The use of esmolol as an alternative to remifentanil during desflurane anesthesia for fast-track outpatient gynecologic laparoscopic surgery

A Comparative Study of the Effect of Labetalol and Remifentanil on Pain Control After Bariatric Surgery

Background

Finding the optimal combination of anesthetics to maintain hemodynamic stability during surgery can be challenging. Traditionally, strong opioid analgesics such as fentanyl and its newer analogs have been used. However, the use of narcotics is associated with certain side effects.

Objectives

This study compares the effects of labetalol and remifentanil in pain control after bariatric surgery in Hazrat Rasool Akram Hospital.

Methods

This randomized, double-blind clinical trial was conducted on 48 laparoscopic bariatric surgery patients. The participants were randomly divided into two groups receiving remifentanil or labetalol. Postoperative pain was measured in the recovery unit using the numerical rating scale (NRS). This score was recorded upon entering recovery, and 30 minutes, 60 minutes, and 120 minutes after surgery for each patient. Also, the duration of anesthesia, the duration of the operation, the recovery time, the dose of the administered opioids, the volume of intravenous fluids, and the dose of administered propofol were recorded for each patient. Nausea and vomiting after the operation were also recorded as outcomes.

Results

There were no significant differences between the two groups regarding the mean duration of surgery and anesthesia, dose of the administered anesthetics, recovery period, nausea and vomiting, and the dose of analgesics after the operation. The mean pain intensity during the given period and also the trend of pain intensity changes between the two groups demonstrated no statistically significant differences (P = 0.112). During the operation, 9 subjects (37.5%) in the labetalol group and 16 (66.7%) in the remifentanil group needed more analgesics (rescue drug); in this regard, a significant difference was observed between the two groups (P = 0.043).

Conclusions

Based on the study's findings, there were no significant differences between labetalol and remifentanil in post and perioperative pain control. However, rescue drugs needed to maintain hemodynamic stability during laparoscopic surgery were significantly lower in patients who received labetalol than remifentanil. Postoperative complications were also comparable between labetalol and remifentanil.

Randomized, double-blind, placebo-controlled study of the analgesic effect of intraoperative esmolol for laparoscopic gastroplasty

Purpose

To evaluate the analgesic effect of esmolol in patients submitted to laparoscopic gastroplasty.

Methods

Forty patients aged between 18 and 50 years with American Society of Anesthesiologists (ASA) physical status scores of II and III who underwent gastric bypass were allocated to two groups. Group 1 patients received a 0.5-mg/kg bolus of esmolol in 30 mL of saline before induction of anesthesia, followed by an infusion at 15 µg/kg/min until the end of surgery. Group 2 patients received 30 mL of saline as a bolus and then an infusion of saline. Anesthesia included fentanyl (3 µg/kg), propofol (2-4 mg/kg), rocuronium (0.6 mg/kg), and 2% sevoflurane, with remifentanil if necessary. The following parameters were evaluated: pain intensity over 24h, remifentanil consumption, the first analgesic request, morphine consumption, and side effects.

Results

Pain intensity was lower in the esmolol group except at T0 (after extubation) and 12h postoperatively. Remifentanil supplementation, recovery time, and postoperative morphine supplementation were lower in the esmolol group. No differences in the time to the first analgesic request or side effects were found between the groups.

Conclusion

Intraoperative esmolol promotes reductions in pain intensity and the need for analgesic supplementation without adverse effects, thus representing an effective drug for multimodal analgesia in gastroplasty.

The effect of intraoperative lidocaine versus esmolol infusion on postoperative analgesia in laparoscopic cholecystectomy: a randomized clinical trial

Background

As a part of multimodal analgesia for laparoscopic cholecystectomy, both intraoperative lidocaine and esmolol facilitate postoperative analgesia. Our objective was to compare these two emerging strategies that challenge the use of intraoperative opioids. We aimed to assess if intraoperative esmolol infusion is not inferior to lidocaine infusion for opioid consumption after laparoscopic cholecystectomy.

