No analgesia given in most circumcisions

OB/GYN News, Nov 15, 2004 by Sherry Boschert

SAN FRANCISCO -- Fewer than half of 1,814 infants undergoing circumcision received analgesia despite recommendations for its use during circumcision by the American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, and the American Society of Anesthesiologists, a retrospective study has found.

"The results of several studies have clearly demonstrated that newborns who are circumcised without analgesia experience pain and physiologic stress" that can be prevented with analgesia, Praveen Kumar, M.D., said in a poster presentation at the annual meeting of the American Academy of Pediatrics.

Obstetricians performed all of the circumcisions studied at Northwestern Memorial Hospital and Children's Memorial Hospital, Chicago. Previous studies by other investigators suggest that obstetricians in general are less likely to use analgesia during circumcision, compared with pediatricians or family physicians, said Dr. Kumar, director of the newborn nursery at Northwestern.

Joint steps taken in 2001 by the medical center's departments of pediatrics and obstetrics and gynecology to improve physician awareness of analgesia options during circumcision have proved inadequate, he noted.

A review in August 2003 of documentation by physicians in the charts of 400 infants who underwent circumcision found that only 8 received analgesia--7 got penile nerve blocks and 1 got a subcutaneous ring block.

Thinking that this might reflect poor documentation by physicians rather than a lack of analgesia, Dr. Kumar reviewed 1,814 circumcisions performed between March 1 and Aug. 30, 2004. He analyzed nursing notes and the pharmacy's database for evidence that lidocaine or EMLA were ordered or used. The pharmacy dispensed lidocaine for 40% of circumcisions and EMLA for 4%. The nursing notes documented lidocaine use in 29% of circumcisions.

Even if all the lidocaine and EMLA had been used, "more than half of the patients did not get analgesia, which is not good," he said.