Nicardipine Is Superior to Esmolol for the Management of Postcraniotomy Emergence Hypertension: A Randomized Open-Label Study

Use of an ultrashort-acting selective β1-adrenergic receptor antagonist esmolol in ear, nose and throat surgery

Background / Aim: The concept of general balanced anaesthesia was devised in order to assure cardiovascular stability and fast post-anaesthesia recovery. This clinical trial was organised in order to investigate the parameters of cardiovascular function and emergence from anaesthesia in elective ear, nose and throat (ENT) surgery patients. Methods: A total of 40 ASA I and II patients of both sexes scheduled for elective ENT surgery were randomly divided into two equal groups. Both groups received a continuous IV infusion of glucose 5 % solution and in the esmolol group this infusion also contained esmolol. Esmolol infusion rate was 0.3 mg/kg/min during the first 5 min and thereafter 0.1 mg/kg/min. In critical phases of anaesthesia and operation (induction, intubation, first incision, surgical manipulations, wound suture, extubation), systolic and diastolic blood pressure were monitored. Recovery after anaesthesia was assessed based on times of eye opening on command, spontaneous eye opening and regaining of full orientation. Increases in cardiovascular parameters by 20 % of the baseline values or more were treated with IV boluses of fentanyl, alone or with droperidol and, if necessary, by adding isoflurane 0.5 % to the inhalational mixture. Consumption of drugs was recorded. Results: Esmolol assured stable values of cardiovascular parameters that were in most critical phases of anaesthesia and operation lower than in the control group. The duration of anaesthesia did not differ between the groups. In the esmolol group, lower consumption of fentanyl, droperidol and sevoflurane was registered. Patients in the esmolol group emerged from anaesthesia faster than patients in the control group. Conclusion: Continuous IV infusion of esmolol assures better cardiovascular stability, necessitates lower consumption of analgesics and anaesthetics and results in faster emergence from general anaesthesia in elective ENT surgery.

Risk Factors for Complications Following Lateral Skull Base Surgery and the Utility of ICU Monitoring

OBJECTIVE

To examine the role of intensive care unit (ICU) management following lateral skull base surgery for vestibular schwannoma and identify risk factors for complications warranting admission to the ICU.

STUDY DESIGN

Retrospective review.

SETTING

Tertiary referral center.

PATIENTS

Two hundred consecutive patients undergoing lateral skull base surgery for vestibular schwannomas.

INTERVENTION

Lateral skull base approach for resection of vestibular schwannoma and postoperative monitoring.

MAIN OUTCOME MEASURES

Patients were grouped if they sustained an ICU complication, a non-ICU complication, or no complication. Analysis was performed to determine patient or treatment factors that may be associated with ICU complications. Multivariate and three-way analysis of variance compared groups, and multivariate logistic regression determined adjusted odds ratios (aOR) for analyzed factors.

RESULTS

Seventeen of 200 patients sustained ICU complications (8.5%), most commonly hypertensive urgency (n = 15). Forty-six (23%) sustained non-ICU complications, and 137 (68.5%) had no complications. When controlling for age, sex, obesity, and other comorbidities, only hypertension (aOR 5.43, 95% confidence interval (CI) 1.35-21.73, p = 0.017) and tumor volume (aOR 3.29, 95% CI 1.09-9.96, p = 0.035) were independently associated with increased risk of ICU complications.

CONCLUSIONS

The necessity of intensive care following lateral skull base surgery is rare, with the primary ICU complication being hypertensive urgency. Preoperative hypertension and large tumor volume (>4500 mm3) were independently associated with increased risk for ICU complications. These findings may allow for risk stratification of patients appropriate for admission to stepdown units following resection of vestibular schwannomas. Further prospective, multi-center, randomized studies are necessary to validate these findings before systematic changes to current postoperative care practices.

Esmolol as an adjunct to general balanced anaesthesia in neurosurgery

Background/Aim: In surgery, and especially in the neurosurgical operations, maintenance of cardiovascular stability during and in the phase of the immediate postoperative recovery is of vital importance. The aim of this study was to investigate the effects of continuous esmolol infusion on the values of cardiovascular parameters and quality of the emergence from anaesthesia in neurosurgical patients. Methods: A total of 40 patients of both sexes scheduled for elective supratentorial surgery were randomly assigned to two groups. Esmolol group received intravenous (iv) infusion of esmolol dissolved in 5 % glucose solution (during the first 5 min at a rate of 0.3 mg/kg/min and thereafter at a rate of 0.1 mg/kg/min), while the ones from the control group received a 5 % glucose solution without esmolol at the same volume and rate. Cardiovascular parameters were registered at critical phases of anaesthesia and operation (induction, intubation, placement of Mayfield frame, craniotomy, skull closure, extubation). Recovery after anaesthesia was assessed based on times of eye opening on command, spontaneous eye opening and regaining of full orientation. Results: Values of systolic blood pressure and heart rate were significantly lower in the esmolol than in the control group of patients. Although the durations of anaesthesia did not differ, patients from the esmolol group required significantly less opioids and isoflurane and recovered after the anaesthesia significantly faster than the patients in the control group. Conclusion: Ultrashort-acting beta-adrenergic receptor antagonist esmolol, administered as a continuous iv infusion, assures better cardiovascular stability and smoother emergence from the balanced inhalation general anaesthesia than the control glucose infusion in elective neurosurgical patients.