Methods

In this prospective, randomized, double-blind, non-inferiority clinical trial, 90 female patients scheduled for elective laparoscopic cholecystectomy received either intravenous (IV) lidocaine bolus 1.5 mg/kg at induction followed by an infusion (1.5 mg/ kg/h) or IV bolus of esmolol 0.5 mg/kg at induction followed by an infusion (5–15 μg/kg/min) till the end of surgery. Remaining aspect of anesthesia followed a standard protocol apart from no intraoperative opioid supplementation. Postoperatively, patients received either morphine or tramadol IV to maintain visual analogue scale (VAS) scores ≤3. The primary outcome was opioid consumption (in morphine equivalents) during the first 24 postoperative hours. Pain and sedation scores, time to first perception of pain and void, and occurrence of nausea/vomiting were secondary outcomes measured up to 24 h postoperatively.

Results

Two patients in each group were excluded from the analysis. The postoperative median (IQR) morphine equivalent consumption in patients receiving esmolol was 1 (0–1.5) mg compared to 1.5 (1–2) mg in lidocaine group (p = 0.27). The median pain scores at various time points were similar between the two groups (p > 0.05). More patients receiving lidocaine were sedated in the post-anesthesia care unit (PACU) than those receiving esmolol (p < 0.05); however, no difference was detected later.

Conclusion

Infusion of esmolol is not inferior to lidocaine in terms of opioid requirement and pain severity in the first 24 h after surgery. Patients receiving lidocaine were more sedated during their stay in PACU than those receiving esmolol.

Trial registration

ClinicalTrials.gov- NCT02327923. Date of registration: December 31, 2014.

Effect of esmolol and lidocaine on agitation in awake phase of anesthesia among children: a double-blind, randomized clinical study

Background:

Sevoflurane is widely used to anesthetize children because of its rapid action with minimal irritation of the airways. However, there is a high risk of agitation after emergence from anesthesia. Strabismus surgery, in particular, can trigger agitation because patients have their eyes covered in the postoperative period. The aim of this study was to determine whether or not esmolol and lidocaine could decrease emergence agitation in children.

Methods:

Eighty-four patients aged 3 to 9 years undergoing strabismus surgery were randomly assigned to a control group (saline only), a group that received intravenous lidocaine 1.5 mg/kg, and a group that received intravenous esmolol 0.5 mg/kg and lidocaine 1.5 mg/kg. Agitation was measured using the objective pain score, Cole 5-point score, and Richmond Agitation Sedation Scale score at the end of surgery, on arrival in the recovery room, and 10 and 30 min after arrival.

Results:

The group that received the combination of esmolol and lidocaine showed lower OPS and RASS scores than the other two groups when patients awoke from anesthesia (OPS = 0 (0–4), RASS = –4 [(–5)–1]) and were transferred to the recovery room (OPS = 0 (0–8), RASS = –1 [(–5)–3]) (P < 0.05). There was no significant difference in the severity of agitation among the three groups at other time points (P > 0.05).

Conclusions:

When pediatric strabismus surgery is accompanied by sevoflurane anesthesia, an intravenous injection of esmolol and lidocaine could alleviate agitation until arrival in the recovery room.

Trial registration:

Clinical Research Information Service, No. KCT0002925; https://cris.nih.go.kr/cris/en/search/search_result_st01.jsp?seq=11532

Potentiation of Morphine-Induced Antinociception by Propranolol: The Involvement of Dopamine and GABA Systems

