
- Amount of pain medication required after dilator insertion [Collected with each subject contact (1 hour, 2 hours, 6 hours after osmotic dilator insertion and at time of presentation for D&E)]
Assessment of overall pain medication use (narcotic and/or ibuprofen) between both group after osmotic dilator placement and before dilation and evacuation procedure. Subject report of how many tablets of medication they have taken. This will be assessed via text message.
- Frequency of opioid related side effects [Collected with each subject contact (immediately after dilator placement, 1 hour, 2 hours, 6 hours after osmotic dilator insertion and at time of presentation for D&E)]
Assessment of side effects: nausea, vomiting, dizziness, headache, sweating, feeling sleepy. This will be assessed immediately after dilator insertion and via text message at specified time points after dilator insertion.
- Patient satisfaction: Likert scale [5 minutes after dilator insertion and on the morning of D&E procedure]
To determine patient satisfaction with pain control during and after osmotic dilator insertion. This will be assessed 5 minutes after dilator insertion and on the morning of D&E procedure. Participants will be asked the following questions and rate responses on a Likert scale: How satisfied are you with the amount of pain control that you had during the procedure? Would you recommend the form of pain control you received today to a friend who was going to have this procedure? If you had to have these dilators placed for a procedure in the future, would you choose to have the same pain medication that you received during your procedure?
Eligibility Criteria
Criteria
Inclusion Criteria:
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Gestational age 14 0/7 weeks to 23 6/7 weeks at time of osmotic dilator insertion
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Require cervical preparation with placement of osmotic dilators
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At least 18 years of age
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Fluent in English or Spanish
Exclusion Criteria:
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Same day dilation and evacuation procedure
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Request for sedation during osmotic dilator insertion
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Liver disease
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Allergy to buprenorphine, lidocaine, or ibuprofen
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Narcotic or opioid medication use in the preceding 24 hours
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Use of recreational/illicit medications in the preceding 24 hours
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Currently incarcerated
Contacts and Locations
Locations
Site | City | State | Country | Postal Code | |
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1 | University of California San Diego Health | San Diego | California | United States | 92093 |
Sponsors and Collaborators
- University of California, San Diego
- Society of Family Planning
Investigators
- Principal Investigator: Nicole Economou, MD, UC San Diego Health
Study Documents (Full-Text)
None provided.More Information
Publications
- Bailard NS, Ortiz J, Flores RA. Additives to local anesthetics for peripheral nerve blocks: Evidence, limitations, and recommendations. Am J Health Syst Pharm. 2014 Mar 1;71(5):373-85. doi: 10.2146/ajhp130336. Review.
- Creinin MD, Schimmoeller NR, Matulich MC, Hou MY, Melo J, Chen MJ. Gabapentin for pain management after osmotic dilator insertion and prior to dilation and evacuation: A randomized controlled trial. Contraception. 2020 Mar;101(3):167-173. doi: 10.1016/j.contraception.2019.12.001. Epub 2020 Jan 10.
- Kosel J, Bobik P, Tomczyk M. Buprenorphine--the unique opioid adjuvant in regional anesthesia. Expert Rev Clin Pharmacol. 2016;9(3):375-83. doi: 10.1586/17512433.2016.1141047. Epub 2016 Jan 28. Review.
- Mercier RJ, Liberty A. Intrauterine lidocaine for pain control during laminaria insertion: a randomized controlled trial. Contraception. 2014 Dec;90(6):594-600. doi: 10.1016/j.contraception.2014.07.008. Epub 2014 Jul 23.
- Schivone GB, Lerma K, Montgomery C, Wright P, Conti JA, Blumenthal PD, Shaw KA. Self-administered lidocaine gel for local anesthesia prior to osmotic dilator placement: a randomized trial. Contraception. 2019 Mar;99(3):148-151. doi: 10.1016/j.contraception.2018.11.013. Epub 2018 Nov 27.
- Soon R, Tschann M, Salcedo J, Stevens K, Ahn HJ, Kaneshiro B. Paracervical Block for Laminaria Insertion Before Second-Trimester Abortion: A Randomized Controlled Trial. Obstet Gynecol. 2017 Aug;130(2):387-392. doi: 10.1097/AOG.0000000000002149.
- Swain A, Nag DS, Sahu S, Samaddar DP. Adjuvants to local anesthetics: Current understanding and future trends. World J Clin Cases. 2017 Aug 16;5(8):307-323. doi: 10.12998/wjcc.v5.i8.307.
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