ORIGINAL ARTICLE

Local Anesthesia Combined With Sedation

Compared With General Anesthesia for
Ambulatory Operative Hysteroscopy:
A Randomized Study
Lone Dragnes Brix, MHSc, RN, Theis Muncholm Thillemann, MD, PhD,
Lone Nikolajsen, MD, DMSc
Purpose: The purpose of this study was to compare two anesthetic tech-

niques for postoperative pain after ambulatory operative hysteroscopy.

Design: A randomized trial.
Methods: Women (N 5 153) scheduled for ambulatory operative

hysteroscopy were assigned to receive either paracervical local anesthesia

combined with sedation (group LA 1 S; n 5 76) or general anesthesia
(group GA; n 5 77). Primary outcome was the worst pain intensity score
in the postanesthesia care unit (PACU) rated by the patients on a
numerical rating scale.
Finding: Data from 144 patients were available for analysis (LA 1 S:
n 5 69; GA: n 5 75). There were no significant differences in worst
pain intensity between groups in the PACU (P 5 .13) or after discharge
from PACU (P 5 .40). In group LA 1 S, fewer patients received treatment
with intravenous fentanyl intraoperatively (P , .01) and time until
discharge from PACU was shorter (P , .01). More patients in group
LA 1 S experienced vomiting after discharge (P , .05).
Conclusions: Local anesthesia with sedation can be recommended as a
first choice anesthetic technique for operative ambulatory hysteroscopy.
Keywords: postoperative pain, anesthesia, ambulatory surgery, operative hysteroscopy.
2016 by American Society of PeriAnesthesia Nurses

HYSTEROSCOPY PROCEDURES SUCH as polypectomy, endometrial ablation, and myomectomy

are frequently performed in ambulatory surgery
settings,1 with many benefits for the patients and

care providers, such as a decrease in complication

rates, a short recovery time with rapid return
to work, and shorter hospital stays and thus
reduced costs.2-4

Lone Dragnes Brix, MHSc, RN, PhD student at the

Department of Anesthesiology, Horsens Regional Hospital,
Horsens, Denmark; Theis Muncholm Thillemann, MD, PhD,
Speciality registrar at the Department of Orthopedic Surgery,
Aarhus University Hospital, Aarhus, Denmark; and Lone
Nikolajsen, MD, DMSc, Research consultant at the Danish
Pain Research Centre and Department of Anesthesiology,
Aarhus University Hospital, Aarhus, Denmark.
L.D.B. has received funding from the Family Hede Nielsen
Foundation, the Gurli and Hans Engell Friis Foundation,
the Aase and Ejnar Danielsens Foundation (10-001290),
and the Health Research Fund of Central Denmark. The foun-

dations had no influence on the study design, collection, analysis or interpretation of data, or in writing the article or in the
decision to submit it for publication.
Conflicts of interest: None to report.
Address correspondence to Lone Dragnes Brix, Department
of Anesthesiology, Horsens Regional Hospital, Sundvej 30,
Horsens 8700, Denmark; e-mail address: [email protected].
2016 by American Society of PeriAnesthesia Nurses
1089-9472/$36.00
http://dx.doi.org/10.1016/j.jopan.2015.09.009

Journal of PeriAnesthesia Nursing, Vol -, No - (-), 2016: pp 1-8

Hysteroscopy is painful, and various methods for

anesthesia have been described, including paracervical local anesthetic injections combined with
sedation and general anesthesia.5-7 Effective
postoperative pain management is essential for
early discharge after ambulatory surgery.
However, there is no consensus on the choice of
anesthesia. We therefore decided to compare
two commonly used anesthetic methods:
paracervical local anesthesia combined with
sedation (LA 1 S) and general anesthesia (GA).

