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Anesthesia Alert: IV Ibuprofen Before Surgery Speeds Recovery
Study: It pays to modulate the body's stress response to surgery.
Vanny Le
Publish Date: May 13, 2015   |  Tags:   Pain Management
medication TIMING IS EVERYTHING The best time to give patients IV ibuprofen is before surgery, not after.

A dministering IV ibuprofen (Caldolor) before surgery can pay for itself many times over — hastening recovery, increasing patient satisfaction, and reducing pain and the need for opioids. Pre-op administration of the NSAID may even improve the way patients bounce back cognitively.

Preempting post-op pain
Those were among our findings in a recent study at the Rutgers University New Jersey School of Medicine. Using a diverse population of 55 patients undergoing laparoscopic cholecystectomies at 3 tertiary academic hospitals, we demonstrated the benefit of administering anti-inflammatories before surgery instead of waiting until after, when the body's stress response to surgery has already kicked in. We suspect other anti-inflammatories and analgesics may have the same positive effect. In fact, our team plans to look at ketorolac and acetaminophen in the days ahead.

In the randomized, double-blind ibuprofen study, "Preoperative Administration of IV Ibuprofen Improves Quality of Recovery After Laparoscopic Cholecystectomy" (osmag.net/SQW6pu), we gave 28 patients 800 mg of ibuprofen and 27 patients a placebo-saline before they were induced with general anesthesia. To compare responses, we used the 40-item Quality of Recovery questionnaire, a 9-item Modified Fatigue Severity Scale and a 15-item Geriatric Depression Scale, each of which we assessed 4 times — before surgery, in the PACU, 1 day after surgery and 3 days after surgery.

Among other findings, the patients given ibuprofen fared significantly better in just about every way and at every step along the way. They had less pain, they were more upbeat, they slept better and they were able to get back to normal activities faster. Additionally, while the placebo group showed a spike in fatigue immediately after surgery, the ibuprofen group had no change in fatigue. The only area in which the ibuprofen group didn't show a benefit involved the ability to communicate with staff and to follow instructions. Here, there was no difference between the groups.

By measuring immune responses and production of cytokines, we were able to show how the benefits are accrued. For example, ibuprofen suppressed the body's production of interleukin 10, an anti-inflammatory cytokine. In short, the hormonal responses to inflammation were mitigated, which kept patients on a more even keel and a shorter path to recovery.

Though the results of a Digits Span Forward and Backward test were less striking, the ibuprofen group also appeared to have slightly better cognitive function after surgery. That is, they were better able to recite a sequence of numbers backwards. (There was no difference in the ability to recite the sequence forward.)

Tamping down the stress response
The stress response to surgery is characterized by activation of the sympathetic nervous system, increased secretion of pituitary hormones, as well as the inflammatory response. This combined effect may lead to a number of post-op complications as well as diminished quality of recovery. Anti-inflammatory agents may decrease the activation of the stress response. We hypothesized that IV ibuprofen would improve recovery characteristics.

It's reasonable to assume that any drug that affects perioperative inflammation is beneficial — especially if we believe that most adverse post-op outcomes are related to inflammation. While a stress response to surgery is important — it's how people recover — we also know that extreme abnormal responses can lead to multi-organ breakdown and even death. What our team is trying to do is see if there are ways to help the body recover normally without going into that overdrive stress response — to simply wake up and be better the next day, or even within a couple of hours.

Ultimately, we expect to see patients spending less time in recovery, using fewer opioids because they have less pain, going home more satisfied, needing less medication after they're home and experiencing fewer post-operative complications.

Anesthesia Notebook

  • MHAUS recommends core temperature monitoring. The Malignant Hyperthermia Association of the United States (MHAUS) recommends that you monitor core temperatures for all patients under general anesthesia for more than 30 minutes. Appropriate monitoring sites, they say, are the esophagus, nasopharynx, tympanic membrane (with the probe in contact with the membrane), bladder and pulmonary artery. Citing a 2014 study (osmag.net/dv6KUD), MHAUS says the risk of death from an MH event was significantly higher with patients for whom a skin temperature probe was used than it was for patients whose core temperatures were monitored.
  • Is your anesthesia team underperforming? Does your anesthesia team provid exceptional clinical services to patients, but fail to achieve satisfaction among physicians, nurses, or patients, or prove unable to meet your facilities' financial goals? Download "Five Warning Signs of an Underperforming Anesthesia Team" (osmag.net/S2kyZY) from Somnia Anesthesia, a national anesthesia practice management company.
  • Post-op cognition in elderly. Can 8 mg of IV dexamethasone dramatically decrease the incidence of post-operative cognitive dysfunction (POCD) in older patients undergoing anesthesia? The answer appears to be yes. Researchers in Brazil studied 170 patients between the ages of 60 and 87 and found that those given the steroid before undergoing both deep and superficial anesthesia were much less likely to display POCD at various time intervals that followed. On the third day after surgery, when the initial testing was done, 68.2% of those in the group who'd had deep anesthesia and 27.2% of those in the group who'd had superficial anesthesia showed cognitive dysfunction. Among those given dexamethasone, the corresponding numbers were 25.2% and 15.3%. Patients were also tested on Days 7, 21, 90 and 180 after surgery and in all cases, POCD was significantly higher in the control groups.
  • California may recognize anesthesiologist assistants. Legislation recently introduced in California would make it the 18th state to recognize "anesthesiologist assistants" — certified secondary providers who would be allowed to perform certain support functions as well as assist in the development and implementation of anesthesia care plans for patients. Under the proposal, supervising anesthesiologists would still have to be "physically present" and "available to the assistant when medical services are being rendered" and would have to both oversee and accept responsibility for all services being rendered by the assistant.
  • Pacira blocked on Exparel. Pacira Pharmaceuticals continues to bump up against a wall in its efforts to have its long-acting analgesic, Exparel, approved as a nerve block. The FDA recently rejected the drug maker's application, forcing the company back to the lab again. Exparel, which has garnered favorable reviews as a surgical-site analgesic in hernia surgery and other cases, uses a time-release system to deliver bupivacaine for up to 3 days. In clinical trials, it's also shown promise as a femoral nerve block, but fallen short as an intercostal block. Pacira, which vows to press forward, has had an up-and-down history with Exparel. It was issued a warning letter by the FDA in 2014, accusing it of both overstating the drug's efficacy and of promoting indications for which it lacked FDA approval, including knee arthroplasty, lumbar fusion and gastric sleeve procedures. In response, Pacira claimed that its labeling supported the claims being challenged and that it would work with the FDA to resolve the issues.

— Jim Burger

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