Effect of intravenous esmolol on analgesic requirements in laparoscopic cholecystectomy

Intra-operative esmolol and pain following mastectomy: A randomised clinical trial

BACKGROUND

Esmolol is a beta-1 selective blocker that has been shown to reduce postoperative pain. Its antinociceptive effects have not been tested following mastectomy.

OBJECTIVE

To evaluate the safety, efficacy and antinociception of intra-operative esmolol infusion after mastectomy.

DESIGN

Randomised, double-blinded, placebo-controlled trial.

SETTING

Tertiary referral centre, Brasília, Brazil. Recruitment: July 2015 to July 2017.

PATIENTS

Seventy women scheduled for mastectomy, ASA I to III, aged 18 to 75 years. Four were excluded.

INTERVENTIONS

All underwent general anaesthesia. The intervention group received a bolus of 0.5 mg kg-1 of esmolol over 10 min followed by a continuous infusion of 100 μg kg-1 min-1. The placebo group received saline.

MAIN OUTCOME MEASURES

The primary outcome was pain at rest 24 h after mastectomy as measured by a 0 to 10 numeric rating scale.

RESULTS

Pain scores at rest 24 h after mastectomy were lower in esmolol-treated patients compared with placebo (mean difference = -1.51, 95% confidence interval (CI), -2.36 to -0.65, P = 0.001). On arrival in the postanaesthesia care unit (PACU), the occurrence of pain was also lower in the esmolol group, at rest and on effort (P = 0.009 and P = 0.013, respectively), on discharge from PACU (P = 0.009 and P = 0.015), 12 h (P = 0.01 and P = 0.007) and on effort in the 24 postoperative hours (P = 0.003). Mean morphine consumption was reduced by 77% in the esmolol group compared with the placebo group (mean difference  = -2.52 mg, 95% CI = -3.67 to -1.38, P < 0.001). The length of hospital stay was shorter for the esmolol group (mean difference = -6.9 h, 95% CI, -13.4 to -0.31, P = 0.040).

CONCLUSION

Esmolol was well tolerated, allowed a notable reduction in the dose of rescue analgesics and demonstrated superior efficacy compared to placebo for pain management after mastectomy.

TRIAL REGISTRATION

ClinicalTrials/NCT02466542.

Effects of esmolol infusion on cardiovascular parameters and quality of general anaesthesia in younger and older patients

Background: Esmolol is a cardioselective b-adrenergic antagonist that is used during general anaesthesia to blunt the sympathetic reflex tachycardia and hypertension. The aim of the study was to investigate whether the potential beneficial and adverse effects of esmolol differ depending on the patient age. Methods: A total of 50 ASA I/II patients scheduled for elective upper abdominal surgery were divided in two groups: younger (patients aged up to 35 years) and older (patients older than 65). After premedication with Diazepam, they were infused with esmolol during the first 5 min at a rate of 0.3 mg/kg/min and 0.1 mg/kg/min thereafter. Anaesthesia was induced with thiopental sodium 3-5 mg/kg intravenously (iv) and fentanyl 1.5 µg/kg IV. Tracheal intubation was facilitated with suxamethonium 1-2 mg/kg IV. Long-term neuromuscular blockade was induced with pancuronium bromide 0.07 mg/kg IV bolus and maintained with incremental IV boluses of 0.01 mg/ kg. Inhalational anaesthesia was maintained with a mixture of oxygen and nitrous oxide (O2 /N2 O) 2 : 1. Results: The systolic blood pressure remained constant during the intubation phase in the group of older patients, at the same time being around 89 % of the pre-induction values, while in younger patients it rose up to 100 %. During the same phase of anaesthesia, the diastolic blood pressure in older patients remained at about 91 %, while in younger patients it rose up to 107 % of the pre-induction values. The consumption of drugs and the speed and quality of the recovery from anaesthesia did not differ between the two groups of patients. Conclusion: Infusion of esmolol contributes to the concept of general balanced anaesthesia in elective patients scheduled for upper abdominal surgery equally in younger and older patients.