Materials and Methods

Patients
The study was approved by the Central Denmark Region Committees on Health Research Ethics
(M-20110023), the Danish Health and Medicines
Authority (EudraCT number: 2010-023843-13),
and the Danish Data Protection Agency. It was
registered at Clinicaltrial.gov (NCT01412632),
conducted in accordance with guidelines for Good
Clinical Practice (GCP), and monitored by the
GCP-unit at Aarhus University Hospital, Denmark.
After obtaining written informed consent, 153
patients were enrolled at the Day Surgery Unit at
Horsens Regional Hospital, Denmark. Inclusion
criteria were planned operative hysteroscopy
procedure and age $18 years. Exclusion criteria
were pregnancy, fibroids .3 3 3 cm, body mass
index $40, psychiatric illness, inability to communicate in Danish, or known allergy to remifentanil,
propofol, or prilocaine.
Randomization and Intervention
On the day of surgery, patients were randomized to
receive LA 1 S or GA by using sequentially
numbered opaque-sealed envelopes. Randomization was performed in block sizes of 20 patients,
each with a ratio of 1:1 according to a computergenerated sequence. Both groups received dexamethasone 8 mg, paracetamol 1 g, and ibuprofen
600 mg orally as premedication before anesthesia.
If ibuprofen was contraindicated, it was replaced
by tramadol 50 mg orally. According to the
standard protocol of postoperative nausea and
vomiting (PONV) prophylaxis, intraoperative
4-mg intravenous (IV) ondansetron was used for
patients with a high risk of PONV.

BRIX, THILLEMANN, AND NIKOLAJSEN

For patients in group LA 1 S, anesthesia was

induced with propofol 2.5 mg/kg/hour and remifentanil 12.5 mcg/kg/hour. When the patient
was able to sense the effect of remifentanil, infusion rates were reduced and maintained by a
continuous infusion of propofol 1.33 mg/kg/
hour and remifentanil 3 to 5 mcg/kg/hour. The
infusion rates were adjusted equal to a patient
sedation level at 3 to 4 on the Ramsay Sedation
Scale (1 to 6). Using a .4 3 35 long needle, the
gynecologist applied 3.60- to 7.2-mL Citanest
Dental Octapressin (30 mg/mL 1 .54 mcg/mL
prilocaine hydrochloride 1 felypressin; Pierrel
S.p.A., Capua, Italy) for paracervical local anesthesia. Bolus doses of 50- to 100-mcg fentanyl
IV were used for treatment of intraoperative
pain $3 on a Numerical Rating Scale (NRS;
0 5 no pain and 10 5 worst pain possible).
For patients in group GA, anesthesia was induced
with propofol 10 mg/kg/hour and remifentanil
50 mcg/kg/hour; and when the patient was able
to sense the effect of remifentanil, a bolus dose
of propofol 2 to 2.5 mg/kg was given. Hereafter,
the infusions were maintained by continuous infusion of propofol 5 mg/kg/hour and remifentanil
2.5 mcg/kg/hour. The infusion rates were adjusted
equal to a patient sedation level at 6 on Ramsay
Sedation Scale, 1 to 6. The airway was managed
with a laryngeal mask, and the lungs were ventilated with 40% to 45% oxygen in air. Bolus doses
of 50- to 100-mcg fentanyl IV were used for
intraoperative pain, guided by increases in pulse
and blood pressure and/or motor unrest during
anesthesia. In both groups, remifentanil and propofol infusions were discontinued 4 to 5 minutes
before the end of surgery. Surgery was performed
by experienced gynecologists specialized in hysteroscopic procedures and trained in paracervical
local anesthesia.
The same team of anesthesia providers and nurses
in the PACU took care of and treated the two
groups according to standard protocols regarding
pain and PONV/postdischarge nausea and vomiting (PDNV).
Care and Treatment
In the PACU, intensity of pain (NRS, 0-10) and
nausea and vomiting (yes/no) were assessed at
arrival, and every 15 minutes, or with shorter

