Treating anxiety
Anxiolytics can be easily employed to help ease day-of-surgery anxiety, Dr. Jerry Brewer said at the meeting. Generally speaking, the medications are safe, well-tolerated, and very effective.
“One thing we should remember, however, is that anxiolytics do not affect pain. They have no effect on pain receptors, although they may affect a patient’s memory of pain. For people who are anxious, though, this can be a really great help,” said Dr. Brewer of the Mayo Clinic, Rochester, Minn.
He favors the short-acting benzodiazepines, particularly midazolam. It has a peak concentration of 17-55 minutes, so it’s particularly well suited for shorter cases. It also has a very rapid metabolization profile, with an elimination half life of 3-7 hours.
Since midazolam has twice the affinity for the benzodiazepine receptors as does diazepam, it can be effective in relatively small doses – usually about 0.25 mg/kg. The dose should be reduced by half for elderly patients and for those with renal or hepatic failure. In those patients, the elimination half-life can be increased up to 13 hours.
The typical dose for both adults and children is 10-20 mg. “We should remember that patients who take narcotics and those who take a benzodiazepine as a sleep aide may be quite tolerant and need a higher dose,” Dr. Brewer said.
Diazepam has a peak concentration of about 2 hours, but a much longer elimination half-life – up to 48 hours in a healthy adult and up to 80 hours in an elderly person. “It’s important that patients know they’re going to have this drug in their system for a couple days. This should be part of the consenting process,” Dr. Brewer pointed out.
Lorazepam has a peak concentration of about 2 hours as well, but a shorter half-life of 12-18 hours. That can be prolonged by 75% in patients with renal problems.
With the right clinical supervision, these medications are very safe, he said. “We treat about 800 patients per year with these and have data on about 12,000. Of those, we have had very few problems. Two have fallen out of bed. One patient wrote and said he was discharged too early, as he was very tired. One person fell and hit his head in the bathroom. One was sedated enough to need a sternal rub to improve responsiveness. And one gentleman enjoyed the medication so much that when the nurse left the room for a moment he grabbed the rest of the dose and drank it.”
Safe discharge is crucial when using anxiolytics, he added. “They absolutely cannot drive themselves home and they cannot go back to work. We make sure there is a reliable person to stay with the patient for at least 4 hours after discharge.”
Dr. Brewer does not discharge any patient until that person displays a zero rating on the Richmond Agitation-Sedation Scale (RASS) sedation scale. “That means he is awake, alert, and calmly interacting with you.”
Neither Dr. Sobanko nor Dr. Brewer had any financial declarations.