When should diclofenac be given in ambulatory surgery: preoperatively or postoperatively?

STUDY OBJECTIVE: To determine the optimum time of administration of diclofenac in patients undergoing ambulatory knee arthroscopy: either preoperatively or postoperatively. DESIGN: Randomized, double-blind study. SETTING: Ambulatory surgical unit in a tertiary referral hospital. PATIENTS: 127 ASA physical status I and II patients undergoing ambulatory knee arthroscopy. INTERVENTIONS: Patients were randomized into three groups. The Preop group received 50 mg of potassium diclofenac orally 1 hour preoperatively and a placebo 30 minutes postoperatively. The Pre+postop group received 25 mg of potassium diclofenac 1 hour preoperatively and 25 mg diclofenac 30 minutes postoperatively. The Postop group received a placebo 1 hour before surgery and 50 mg of potassium diclofenac 30 minutes postoperatively. MEASUREMENTS AND MAIN RESULTS: The Postop group received a placebo 1 hour preoperatively and 50 mg of potassium diclofenac 30 min postoperatively. Postoperatively, patients used intravenous patient-controlled analgesia (PCA) with fentanyl. Total fentanyl consumption was recorded. During the recovery period, pain was assessed using a visual analog scale (VAS) at 30-minute intervals. Pain was assessed in both legs at rest, on flexion, and extension of the knee. There were no significant differences in pain scores either at rest or on movement of the operative knee among the Preop, Pre+postop, and Postop groups. The consumption of fentanyl via PCA showed no significant differences among the groups. CONCLUSIONS: There is no difference in pain relief whether diclofenac is given preoperatively or postoperatively in patients undergoing unilateral ambulatory knee arthroscopy. Preoperative and postoperative treatment with diclofenac potassium is equally effective.

Neuroleptanesthesia: current status.

PURPOSE: To review the current status and possible future of neuroleptanalgesia/anesthesia, techniques that may be nearly extinct. SOURCE: Articles from 1966 to present were obtained from the Current Science and Medline databases. Search terms include neurolepananalgesia/anesthesia, conscious sedation, droperidol, benzodiazepines, propofol, ketamine, and opioids. Information and abstracts obtained from meetings on this topic helped complete the collection of information. PRINCIPAL FINDINGS: Droperidol/fentanyl may still be clinically indicated in the management of surgical seizure therapy for electrocorticography. However, the high incidence of post-operative sedation and restlessness discourage its use for other surgical or diagnostic procedures. Many surgical interventions, once thought ideally suited for neuroleptic agents, now meet better success with newer medications. The use of midazolam and/or propofol, in association with newer opioids, provides ideal anesthetic combinations. CONCLUSION: The advantages of newer anesthetic agents have redefined the clinical indications for neuroleptanesthesia. In routine modern anesthesia, anxiolysis, sedation, and/or analgesia is better provided, with quicker recovery, by the new pharmacokinetic and pharmacodynamic characteristics of recent medications than by the neuroleptic component of neuroleptanesthesia.

Postoperative symptoms 24 hours after ambulatory anaesthesia.

PURPOSE: To test the hypothesis that the type of surgical procedure influences the incidence of postoperative symptoms. Also the effect of demographic and clinical risk variables: age, sex, ASA status, duration of anaesthesia on the postoperative symptoms were evaluated for each type of surgery. METHODS: Demographic, medical, anaesthetic and surgical data on 1,017 patients were prospectively collected by a research assistant who telephoned each patient 24 hr after discharge to administer a questionnaire to determine postoperative symptoms. Postoperative symptoms included incisional pain, nausea/vomiting, drowsiness, dizziness, headache and fever. In addition, 270 patients were asked the % (0-100) of their return to daily living function at 24 hr. RESULTS: Incisional pain (26.9%), headache (11.6%), and drowsiness (11.5%) were the most frequently reported symptoms. Dizziness was reported by 9.7% and nausea/vomiting by 7.1%. Approximately 50% of patients undergoing laparoscopy, orthopaedic and general surgery reported 24-hr postoperative incisional pain. The incidence of 24-hr postoperative nausea/vomiting was highest after general 17.4%, orthopaedic, 11.2%, and laparoscopic surgery, 9.4%. Drowsiness was highest after laparoscopy 36.1%, followed by general surgery, 21.4%. Dizziness was most frequent after laparoscopy, 24.1%, followed by general surgery, 16.1%. After laparoscopy, postoperative drowsiness or dizziness was related to anaesthesia duration. After general surgery, postoperative dizziness or drowsiness were related to age; the younger the patient, the more likely the symptoms. CONCLUSIONS: Postoperative pain, nausea/vomiting, drowsiness, dizziness, and headache were the more frequent postoperative symptoms 24 hr after ambulatory surgery and they were influenced by the type of surgical procedure. In addition, the type of surgery and the 24-hr postoperative symptoms determined the degree of return to daily living function.