LOCAL ANESTHESIA COMBINED WITH SEDATION

intervals if any changes in the intensity of pain,

nausea, and/or vomiting occurred. Pain in the
PACU (NRS $ 3) was treated with bolus doses of
25- to 50-mcg fentanyl IV with a maximum of
300 mcg in the PACU. PONV in the PACU was
treated with 4-mg ondansetron IV, .625-mg dehydrobenzperidol (droperidol) IV, and 10-mg metoclopramide IV. Shivering in the PACU was treated
with 20-mg pethidine IV.
Oral postoperative analgesic treatment was started
before discharge from the PACU and consisted of
paracetamol (acetaminophen) 1 g orally every
6 hours up to 4 g daily and ibuprofen 600 mg orally,
up to 1,800 mg daily as rescue medication. If
ibuprofen was contraindicated, it was replaced
by oral tramadol 50 mg, up to 200 mg daily.
Patients were discharged directly from the PACU
and were provided these oral analgesics to use at
home.
Data Collection and Outcome Measures
Baseline patient characteristics were collected
from medical records. The primary outcome measure was the worst pain intensity score in the
PACU rated by the patients on the NRS (0-10)
from arrival to the PACU until discharge. Secondary outcome measures were use of intraoperative
fentanyl (no/yes), use of analgesic and antiemetic
medication in the PACU (no/yes), PONV (no/yes),
time until discharge from PACU (minutes), recalled
worst pain after discharge (NRS, 0-10), and
recalled PDNV (no/yes).
Before discharge, all patients were supplied with a
questionnaire including questions regarding pain
and side effects during the 2 weeks after surgery.
The questionnaire was a log for the investigator
to document the patients verbal response when
they were contacted by phone 2 weeks after surgery and asked to recall the worst pain after
discharge from PACU and PDNV.
Statistical Analysis
The sample size calculation was based on an
expected difference of 1 on the NRS with 80% power (a 5 .05, b 5 .2). A sample size of 47 per
group was required, ie, a total of 94 patients. Based
on an expected response rate of 65% after 2 weeks,
it was decided to include at least 150 patients.

Normality of data was tested without pointing toward normal distribution. Therefore, nonparametric testing was performed. Fisher exact test
was used for dichotomous covariates and the
Wilcoxon rank sum test for continuous covariates.
Results are presented as frequencies or medians
with range as appropriate. All P values are two
sided, and those below .05 were considered significant. Intention-to-treat analysis was performed.
EpiData, version 3.1 (Epidata Association, Odense,
Denmark), was used for double entry, and statistical analysis was performed with Stata software,
version 12.0 (StataCorp, TX).

Results
A total of 364 women were assessed for eligibility
from November 2011 through June 2013; 22 were
excluded based on the exclusion criteria, 157
declined to participate (72 preferred LA 1 S, 50
preferred GA, 35 declined to participate for other
reasons), and 32 were excluded because of logistic
reasons. One hundred fifty-three patients were
randomized: 76 to the LA 1 S group and 77 to
the GA group (Figure 1). Baseline characteristics
including age, height, weight, body mass index,
smoking status, surgical procedure, and duration
of surgery were comparable between groups
(Table 1).
There was no significant difference in worst pain
intensity between group LA 1 S and group GA in
the PACU (1.5 [0 to 8] vs 2.2 [0 to 9], P 5 .13, median [Range]; Figure 2A). Intraoperatively, fewer
patients in the LA 1 S group received treatment
with fentanyl IV (14 vs 62; P , .01; Table 2). In
the PACU, there was no statistical difference between group LA 1 S and group GA in the number
of patients treated with fentanyl IV (6 vs 13;
P 5 .13; Table 2). There was no significant difference in the number of patients who experienced
nausea in the PACU between group LA 1 S and
group GA (4 vs 4; P 5 .90) or the number of
patients who received ondansetron IV (4 vs 4;
P 5 .90). In group LA 1 S, fewer patients received
PONV prophylaxis (5 vs 31; P , .01). None of the
patients vomited during hospitalization (Table 3).
Time in the PACU (63 [15 to 210] vs 81 [15 to
200] minutes, P , .01, median [range]) and time
from start of surgery until discharge (99 [40 to
305] vs 121 [60 to 265] minutes, P , .01) were
significantly shorter in group LA 1 S group.

