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.