Hemodynamic Stability of Bupivacaine With and Without Adrenaline for Paracervical Block for Cervical Conization
Hemodynamic Stability of Bupivacaine With and Without Adrenaline for Paracervical Block for Cervical Conization
Cervical conization is done for pre-cancer disease. The procedure is performed with local
 anesthesia and general anesthesia. Local anesthesia is given by paracervical block, and
 several different local anesthetics is being used including bupivacaine with and without
 adrenaline. Adrenaline might reduce local bleeding and reduce toxicity of bupivacaine by
 reducing absorption, but might affect cardiovascular function. This study will examine this
 effect.
Most patients scheduled for cervical conization are healthy, young women. Some do this
 procedure with local anesthesia (paracervical block) and sedation, others general anesthesia
 combined with local anesthesia. Lidocaine with adrenaline is often used, but some uses longer
 acting substances like bupivacaine 2,5 mg/ml with adrenaline 5 microg/ml.

 Adding of adrenaline prolongs the effect of anesthesia and the effect is probably strongest
 for short-acting local anesthetics. Adrenaline may delay absorption of local anesthetics
 avoiding toxic plasma concentrations and reduce local bleeding. Injection of local
 anesthetics with adrenaline may affect haemodynamic stability.

 Para-cervical block has been used for analgesia in first stage of labor, but may give foetal
 bradycardia in 3-4 % and may affect the cardiotocogram in 10-12%. This effect is observed
 with bupivacaine and the less toxic levobupivacaine. Because of fear for complications and
 foetal injury this block has been replaced by more effective and safer methods like epidural
 and spinal anesthesia.

 In gynecological practice the para-cervical block is still used for termination of pregnancy,
 cervical conization and for instrumentation of uterus.

 We have observed affection of hemodynamic stability when using local anesthetics with
 adrenaline in nasal mucosa and during cervical conization. Some patients may experience
 increase or decrease in blood pressure and heart rate with a duration of 3-5 minutes.

 Kerkkamp and coworkers have observed an 64% increase in cardiac output when using bupivacaine
 with adrenaline 100 microg epidurally but de Leeuw et al find an effect of less than 10%
 change in cardiac output during combined psoas compartment and ischiadic-block. We have
 performed a non-randomized, non-blinded pilot-study showing a 86% increase in systolic blood
 pressure and 65% increase in cardiac output after para-cervical block with bupivacaine 50 mg
 and adrenaline 100 microg. We want to confirm these results by doing a randomized, blinded
 study.

 Most day-surgical patients are classified as ASA (American Society of Anesthesiologists)
 grade 1-2, and the complication rates are low. Still we may experience cardiovascular events
 during anesthesia with patients considered without cardiovascular diseases. Hemodynamic
 stability during anesthesia is a goal for all patients.

 LiDCOplus (Lithium Dilution Cardiac Output) is a minimal invasive hemodynamic monitor for
 measuring cardiac output (CO) and systemic resistance (SVR). It uses two algorithms. PulseCO
 is an analysis of artery-waveform and gives nominal values. LiDCO is calibration with a small
 dose Lithium and gives absolute values. This study will examine relative changes, and
 calibration is not necessary.

 The primary endpoints with respect to the hemodynamic effects of the interventions are group
 differences in systolic blood pressure and cardiac output the first 0-10 minutes after
 intervention. Secondary endpoints are other hemodynamic variables as stroke volume (SV),
 heart rate (HR), and systemic vascular resistance (SVR).

 Demographic data and baseline measurements will be presented as mean (SD) if normally
 distributed or as median and range if not normally distributed, and group differences will be
 tested using the one-way ANOVA or Kruskal-Wallis tests, respectively. Baseline hemodynamic
 values represent measurements collected before administration of local anesthesia.
Inclusion Criteria:

 • Clinical diagnosis of cervical pre-cancer

 Exclusion Criteria:

 -  Pregnancy

 -  Feeding mother

 -  Bad nutritional state

 -  Infection

 -  Treatment for hypertension

 -  Diabetes for many years or complications

 -  Cardiovascular disease

 -  Serious anemia

 -  Cardial arrythmia

 -  Serious liver-disease

 -  Hypersensitivity to local anesthesia of amide-type