BRIX, THILLEMANN, AND NIKOLAJSEN

Analyzed

Analyzed

Figure 1. CONSORT study flow diagram. BMI, body mass index; CONSORT, CONsolidated Standards of Reporting
Trials; GA, general anesthesia; LA 1 S, local anesthesia combined with sedation.

Two weeks after discharge from PACU, there was

no significant difference in recalled worst pain
intensity between group LA 1 S and group GA
(1.5 [0 to 8] vs 1.5 [0 to 8], P 5 .40, median
[Range]; Figure 2B). A total of 12 patients, five
in the LA 1 S and seven in group GA, recalled
having suffered from nausea (P 5 .46) and four
patients, all belonging to group LA 1 S, recalled
having vomited after discharge (P 5 .05;
Table 3).

Discussion
In this study of ambulatory operative hysteroscopy
procedures, LA 1 S did not significantly decrease
patients worst pain intensity in the PACU. However, the number of patients treated with IV fentanyl
intraoperatively and time from start of surgery until discharge from PACU were significantly reduced
in group LA 1 S. More patients in group LA 1 S
vomited after discharge.

LOCAL ANESTHESIA COMBINED WITH SEDATION

Table 1. Baseline Demographic and Clinical Characteristics of Study Participants

Baseline Characteristics
Age (y)
Height (m)
Weight (kg)
BMI (kg/m2)

LA 1 S (n 5 69)

GA (n 5 75)

P value

47
[29 to 78]
1.67
[153 to 185]
71 kg
[48 to 100]
25.2
[18.6 to 37.2]

45
[27 to 67]
1.68
[150 to 187]
73 kg
[50 to 111]
24.6
[19.2 to 38.1]

.05

53/16/0

63/10/2

.14

33
2
22
12

46
2
19
8

.06

35
[15 to 95]

37.5
[20 to 80]

.07

Smoking status (no/yes/missing)

Surgical procedure
Endometrial ablation
Myomectomy
Polymectomy
Combined operations
Duration of surgery (min)

.28
.97
.93

BMI, body mass index; GA, general anesthesia; LA 1 S, local anesthesia combined with sedation; PACU, postanesthetic care unit.
Patient characteristics in the interventions group (LA 1 S) and in the control group (GA).
Median [range].

be judged as having received either LA 1 S or GA

just by observation on arrival in the PACU. Finally,
most patients knew how they were anesthetized.

Some methodological issues must be considered.

First is the lack of blinding. Attempts to blind the
study would have failed for several reasons. In
the operating room, blinding was obviously not
possible and in the PACU, the organization of the
unit, with the nursing staff working in both the
operating room and in the PACU made blinding
impossible. In addition, almost every patient could

40
30
0

10

20

Number of patients

30
20
10

Number of patients

40

Second, the lack of difference can be attributed to

low pain intensity score in both groups. In the present study, both groups received propofol, which
is associated with significantly less postoperative

LA+S

10

10

NRS, 0-10

NRS, 0-10

GA

LA+S

GA

Figure 2. A1B: Maximum pain intensity in the PACU (A) and after discharge (B) The maximum pain intensity
scores in the PACU (A) and after discharge (B) after ambulatory operative hysteroscopy. GA, general anesthesia;
LA 1 S, local anesthesia combined with sedation; NRS 0-10, Numerical Rating Scale from 0 5 no pain to
10 5 worst pain possible; PACU 5 postanesthesia care unit.

BRIX, THILLEMANN, AND NIKOLAJSEN

Table 2. Number of Patients Who Received Fentanyl Intraoperatively and in the PACU
Analgesic medication

LA 1 S (n 5 69)

GA (n 5 75)

P Value

55/14
63/6

13/62
62/13

, .01
.13

Fentanyl IV intraoperatively (no/yes)

Fentanyl IV in PACU (no/yes)

GA, general anesthesia; IV, intravenous; LA 1 S, local anesthesia with sedation; PACU, postanesthetic care unit.
Bold indicates significant level was set at P , 0.05.