Tolerance to the analgesic effect of morphine is a major clinical problem which can be managed by co-administration of another drug. This study investigated the ability of propranolol to potentiate the antinociceptive action of morphine and the possible mechanisms underlying this effect. Antinociception was assessed in three nociceptive tests (thermal, hot plate), (visceral, acetic acid), and (inflammatory, formalin test) in mice and quantified by measuring the percent maximum possible effect, the percent inhibition of acetic acid-evoked writhing response, and the area under the curve values of number of flinches for treated mice, respectively. The study revealed that propranolol (0.25-20 mg/Kg, IP) administration did not produce analgesia in mice. However, 10 mg/Kg propranolol, enhanced the antinociceptive effect of sub-analgesic doses of morphine (0.2, 1, and 2 mg/Kg, IP) in the three nociceptive tests. It also shifted the dose response curve of morphine to the left. The combined effect of propranolol and morphine was attenuated by haloperidol (D₂ receptor antagonist, 1.5 mg/Kg, IP), and bicuculline (GABA_A receptor antagonist, 2 mg/Kg, IP). Repeated daily administration of propranolol (10 mg/Kg, IP) did not alter the nociceptive responses in the three pain tests, but it significantly potentiated morphine-induced antinociception in the hot plate, acetic acid-evoked writhing, and in the second phase of formalin tests. Together, the data suggest that a cross-talk exists between the opioidergic and adrenergic systems and implicate dopamine and GABA systems in this synergistic effect of morphine-propranolol combination. Propranolol may serve as an adjuvant therapy to potentiate the effect of opioid analgesics.

The effect of esmolol compared to opioids on postoperative nausea and vomiting, postanesthesia care unit discharge time, and analgesia in noncardiac surgery: A meta-analysis

Background and Aims:

Perioperative esmolol as an opioid alternative has been shown to reduce postoperative nausea vomiting using opioid sparing. The aim of this meta-analysis was to compare esmolol and opioids on postoperative nausea and vomiting (PONV), time spent in recovery, and analgesia in noncardiac surgeries.

Material and Methods:

OVID Medline (1980–February 2014), OVID EMBASE, EBSCO, CINAHL, and the Cochrane Register of Controlled Trials were searched for randomized controlled trials (RCTs) comparing esmolol and opioids on early postoperative recovery and pain intensity during general anesthesia in noncardiac surgeries. The primary outcomes were related to PONV and postanesthesia care unit (PACU) discharge time, whereas secondary outcomes were related to early postoperative pain.

Results:

Eight trials were identified involving 439 patients, 228 of whom received esmolol while 211 received opioids. A random-effects meta-analysis showed that in comparison with opioids, esmolol led to a 69% reduction in the incidence of PONV (odds ratio 0.31, 95% confidence interval [CI] 0.13–0.74, P = 0.008, I² = 44.1%). An increase in the volatile anesthetic requirement was evident in the esmolol group compared with opioid (MD + 0.67% desflurane equivalent, 95% CI 0.27–1.08, P = 0.001, I² =23.5%). There was no statistically significant difference between the esmolol and opioid groups in relation to PACU discharge time, early postoperative pain scores, opioid requirement, and cumulative opioid consumption. Significant heterogeneity was noted between studies. No significant adverse effects were noted.

Conclusion:

Compared with opioids, perioperative esmolol may reduce the incidence of postoperative nausea vomiting and increase the volatile anesthetic requirement. Esmolol administration may not improve the early postoperaive pain intensity. Nonetheless, these findings are limited by the absence of high-quality RCTs and the heterogeneity among studies. Further, large-scale studies are needed to explore these results.

Laparoscopic surgery: a narrative review of pharmacotherapy in pain management

Laparoscopic surgery is widespread, and an increasing number of surgeries are performed laparoscopically. Early pain after laparoscopy can be similar or even more severe than that after open surgery. Thus, proactive pain management should be provided. Pain after laparoscopic surgery is derived from multiple origins; therefore, a single agent is seldom sufficient. Pain is most effectively controlled by a multimodal, preventive analgesia approach, such as combining opioids with non-opioid analgesics and local anaesthetics. Wound and port site local anaesthetic injections decrease abdominal wall pain by 1-1.5 units on a 0-10 pain scale. Inflammatory pain and shoulder pain can be controlled by NSAIDs or corticosteroids. In some patient groups, adjuvant drugs, ketamine and α2-adrenergic agonists can be helpful, but evidence on gabapentinoids is conflicting. In the present review, the types of pain that need to be taken into account while planning pain management protocols and the wide range of analgesic options that have been assessed in laparoscopic surgery are critically assessed. Recommendations to the clinician will be made regarding how to manage acute pain and how to prevent persistent postoperative pain. It is important to identify patients at the highest risk for severe and prolonged post-operative pain, and to have a proactive strategy in place for these individuals.