Esmolol Infusion Reduces Blood Loss and Opiate Consumption during Fertility Preserving Myomectomy

Objectives

The objective of this study is to evaluate the effect of esmolol-induced hypotensive anesthesia (EIHA) on intra-operative (IO) bleeding during open myomectomy.

Patients and Methods

Eighty-eight women were randomly divided into the study group received EIHA without uterine tourniquet and control group who received normotensive anesthesia with uterine tourniquet. EIHA was provided as priming dose of esmolol (0.5 mg.kg^-1) before the induction of anesthesia and esmolol infusion (0.05-0.3 mg.kg^-1.min^-1) to maintain mean arterial pressure at 60-70 mmHg that was stopped on completion of myomectomy. Fentanyl was used as IO analgesia (loading dose: 1.0 μg.kg^-1 then infusion of 0.2-0.4 μg.kg^-1.h^-1). All patients received 6% hydroxyethyl starch (HES; initially, 3 mL.kg^-1 over 5-10 minutes and supplemental doses according to requirements) and Lactated Ringer's solution (LR; 5 mL.kg^-1.h^-1). Trigger for blood transfusion was hemoglobin concentration (HBC) <7 g.dL^-1. Study outcomes included the extent of postoperative (PO) HBC deficit in relation to preoperative HBC, frequency of tourniquet application for the study patients, and total fentanyl consumption.

Results

EIHA significantly reduced blood pressure measures since laryngoscopy and tracheal intubation till the end of surgery in the study group compared to control group. Eight study patients (18.9%) required tourniquet application for control of bleeding; however, amount of IO blood loss; total field visibility score and PO HBC deficit were non significantly lower in the study group. EIHA allowed significant reduction of the IO amount of LR and additional amounts of HES infusions. Study patients group consumed significantly lower IO fentanyl doses with significantly longer duration till the 1^st PO request and the number of additional fentanyl, and lower numeric rating scale scores in study group compared to controls.

Conclusion

Open myomectomy under EIHA is feasible and safe and allows fertility-sparing with minimal risk of blood transfusion. The applied procedure of EIHA allowed blunting of pressor reflexes secondary to LIT, surgical stresses and extubation, and allowed reduction of IO and PO opioid doses.

Esmolol does not improve quality of postsurgical recovery after ambulatory hysteroscopy: A prospective, randomized, double-blinded, placebo-controlled, clinical trial

INTRODUCTION

Intraoperative systemic esmolol has been shown to reduce postsurgical pain. Nonetheless, it is unknown whether the use of intraoperative systemic esmolol can improve patient-reported postsurgical quality of recovery. The main objective of the current investigation was to evaluate the effect of intraoperative esmolol on postsurgical quality of recovery. We hypothesized that patients receiving intraoperative esmolol would report better quality of postsurgical recovery than the ones receiving saline.

METHODS

The study was a prospective randomized double-blinded, placebo-controlled, clinical trial. Healthy female subjects undergoing outpatient hysteroscopic surgery under general anesthesia were randomized to receive intravenous esmolol administered at a rate of 0.5 mg/kg bolus followed by an infusion of 5 to 15 μg/kg/min or the same volume of saline. The primary outcome was the Quality of Recovery 40 (QOR-40) questionnaire at 24 hours after surgery. Other data collected included postoperative opioid consumption and pain scores. Data were analyzed using group t tests and the Wilcoxon exact test.

RESULTS

Seventy subjects were randomized and 58 completed the study. There was not a clinically significant difference in the global QoR-40 scores between the esmolol and saline groups at 24 hours, median (interquartile range) of 179 (171-190) and 182 (173-189), respectively, P = .82. In addition, immediate post-surgical data in the post-anesthesia care unit did not show a benefit of using esmolol compared to saline in regard to pain scores, morphine consumption, and postoperative nausea and vomiting.

CONCLUSIONS

Despite current evidence in the literature that intraoperative esmolol improves postsurgical pain, we did not detect a beneficial effect of intraoperative esmolol on patient-reported quality of recovery after ambulatory surgery. Our results confirm the concept that the use of patient-centered outcomes rather than commonly used outcomes (e.g., pain scores and opioid consumption) can change the practice of perioperative medicine.