pain. Combined with a short duration of surgery,

this may have contributed to the low pain intensity.8-12 A presumably large proportion of
patients declined to participate because they had
strong preferences regarding either general
anesthesia or local anesthesia combined with
sedation. Being given a choice of anesthetic
induction method can reduce anxiety,13 and the
enrolled patients may therefore have a higher level
of anxiety and pain intensity than all patients
eligible for the study. The most anxious patients
may have chosen not to participate in the study.
However, the low pain score is in accordance
with other studies which found that gynecological
patients have fewer postoperative symptoms,
including postoperative pain, than orthopaedic
and general surgery patients.14-16
Third, patients were interviewed by telephone
2 weeks after surgery regarding the worst pain intensity after discharge. The pain intensity score
after discharge may be influenced by recall bias,
due to the fact that patients were asked to recall
the worst pain after discharge from PACU on the
NRS.

Compared with previous studies, we found that

patients in both groups had a lower incidence of
nausea in the PACU12,17 and after discharge.18
The lower incidence of nausea in the PACU
is, however, similar to recent findings showing
that patients who were anesthetized with
remifentanil-propofol had less postoperative nausea
than patients anesthetized with remifentanil only.19
A previous study found as many as 36% of patients
who experienced PDNV did not experience
nausea and vomiting before discharge from hospital.17 In the present study, only patients in group
LA 1 S vomited after discharge. This could be
attributed to the lower number of patients in the
LA 1 S group who received PONV prophylaxis
because of a lower risk of PONV. PDNV is considered to be a growing concern, and suitable strategies should be planned for patients after discharge
because patients often do not have access to
antiemetic
treatment
after
discharge.11,17
Preventing PDNV is important because it may
delay the resumption of normal activities,
readiness for work, and have a negative impact
on the patients experience and recovery.9,12

Table 3. Number of Patients Who Experienced PONV, PDNV, and Received Antiemetic Treatment
PONV
Ondansetron (no/yes) intraop
Nausea (no/yes)
Vomiting (no/yes)
Ondansetron (no/yes) PACU
DHB (no/yes)
PDNV
Nausea (no/yes)
Vomiting (no/yes)

LA 1 S (n 5 69)

GA (n 5 75)

P Value

64/5
66/4
69/0
65/4
70/0

44/31
71/4
75/0
71/4
74/1

, .01
.90

.90
.52

LA 1 S (n 5 62)

GA (n 5 69)

57/5
58/4

62/7
69/0

.46
, .05

GA, general anesthesia; DHB, dehydrobenzperidol; LA 1 S, local anesthesia combined with sedation; PACU, postanesthesia care unit; PDNV, postdischarge nausea and vomiting; PONV, postoperative nausea and vomiting.
The number of patients who experienced PONV, PDNV, and received antiemetic treatment.

LOCAL ANESTHESIA COMBINED WITH SEDATION

As in the present study, another Danish study

found a significantly reduced time from surgery
until discharge in patients who were anesthetized
with paracervical local anesthesia with sedation
compared to patients who were anesthetized
with general anesthesia for ambulatory operative
hysteroscopy.19
Although some methodological issues exist, as
described, the present study is distinguished by
successful randomization and adherence to the
principles of GCP. No serious side effects were
observed. We find external validity to be strengthened by the fact that the study was carried out in a
daily clinical setting with the anesthesia protocols
and discharge criteria reflecting daily practice.
Overall, the findings of the study can be generalized to women having operative hysteroscopy procedures in an ambulatory surgery setting.
Recommendations for future studies include having a smaller team of specially trained providers
who are responsible for data collection and a
data collection instrument using a series of
possible responses instead of dichotomous
answers. Further studies should also monitor

patients more closely during the follow-up period

and preoperative pain, psychological factors, and
time before resumptions of normal activities after
discharge need to be taken into account.

Conclusion
In summary, no statistically significant difference
between the groups was evident for postoperative
pain. However, local anesthesia combined with
sedation with remifentanil and propofol could be
recommended as the first choice of anesthetic
technique for patients undergoing ambulatory
operative hysteroscopy because of the decreased
number of patients treated with IV fentanyl intraoperatively and the reduced time from start of
surgery until discharge from PACU. Increased
emphasis on PDNV prophylaxis must be considered for these patients.

