Alejandro Recart

The efficacy of celecoxib premedication on postoperative pain and recovery times after ambulatory surgery: A dose-ranging study

Recently, the Food and Drug Administration increased the celecoxib dosage recommendation from 200 mg to 400 mg for acute pain management. No studies have directly compared the analgesic efficacy of different doses of celecoxib for the prevention of postoperative pain. In this prospective, double-blinded, placebo-controlled study, we compared oral celecoxib 200 mg to 400 mg when administered for premedication of outpatients undergoing minor ear-nose-throat surgery. A total of 93 healthy outpatients were assigned to 1 of 3 study groups: control (placebo; n = 30), celecoxib 200 mg (n = 30), or celecoxib 400 mg (n = 33). The study drug was given orally 30–45 min before surgery, and all patients received a standardized general anesthetic technique. During the postoperative period, pain scores (0–10), recovery times, the need for rescue analgesics, quality of recovery (0–100), patient satisfaction with pain management (0–100), and side effects were recorded. Pain was assessed at 30-min intervals using a verbal rating scale, with 0 = no pain to 10 = worst pain imaginable, in the postanesthesia care unit and day surgery unit recovery areas and at 24 h after surgery. Celecoxib 400 mg was significantly more effective than 200 mg (and placebo) in reducing postoperative pain. Both celecoxib 200 mg and 400 mg were more effective than placebo in reducing the postoperative fentanyl requirement (74 ± 67 &mgr;g and 56 ± 62 &mgr;g versus 120 ± 86 &mgr;g, respectively). The larger dose of celecoxib significantly reduced the percentage of patients with severe pain at discharge (6% versus 37% and 30% in the celecoxib 200 mg and control groups, respectively). The median number of doses of oral analgesic medication after discharge was also significantly reduced in the celecoxib 400 mg group (0 versus 2 and 2 in the celecoxib 200 mg and control groups, respectively). However, no differences were found among the three study groups with respect to recovery times and secondary outcome variables (e.g., patient satisfaction and quality of recovery). We conclude that oral premedication with celecoxib 400 mg was more effective than 200 mg in reducing severe postoperative pain and the need for rescue analgesic medication in the postoperative period. IMPLICATIONS: Oral premedication with celecoxib 400 mg was more effective than 200 mg in reducing postoperative pain and the need for rescue analgesic medication in the early postoperative period. However, neither dose of celecoxib was more effective than a placebo in facilitating the recovery process after outpatient surgery.

Optimal Timing of Acustimulation for Antiemetic Prophylaxis as an Adjunct to Ondansetron in Patients Undergoing Plastic Surgery

We designed this study to evaluate the antiemetic efficacy of transcutaneous electrical acupoint stimulation in combination with ondansetron when applied before, after, or both before and after plastic surgery. A randomized, double-blind, sham-controlled study design was used to compare three prophylactic acustimulation treatment schedules: preoperative—an active device was applied for 30 min before and a sham device for 72 h after surgery; postoperative—a sham device was applied for 30 min before and an active device for 72 h after surgery; and perioperative—an active device was applied for 30 min before and 72 h after surgery (n = 35 per group). All patients received a standardized general anesthetic, and ondansetron 4 mg IV was administered at the end of surgery. The incidence of vomiting/retching and the need for rescue antiemetics were determined at specific time intervals for up to 72 h after surgery. Nausea scores were recorded with an 11-point verbal rating scale. Other outcome variables assessed included discharge times (for outpatients), resumption of normal activities of daily living, complete antiemetic response rate, and patient satisfaction with antiemetic therapy and quality of recovery. Perioperative use of the ReliefBand® significantly increased complete responses (68%) compared with use of the device before surgery only (43%). Median postoperative nausea scores were significantly reduced in the peri- and postoperative (versus preoperative) treatment groups. Finally, patient satisfaction with the quality of recovery (83 ± 16 and 85 ± 13 vs 72 ± 18) and antiemetic management (96 ± 9 and 94 ± 10 vs 86 ± 13) on an arbitrary scale from 0 = worst to 100 = best was significantly higher in the groups receiving peri- or postoperative (versus preoperative) acustimulation therapy. For patients discharged on the day of surgery, the time to home readiness was significantly reduced (114 ± 41 min versus 164 ± 50 min; P < 0.05) when acustimulation was administered perioperatively (versus preoperatively). In conclusion, acustimulation with the ReliefBand® was most effective in reducing postoperative nausea and vomiting and improving patients’ satisfaction with their antiemetic therapy when it was administered after surgery.

Effect of auditory evoked potential index monitoring on anesthetic drug requirements and recovery profile after laparoscopic surgery: A clinical utility study

Background The auditory evoked potential (AEP) monitor provides an electroencephalogram-derived index (AAI) that has been reported to correlate with the central nervous system depressant effects of anesthetic drugs. This clinical utility study was designed to test the hypothesis that AAI-guided administration of the maintenance anesthetics and analgesics would improve their titration and thereby provide a faster recovery from general anesthesia. Methods Seventy consenting patients undergoing elective general surgery procedures were randomly assigned to either a control (standard clinical practice) or AEP-monitored group. Although the AEP monitor was connected to all patients, the information from the monitor was only made available to the anesthesiologists assigned to patients in the AEP-monitored group. In the AEP-monitored group, the inspired desflurane concentration was titrated to maintain an AAI value of 15–20. In the control group, the inspired desflurane concentration was varied based on standard clinical signs. The AAI values and hemodynamic variables, as well as end-tidal desflurane concentrations, were recorded at 3- to 5-min intervals. The recovery times to achieve a White fast-track score greater than 12 and an Aldrete score of 10, as well as the actual duration of the PACU stay, were evaluated at 5- to 10-min intervals. Patient satisfaction with recovery from anesthesia was assessed using a 100-point verbal rating scale at 24 h after surgery. Results The average intraoperative AAI value in the AEP-monitored group was significantly higher than in the control group (16 ± 5 vs. 11 ± 8, P < 0.05). Use of the AEP monitor reduced the desflurane requirement by 26% compared to the control group (P < 0.01). In addition, the AEP-monitored group received less intraoperative fentanyl (270 ± 120 vs. 390 ± 203 &mgr;g, P < 0.05) and more rapidly achieved fast-track eligibility (29 ± 19 vs. 56 ± 41 min, P < 0.05). The time required to achieve an Aldrete score of 10 (60 ± 31 vs. 98 ± 55 min) and the duration of stay in the recovery room (78 ± 32 vs. 106 ± 54 min) were also significantly reduced in the AEP-monitored (vs. control) group (P < 0.05). Conclusion Use of AEP monitoring as an adjunct to standard clinical monitors improved titration of anesthetic drugs, thereby facilitating the early recovery process after laparoscopic surgery.