Esmolol reduces anesthetic requirements thereby facilitating early extubation; a prospective controlled study in patients undergoing intracranial surgery

BACKGROUND

Adequate cerebral perfusion pressure with quick and smooth emergence from anesthesia is a major concern of the neuroanesthesiologist. Anesthesia techniques that minimize anesthetic requirements and their effects may be beneficial. Esmolol, a short acting hyperselective β-adrenergic blocker is effective in blunting adrenergic response to several perioperative stimuli and so it might interfere in the effect of the anesthetic drugs on the brain. This study was designed to investigate the effect of esmolol on the consumption of propofol and sevoflurane in patients undergoing craniotomy.

METHOD

Forty-two patients that underwent craniotomy for aneurysm clipping or tumour dissection were randomly divided in two groups (four subgroups). Anesthesia was induced with propofol, fentanyl and a single dose of cis-atracurium, followed by continuous infusion of remifentanil and either propofol or sevoflurane. Patients in the esmolol group received 500 mcg/kg of esmolol bolus 10 min before induction of anesthesia, followed by additional 200 mcg/kg/min of esmolol. Monitoring of the depth of anesthesia was also performed using the Bispectral Index-BIS and cardiac output. The inspired concentration of sevoflurane and the infusion rate of propofol were adjusted in order to maintain a BIS value between 40-50. Intraoperative emergence was detected by the elevation of BIS value, HR or MAP.

RESULTS

The initial and the intraoperative doses of propofol and sevoflurane were 18-50 mcg/kg/min and 0.2-0.5 MAC respectively in the esmolol group, whereas in the control group they where 100-150 mcg/kg/ and 0.9-2.0 MAC respectively (p = 0.000 for both groups). All procedures were anesthesiologically uneventful with no episodes of intraoperative emerge.

CONCLUSIONS

Esmolol is effective not only in attenuating intraoperative hemodynamic changes related to sympathetic overdrive but also in minimizing significant propofol and sevoflurane requirements without compromising the hemodynamic status. ClinicalTrials.gov Identifier: NCT02455440 . Registered 26 May 2015.

Effect of Intravenous Intraoperative Esmolol on Pain Management Following Lower Limb Orthopedic Surgery

BACKGROUND

Lack of proper control of acute postoperative pain often leads to lingering or chronic pain. Several studies have emphasized the role of beta-blockers in reducing postoperative pain. Esmolol is a selective short-acting beta-blocker that produces few side effects. The purpose of this study was to examine the effect of intravenous intraoperative esmolol on postoperative pain reduction following orthopedic leg fracture surgery.

METHODS

In a clinical trial, 82 patients between 20-65 years of age with tibia fractures and American Society of Anesthesiologists (ASA) physical status I & II who underwent surgery were divided into two groups. Group A received esmolol and group B received normal saline. Postoperative pain was measured at three time points: entering the recovery unit, and at 3 h and 6 h following surgery, using the Visual Analogue Scale (VAS). A P value of < 0.05 was considered significant.

RESULTS

Mean VAS scores at all three time points were significantly different between the two test groups (P = 0.02, P = 0.0001, and P = 0.0001, respectively). The consumption of pethidine was lower in group A than in group B (P = 0.004) and the duration of its effect was significantly longer in time (P = 0.026).

CONCLUSIONS

Intravenous intraoperative esmolol is effective in the reduction of postoperative pain following leg fracture surgery. It reduced opioid consumption following surgery and delayed patient requests for analgesics.