Acknowledgments
The authors would like to thank the patients who participated
in this study, the staff at the Department of Gynecology and
Obstetrics and the Department of Anesthesiology at Horsens
Regional Hospital.

References
1. Nathani F, Clark TJ. Uterine polypectomy in the management of abnormal uterine bleeding: A systematic review.
J Minim Invasive Gynecol. 2006;13:260-268.
2. Fothergill RE. Endometrial ablation in the office setting.
Obstet Gynecol Clin North Am. 2008;35:317-330. x.
3. Kremer C, Duffy S, Moroney M. Patient satisfaction with
outpatient hysteroscopy versus day case hysteroscopy: Randomised controlled trial. BMJ. 2000;320:279-282.
4. OFlynn H, Murphy LL, Ahmad G, Watson AJ. Pain relief in outpatient hysteroscopy: A survey of current UK
clinical practice. Eur J Obstet Gynecol Reprod Biol.
2011;154:9-15.
5. Cooper NA, Khan KS, Clark TJ. Local anaesthesia for pain
control during outpatient hysteroscopy: Systematic review and
meta-analysis. BMJ. 2010;340:c1130.
6. Goulson DT. Anesthesia for outpatient gynecologic surgery. Curr Opin Anaesthesiol. 2007;20:195-200.
7. Wallage S, Cooper KG, Graham WJ, Parkin DE. A randomised trial comparing local versus general anaesthesia for
microwave endometrial ablation. BJOG. 2003;110:799-807.
8. Eger EI, White PF, Bogetz MS. Clinical and economic
factors important to anaesthetic choice for day-case surgery.
Pharmacoeconomics. 2000;17:245-262.
9. Kumar G, Stendall C, Mistry R, Gurusamy K, Walker D.
A comparison of total intravenous anaesthesia using propofol
with sevoflurane or desflurane in ambulatory surgery:

systematic review and meta-analysis. Anaesthesia. 2014;69:

1138-1150.
10. Li M, Mei W, Wang P, et al. Propofol reduces early postoperative pain after gynecological laparoscopy. Acta Anaesthesiol Scand. 2012;56:368-375.
11. Gan TJ. Consensus guidelines for the management of
postoperative nausea and vomiting. Anesth Analg. 2014;118:
85-113.
12. Awad IT, Chung F. Factors affecting recovery and
discharge following ambulatory surgery. Can J Anaesth. 2006;
53:858-872.
13. Mitchell M. Influence of gender and anaesthesia type on
day surgery anxiety. J Adv Nurs. 2012;68:1014-1025.
14. Brattwall M. Patient assessed health profile: A six-month
quality of life questionnaire survey after day surgery. Scand
J Public Health. 2010;38:574-579.
15. Berg K, Kjellgren K, Unosson M, Arestedt K. Postoperative recovery and its association with health-related
quality of life among day surgery patients. BMC Nurs.
2012;11:24.
16. Chung F, Ritchie E, Su J. Postoperative pain in ambulatory
surgery. Anesth Analg. 1997;85:808-816.
17. Wu CL, Berenholtz SM, Pronovost PJ, Fleisher LA.
Systematic review and analysis of postdischarge symptoms
after outpatient surgery. Anesthesiology. 2002;96:
994-1003.

18. Gupta A, Wu CL, Elkassabany N, Krug CE, Parker SD,

Fleisher LA. Does the routine prophylactic use of antiemetics
affect the incidence of postdischarge nausea and vomiting
following ambulatory surgery?: A systematic review of randomized controlled trials. Anesthesiology. 2003;99:488-495.

BRIX, THILLEMANN, AND NIKOLAJSEN

19. Majholm B, Bartholdy J, Clausen HV, Virkus RA,
Engbaek J, Moller AM. Comparison between local anaesthesia
with remifentanil and total intravenous anaesthesia for operative hysteroscopic procedures in day surgery. Br J Anaesth.
2012;108:245-253.