To the Editor:
A recent article on how to improve postoperative pain management states that an epidural is “clearly not appropriate for open hysterectomy.”1This statement seemed unusual to us, especially considering that one of the authors has previously published articles promoting the benefits of neuraxial block for hysterectomy.2–7On the basis of some of these prior studies, a low thoracic epidural together with a propofol infusion seems appropriate for the patient who is anxious about vomiting or those who cannot tolerate “pain medicines.” Table 1 in this recent article1recommends local anesthetic wound infusion for this procedure, but that fails to address opioid use during the procedure.
Hysterectomy is not a single entity. Some hysterectomies can entail lymph node dissections that involve midline incisions above the umbilicus, while others involve very small Pfannenstiel incisions. Likewise, epidural anesthesia is not a single entity. The catheter can be placed in the lumbar or thoracic interspaces, and the drugs and drug combinations are numerous. Indeed, the cited Web site*quotes several unconventional techniques (epidural clonidine, ketamine, neostigmine, lumbar catheters) to support the claim that epidural anesthesia “is not recommended for hysterectomy due to low benefit:risk ratio.” The issue of how to administer the anesthetic should not be decided by referring to a table or a Web site that refers to unusual techniques and then lumping a vast spectrum of operations under a single category designated “hysterectomy.”
The article also states that epidural anesthesia is “clearly not appropriate for nephrectomy.”1There is no reference for this statement, and the cited Web site has no information on nephrectomy. One might think that some modalities of anesthetic management, such as epidural anesthesia, might be “transferable” into “nephrectomy” from other procedures, similar to what is suggested for the use of gabapentanoids.
We do not “give an anesthetic for a nephrectomy.” Rather we “give an anesthetic to a patient who is having a nephrectomy.” This patient almost always has unique fears and apprehensions that often relate to pain on emergence and/or nausea and vomiting.8–11If, for example, a patient states that they are intolerant of “pain medicines, like Vicodin® or morphine” because of unpleasant side effects, such as nausea and vomiting or mental status changes, then it would seem appropriate to suggest that the anesthetic could be conducted without these drugs by using an epidural and an infusion of a drug that has antiemetic properties. Another patient scheduled for nephrectomy might fear the experience of severe pain upon awakening from anesthesia. An epidural titrated to cover the surgical wound site12would essentially guarantee a pain-free emergence that could be accomplished without the (use of and) side effects of opioids. Of course, the patient might also not want to have “a needle in their back”; ideally, all of these issues relating to anesthesia would be thoroughly discussed with the patient during the preoperative interview.
The idea of procedure-based pain therapy (PROSPECT) is reasonable, but the procedure itself may not always be the main factor in deciding how to administer the anesthetic or how to provide for postoperative pain therapy. Other important factors are the skills of the anesthesia provider, the concerns of the patient, and the experience and cooperation of nursing and surgical colleagues.
†University of California, San Francisco, San Francisco, California. firstname.lastname@example.org