Study on the Antinociceptive Effects of Herba Epimedium in Mice

The present study was conducted to investigate the antinociceptive action of relationship between Herba Epimedium (HE) and 5-HT_1A receptor, between Herba Epimedium (HE) and 5-HT_2A receptor. We used the hot-plate method and the writhing assay in mice by the intracerebroventricular (i.c.v.) injection and observed the analgesic effect of HE. Furthermore, through the i.c.v. injection, 5-HT_1A receptor partial agonist Buspirone, antagonist Propranolol, the adrenaline β₁-receptor selective blocking agent Metoprolol, and 5-HT_2A receptor agonist hydrochloride DOI and antagonist Ketanserin were used, and, 5 min later, HE was used to investigate the impacts of drugs on the analgesic effect in the same way. Results showed that HE had fast and significant antinociception in nervous system, and the effects can persist for a long time. Buspirone and Hydrochloride DOI can remarkably increase the antinociception of HE in nervous system. Ketanserin leads to a significant decrease in its antinociception in nervous system; Metoprolol also has antinociceptive action in nervous system, but it can inhibit the antinociceptive effect of Herba Epimediumin peripheral region. These results suggest that HE has significant antinociception effect and its mechanism is related with 5-HT_1A receptor, 5-HT_2A receptor, and adrenaline β₁-receptor.

A Comparison of the Effects of Esmolol and Dexmedetomidine on the Clinical Course and Cost for Controlled Hypotensive Anaesthesia

OBJECTIVE

To compare the effects of esmolol (β-blocker) and dexmedetomidine (α-2-agonist) on patients' clinical course and cost of application of controlled hypotension during middle-ear surgery.

METHODS

Fifty ASA I-II patients scheduled for tympanomastoidectomy were enrolled in the study and were randomized into two groups. Bispectral Index (BIS) and neuromuscular monitoring (TOF GUARD-SX) were applied to all patients. In group E (n=25), 0.5 mg kg(-1) min(-1) esmolol was infused over 1 min before induction and titrated over a range of 10-200 μg kg(-1) min(-1); in group D (n=25), 0.5 μg kg(-1) dexmedetomidine was infused over 10 minutes before induction, and then titrated over a range of 0.2-0.7 μg kg(-1) hr(-1) to maintain mean arterial pressure (MAP) between 55 and 65 mmHg and BIS 40-50 after induction. In both groups, 0.25 μg kg(-1) min(-1) remifentanil infusion was used for anaesthesia maintenance. Maintaining end-tidal CO2 (EtCO2) at 35-40, using 1 MAC sevoflurane in 50% O2-air mixture, mechanical ventilation was started. The effects of both agents on hemodynamic conditions [(heart rate (HR), mean arterial pressure (MAP)], neuromuscular blockage [onset of action (OA), duration of clinical action (DCA), recovery index (RI)], amount of bleeding, surgeon satisfaction, and total dexmedetomidine and esmolol doses used during the intervention were recorded and costs were compared between the groups.

RESULTS

No significant difference was present in hemodynamic conditions, bleeding scores or surgeon satisfaction between groups. Although OA was similar in both groups, DCA and RI were significantly higher in group D. Cost was significantly higher with esmolol than dexmedetomidine.

CONCLUSION

We conclude that although both agents are feasible in inducing hypotensive anaesthesia, while neuromuscular block time prolonged by using dexmedetomidine, higher costs were observed with esmolol.

The effect of perioperative esmolol infusion on the postoperative nausea, vomiting and pain after laparoscopic appendectomy

BACKGROUND

Perioperative opioid administration results in postoperative nausea and vomiting (PONV) and acute opioid tolerance that manifests in increased postoperative pain. Esmolol is an ultra short acting cardioselective β1-adrenergic receptor antagonist, and it has been successfully used for perioperative sympatholysis and it reduces the opioid requirement during total intravenous anesthesia. We tested the hypothesis that perioperative esmolol administration results in decreased PONV and postoperative pain.

METHODS

Sixty patients undergoing laparoscopic appendectomy were randomly assigned to two groups (Group E and Group C). The Group E patients were administered 5-10 µg/kg/min esmolol with remifentanil that was titrated to the autonomic response. The Group C patients received normal saline that was of the same volume as the esmolol in Group E, and the remifentanil was also titrated to the vital sign. Before intubation and extubation, the Group E patients were administered 1.0 mg/kg esmolol, and the Group C patients were administered normal saline of the same volume. The incidence and severity of PONV, the pain score, the rescue antiemetics and the rescue analgesics were assessed 30 min, 6 h and 24 h after surgery. The mean arterial pressure and heart rate under anesthesia were also recorded.

