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Archived Comments for: Parenteral diclofenac infusion significantly decreases brain-tissue oxygen tension in patients with poor-grade aneurysmal subarachnoid hemorrhage

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  1. Paracelsus' wisdom

    Giuseppe Citerio, UO Neuroanestesia e Neurorianimazione, H San Gerardo

    22 May 2013

    I¿ve read with interest this paper by Schiefecke and others on parenteral Diclofenac infusion in SAH patients..
    Fever is a frequent secondary insult in this setting and strategies for controlling high temperature are more than welcome.
    We did publish part of our experience in the use of diclofenac continuous infusion (Neurocritical Care, 6(2), 82¿89. MINERVA ANESTESIOLOGICA, 69(4), 214¿222. Intensive Care Medicine, 26(5), 552¿557) and we are still using it routinely.

    The study results of the study need to be commented:
    - the drug works: body temperature decreased!
    - a decrease in MAP and CPP, necessitated an increase of vasopressors in 26%, colloids in 33% and cristalloids in 5% of interventions, was recored.
    - PbtO2 decreased by 13% from a baseline value, resulting in brain tissue hypoxia in 38% (N=8) of patients and 35% (N=43) of interventions.
    - Cerebral metabolism showed no significant changes after parenteral diclofenac infusion.

    A couple of comments:

    - The dose used: 75 mg diclofenac-sodium diluted in 100 ml normal saline in a bouls is too high.
    We learned since 1994 that continuous infusion of 0.004¿0.08 mg/kg BW/h (keeping the dose as small as possible and the infusion rate as slow as possible once reached the temperature target) in required for succeeding in fever control with minimal impact on systemic parameters.

    - The fall in CPP need to be anticipated (because is a well-known side effect of the drug). In our unit, once the drug is started, noradrenaline is titrated by nurses/residents in order to keep constant CPP.

    - The effect on brain oxygen could be due both to a fall in CPP and to hemodilution.

    In my opinion the results of the study documented that a very efficacious therapy, when administered without cautions and at a wrong dosage, could have important side effects.
    It¿s like to infuse a bolus of 500 ml of mannitol in 10 minutes and to observe polyuria and hypotension and, after the development of hypotension, decide starting fluid administration to counteract it.
    As Paracelsus wrote ¿Poison is in everything, and no thing is without poison. The dosage makes it either a poison or a remedy.¿
    We still think that Diclofenac, used properly, is a remedy not a poison.

    Competing interests