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Pain relief after day case laparoscopy

pharmacological abreaction in the hope that an insight might be gained into the origin of his disorder. The technique was planned on a ‘one-off outpatient basis and in view of the good recovery associated with propofol a decision was made to use this. Small incremental doses of propofol were slowly given to the patient to a total of approximately 125mg, the dose titrated against his degree of sedation so that he was kept drowsy, but still just able to nod his head in response to the questions and prompting of two therapists skilled in adolescent and family psychiatry. After a period of time the patient began slowly to include answers by whisper and eventually came to describe recent significant past events, underlying hostilities, loyalties and violence both within his immediate family as well as with relatives within the extended ethnic family group. It is possible that his ‘condition’ had been used by him, either consciously or subconsciously as a diversion in order to manipulate his family into focusing their attentions and concerns onto him, thus in the process alleviating pre-existing family tensions. Since then, with skilled follow-up and much counselling, he has improved so that he is now talking and walking again. The use of propofol in psychiatry needs further evaluation, but unfortunately suitable opportunities are limited. However, if used in conjunction with psychotherapy, there are a number of observations and precautions to be made. ( I ) As yet, abreaction is not a licensed indication for the use of propofol. (2) Abreaction is a technique likely to be carried out under the subdued lighting and relaxed ambience of the psychiatry couch. However, the usual anaesthetic precautions on administration of a powerful intravenous agent should still apply, i.e. administration of the drug by an experienced anaesthetist to a starved patient, an indwelling canula, resuscitation facilities to hand and minimally obtrusive monitoring such as a pulse oximeter. (3) Psychiatric recommendations include the recognition that clear consent needs to be obtained from all participants. Much work may have to be done to establish that the patient her or himself has made the choice. It is not a form of therapy that should be entered into lightly before other avenues have been explored beforehand. There is the great need to ensure that the therapist has enough control over the situation to deal with a possible suicide risk that might be uncovered, and also that there is adequate skilled follow-up to ensure that the experience is made use of in further consultations.