RESULTS

PONV and postoperative pain were significantly increased in Group C. These patients needed more antiemetics and analgesics in the first 24 postoperative hours. The mean arterial pressure and heart rate were significantly higher in Group C at the time of intubation and extubation.

CONCLUSIONS

Perioperative esmolol administration contributes to the significant decrease in PONV and postoperative pain, and so this facilitates earlier discharge.

Inhibitory effects of landiolol and nicardipine on thiopental-induced yawning in humans

PURPOSE

Either the calcium (Ca(2+))-channel blocker nicardipine or the beta(1)-adrenoceptor antagonist landiolol may be intravenously (IV) administered to reduce the hemodynamic responses to tracheal intubation. In this study, we examined the effects of these drugs on the yawning response elicited by intravenous thiopental in humans.

METHODS

After Institutional Review Board approval, 180 consenting American Society of Anesthesiologists (ASA) I or II patients undergoing elective surgery were recruited. In a double-blind, randomized design, three groups of 60 patients each received one of the following intravenous injections: (1) landiolol 0.1 mg/kg (L-group), (2) nicardipine 0.02 mg/kg (N-group), or (3) saline (S-group). In all patients, anesthesia was subsequently induced IV with 4 mg/kg thiopental. Thereafter, the occurrence of the yawning response (characterized by mouth opening) was continuously assessed as the only clinical endpoint for 1 min. Throughout the study, mean arterial blood pressure and heart rate were also recorded at 1-min intervals.

RESULTS

The incidence of the yawning response was lower in both the L-group (6.7%) and the N-group (16.7%) than in the S-group (46.7%) (each, P < 0.01).

CONCLUSIONS

Prior intravenous administration of either a Ca(2+)-channel blocker or a beta(1)-adrenoceptor antagonist can greatly reduce the thiopental-induced yawning response in humans.

Both clonidine and metoprolol modify anesthetic depth indicators and reduce intraoperative propofol requirement

PURPOSE

Beta-blockers have been used in the past to decrease the depth of anesthesia, but the results are conflicting. However, beta-blockers are known to suppress electroencephalographic activities. This study was carried out to assess the effect of metoprolol on anesthetic depth indicators. We also compared the effect of metoprolol in reducing propofol requirements.

METHODS

Ninety healthy adult patients undergoing peripheral nerve injury repair were enrolled in three groups to receive either: a tablet containing clonidine 200 microg, a tablet containing metoprolol tartrate 100 mg, or a placebo; 1 h prior to surgery. Standard anesthesia technique was followed. The bispectral index was monitored to guide propofol infusion and was maintained between 40 and 60. The total duration of anesthesia and surgery, and the total propofol consumption, were noted.

RESULTS

Demographic variables were comparable in all three groups. Significantly less propofol was consumed by patients in the clonidine and metoprolol groups in comparison to that in the placebo group (P < 0.001). Heart rate and mean blood pressure values differed significantly in the placebo group in comparison to the values in the other two groups.

CONCLUSION

Our study showed that, like clonidine, metoprolol attenuated the hemodynamic response to intraoperative stimuli and also had a sparing effect on the propofol dose requirement.

Labetalol facilitates GABAergic transmission to rat periaqueductal gray neurons via antagonizing beta1-adrenergic receptors--a possible mechanism underlying labetalol-induced analgesia