Calcium Channel Blockers in Acute Care: The Links and Missing Links Between Hemodynamic Effects and Outcome Evidence

Calcium channel blockers (CCBs) exert profound hemodynamic effects via blockage of calcium flux through voltage-gated calcium channels. CCBs are widely used in acute care to treat concerning, debilitating, or life-threatening hemodynamic changes in many patients. The overall literature suggests that, for systemic hemodynamics, although CCBs decrease blood pressure, they normally increase cardiac output; for regional hemodynamics, although they impair pressure autoregulation, they normally increase organ blood flow and tissue oxygenation. In acute care, CCBs exert therapeutic efficacy or improve outcomes in patients with aneurysmal subarachnoid hemorrhage, acute myocardial infarction and unstable angina, hypertensive crisis, perioperative hypertension, and atrial tachyarrhythmia. However, despite the clear links, there are missing links between the known hemodynamic effects and the reported outcome evidence, suggesting that further studies are needed for clarification. In this narrative review, we aim to discuss the hemodynamic effects and outcome evidence for CCBs, the links and missing links between these two domains, and the directions that merit future investigations.

Elevated blood pressure after craniotomy: A prospective observational study

PURPOSE

Close hemodynamic monitoring after craniotomy is routine given risk for post-operative hypertension, systemic and neurological complications. Patient and peri-operative variables associated with increased risk of post-craniotomy hypertension and complications are not well understood. Our analysis aims to estimate the incidence and prevalence of post-craniotomy hypertension, its time course, contributing factors, and post-craniotomy complications.

MATERIAL AND METHODS

This is a prospective study of patients admitted to the Neurosurgical Intensive Care Unit after an elective craniotomy. Variables associated with pre-surgical risk, demographics, and post-operative care were analyzed.

RESULTS

A total of 282 patients were included in the final analysis, 44% had pre-existing hypertension. Post-craniotomy hypertension was seen in 21%, with a higher incidence in patients with pre-existing hypertension (p < .001), smaller craniotomies (p = .0035), and increased use of analgesic medications (p < .001). History of hypertension was the only independent risk factor for post-craniotomy hypertension in a multivariate regression model. Patients who developed post-craniotomy hypertension, showed a significant increase in length of stay, number and duration of antihypertensive treatment. However, post-craniotomy hypertension was not associated with a higher incidence of other post-operative complications.

CONCLUSIONS

Development of hypertension after craniotomy is multi-factorial. In this prospective study, a prior history of hypertension was the only associated independent risk factor.

Nicardipine for the Treatment of Neonatal Hypertension During Extracorporeal Membrane Oxygenation

Extracorporeal membrane oxygenation (ECMO) is one of the primary reasons systemic hypertension is experienced in hospitalized neonates. Commonly used antihypertensive agents have resulted in significant adverse effects in neonatal and pediatric populations. Nicardipine is a desirable option because of its rapid and titratable antihypertensive properties and low incidence of adverse effects. However, data for use in neonatal ECMO are limited. We conducted a retrospective review of patients less than 44 weeks post-menstrual age who received a nicardipine infusion for first-line treatment of systemic hypertension while on ECMO at our institution between 2010 and 2016. Systolic (SBP), diastolic (DBP), and mean arterial (MAP) blood pressures were evaluated for 48-h after nicardipine initiation. Eight neonates received a nicardipine infusion while on ECMO during the study period. Nicardipine was initiated at a mean dose of 0.52 ( ± 0.22) mcg/kg/min and titrated to a maximum dose of 1.1 ( ± 0.85) mcg/kg/min. The median duration of nicardipine use was 51 (range 4-227) hours. Significant decreases in SBP, DBP, and MAP occurred within one hour of initiation of nicardipine and were sustained through the majority of the 48-h evaluation period. No patients experienced hypotension. Prospective studies are warranted to evaluate the optimal dose, safety, and efficacy of nicardipine in neonates who require ECMO.