Nonsteroidal Antiinflammatory Drugs, Opioids, and Routine Anesthesia

To the Editor: The article by Souter et al. [1] regarding the perioperative use of nonsteroidal antiinflammatory drugs was especially interesting, as it confirmed some of the observations made during an investigation recently completed in this hospital. Faced with the dilemma of which analgesic we should use for routine in-patient ear, nose, and throat (ENT) surgery, we compared the perioperative efficacies of diclofenac and five opioids (buprenorphine, nalbuphine, fentanyl, morphine, and pethidine) given intravenously at induction of anesthesia for ENT surgery [2]. A response to Dr. Souter's article is prompted on three accounts. First, in our hands, diclofenac (1 mg/kg) proved to be indistinguishable from placebo (saline) and was shown to have no direct analgesic, analgesic-sparing, preemptive analgesic, or antipyretic effect, although, on the positive side, it was not emetic. We have ceased to use it in the manner described. Second, Souter et al. [1] emphasize the widespread use of short-acting narcotic opioids (fentanyl and analogs) in anesthesia while acknowledging their poor effect in allaying postoperative pain. Our study confirmed this deficiency, but also demonstrated the emetic and respiratory depressant effects of fentanyl. We contend that all surgery is associated with postoperative pain or discomfort, and agree with Semple and Jackson [3] that the deficiency of the short-acting analgesics given intraoperatively in allaying postoperative pain after in-patient surgery strongly suggests that the popularity of these agents needs reevaluation. Finally, we demonstrated the efficacy of nalbuphine (0.13 mg/kg) in providing postoperative analgesia and sedation with few side effects. The article by Souter et al. makes no distinction between the agonist-antagonist opioids (of which nalbuphine is an example) and the narcotic (habit-forming) opioids (morphine, pethidine, fentanyl, etc.). Nalbuphine is extensively described as having a similar or lesser emetic effect but a similar or superior analgesic profile compared with conventional analgesics [2,4-6]. Allied to this, the ceiling effect that nalbuphine has on respiratory depression [7] and its demonstrated safety in clinical practice [8] have prompted our more widespread use of nalbuphine as a routine intra- and postoperative analgesic in ENT (and other) surgery. These data also suggest that nalbuphine specifically, rather than all opioid drugs (as suggested by Souter et al.), should be used and studied in conjunction with the nonsteroidal antiinflammatory drugs. A. A. van den Berg, MBChB, FRCA Armed Forces Hospital, Riyadh 11159, Kingdom of Saudi Arabia