Labetalol, a combined alpha1, beta1, and beta2 adrenoceptor-blocking drug, has been shown to have analgesic properties in vivo. To determine the underlying mechanisms, we examined its effects on GABAA receptor-mediated spontaneous inhibitory postsynaptic currents (sIPSCs) and spontaneous firings of rat ventrolateral periaqueductal gray (PAG) neurons, either mechanically dissociated, or in acute brain slices. These PAG neurons mediate opioid-mediated analgesia and pain transmission and are under tonic control of GABAergic interneurons. An increase in GABAergic transmission to these neurons yields an inhibitory hyperpolarized state and may interrupt pain signal transmission. Using patch clamp techniques, we found that labetalol reversibly increases the frequency of sIPSCs without changing their mean amplitude. This indicates that labetalol enhances GABAergic synaptic transmission by a presynaptic mechanism. Metoprolol, a specific beta1-adrenoceptor antagonist, also reversibly enhanced sIPSC frequency. In the presence of metoprolol, labetalol-induced increase in sIPSC frequency was significantly attenuated or even abolished. These results suggest that labetalol shares the same pathway as metoprolol in enhancing GABAergic transmission via an inhibition of presynaptic beta1-adrenoceptors. We further showed that labetalol reversibly reduced the firing rate of PAG neurons. This reduction was significantly attenuated in the presence of bicuculline, a selective antagonist of GABAA receptors. These data indicate that labetalol-induced inhibition of PAG cell firing is attributable to its potentiation of GABAergic transmission. Based on these data, we postulate that labetalol-induced analgesia is at least in part ascribed to its antagonistic effects on presynaptic beta1-adrenoceptors.

Efficacy and safety of fast-track recovery strategy for patients undergoing laparoscopic nephrectomy

BACKGROUND AND PURPOSE

Factors that adversely affect early recovery after major laparoscopic procedures include ileus, pain, nausea, emesis, and fatigue. The objective of this randomized controlled study was to evaluate the impact of a multimodal fast-track (FT) rehabilitation program on recovery and length of hospital stay after laparoscopic nephrectomy.

PATIENTS AND METHODS

Thirty patients undergoing laparoscopic nephrectomy received either conventional care (control) or an FT recovery program. All patients received a standardized anesthetic technique and patient- controlled analgesia (morphine) for postoperative pain control. In the FT group, patients received premedication with rofecoxib and ranitidine, local anesthesia was administered at the ports and renal fosa during surgery, and postoperative non-opioid analgesic and gastrokinetic drugs were administered as part of an early enteral nutrition and mobilization program. During the postoperative period, pain and nausea were assessed at specific time intervals. In addition, recovery room and hospital discharge times, the need for rescue analgesics and antiemetics, patient satisfaction with pain management and quality of recovery, and side effects were recorded daily for 3 days after surgery. Patients were discharged home when they met previously defined discharge criteria.

RESULTS

The FT group was discharged earlier from the recovery room (74+/-23 v 103+/-47 minutes) and the hospital (41+/-11 v 59+/-11 hours). Pain and nausea scores were consistently lower in the FT group during the first 48 hours after surgery. In addition, the requirement for antiemetic rescue therapy during the first 24 hours was reduced in the FT group (15% v 58%). The FT group also received less morphine during the first 2 postoperative days (14+/-16 v 40+/-24 mg). Finally, patient satisfaction with postoperative pain control was significantly higher in the FT group.

CONCLUSIONS

A multimodal approach to minimizing postoperative side effects led to a reduced recovery room and hospital stay, as well as better pain control and patient satisfaction after laparoscopic nephrectomy.

Circulatory and respiratory complications of carbon dioxide insufflation

BACKGROUND

Although providing excellent outcome results, laparoscopy also induces particular pathophysiological changes in response to pneumoperitoneum. Knowledge of the pathophysiology of a CO(2) pneumoperitoneum can help minimize complications while profiting from the benefits of laparoscopic surgery without concerns about its safety.

METHODS

A review of articles on the pathophysiological changes and complications of carbon dioxide pneumoperitoneum as well as prevention and treatment of these complications was performed using the Medline database.

RESULTS

The main pathophysiological changes during CO(2) pneumoperitoneum refer to the cardiovascular system and are mainly correlated with the amount of intra-abdominal pressure in combination with the patient's position on the operating table. These changes are well tolerated even in older and more debilitated patients, and except for a slight increase in the incidence of cardiac arrhythmias, no other significant cardiovascular complications occur. Although there are important pulmonary pathophysiological changes, hypercarbia, hypoxemia and barotraumas, they would develop rarely since effective ventilation monitoring and techniques are applied. The alteration in splanchnic perfusion is proportional with the increase in intra-abdominal pressure and duration of pneumoperitoneum.

CONCLUSION

A moderate-to-low intra-abdominal pressure (<12 mm Hg) can help limit the extent of the pathophysiological changes since consecutive organ dysfunctions are minimal, transient and do not influence the outcome.

The Effect of Intraoperative Use of Esmolol and Nicardipine on Recovery After Ambulatory Surgery

There is controversy regarding the optimal technique for maintaining hemodynamic stability during anesthesia. We designed this prospective, randomized, double-blinded study to test the hypothesis that the technique used for maintaining hemodynamic stability during general anesthesia can influence recovery after ambulatory surgery. Forty-five healthy consenting women undergoing gynecologic laparoscopy procedures were randomly assigned to 1 of 3 treatment groups: Group 1 (control, n = 15) received normal saline 5 mL and 1 mL, followed by a saline infusion at a rate of 0.005 mL x kg(-1) x min(-1); Group 2 (n = 15) received esmolol 50 mg and saline 1 mL, followed by an esmolol infusion 5 microg x kg(-1) x min(-1); and Group 3 (n = 15) received esmolol 50 mg and nicardipine 1 mg, followed by an esmolol infusion 5 microg x kg(-1) x min(-1). The study drugs were administered after the induction of anesthesia with fentanyl 1.5 microg/kg, and propofol 2 mg/kg I.V. Tracheal intubation was facilitated with vecuronium 0.12 mg/kg I.V. Anesthesia was initially maintained with desflurane 2% end-tidal and N(2)O 67% in oxygen in all 3 groups. During surgery, the mean arterial blood pressure (MAP) was maintained within +/-15% of the baseline value by varying the study drug infusion rate and the inspired concentration of desflurane. In addition to MAP and heart rate values, electroencephalogram bispectral index values were recorded throughout the perioperative period. Recovery times and postoperative side effects were assessed. Compared with the control group, adjunctive use of esmolol and nicardipine attenuated the increase in heart rate (in Group 2) and MAP (in Group 3) after tracheal intubation. Furthermore, the use of an esmolol infusion as an adjunct to desflurane to control the acute autonomic responses during the maintenance period significantly decreased emergence times (4 +/- 2 versus 7 +/- 4 min), decreased the need for postoperative opioid analgesics (43% versus 80%), and reduced the time to discharge (209 +/- 89 versus 269 +/- 100 min). We conclude that the adjunctive use of esmolol alone or in combination with nicardipine during the induction of anesthesia reduced the hemodynamic response to tracheal intubation. Furthermore, use of an esmolol infusion as an adjuvant to desflurane-N(2)O anesthesia for controlling the acute hemodynamic responses during the maintenance period improved the recovery profile after outpatient laparoscopic surgery.

IMPLICATIONS

The adjunctive use of the beta-adrenergic blocker esmolol to control the acute sympathetic responses during desflurane-based anesthesia provided a more rapid awakening from anesthesia, reduced the postoperative opioid analgesic requirement, and decreased the time to discharge home after ambulatory laparoscopic surgery.

Fast-tracking in outpatient surgery

Fast-tracking in outpatient surgery is a new paradigm that allows for rapid throughput and early discharge, thereby facilitating perioperative efficiency. Compared with the conventional recovery process, bypassing the postanesthesia care unit reduces the time to discharge home. An ideal anesthetic technique for fast-tracking would provide for rapid emergence and the prevention of common postoperative complications such as pain, nausea, and vomiting using a multimodal approach.

Inhalational anaesthesia

Sevoflurane and desflurane have important advantages over isoflurane and halothane. Disadvantages, which the clinician should keep in mind, include the degradation of both agents by soda lime under certain circumstances during closed circuit anaesthesia. As a result compound A and carbon monoxide (CO) may be generated in soda lime canisters and may be inhaled by patients. The extent to which this constitutes a significant problem during routine anaesthesia in humans is not clear. Recent developments in absorbent technology have the potential to reduce any hazard to negligible proportions. Other undesirable properties of the newer inhalation agents include agitation with sevoflurane in children and cardiovascular and airway effects with desflurane.