Attenuation of Hemodynamic Response to Tracheal Extubation: A Comparative Study between Esmolol and Labetalol

Metoprolol for prevention of bucking at orotracheal extubation: a double-blind, placebo-controlled randomised trial

BACKGROUND

Respiratory responses to extubation can cause serious postoperative complications. Beta-blockers, such as metoprolol, can interfere with the cough pathway. However, whether metoprolol can effectively control respiratory reflexes during extubation remains unclear. The objective of this study is to evaluate the efficacy of intravenous metoprolol in attenuating respiratory responses to tracheal extubation.

METHODS

Randomized, double-blinded, placebo-controlled trial.

SETTING

Tertiary referral center located in Brasília, Brazil. Recruitment: June 2021 to December 2021.

SAMPLE

222 patients of both sexes with an American Society of Anesthesiologists (ASA) physical status I-III aged 18-80 years. Patients were randomly assigned to receive intravenous metoprolol 5 mg IV or placebo at the end of surgery. The primary outcome was the proportion of patients who developed bucking secondary to endotracheal tube stimulation of the tracheal mucosa during extubation. Secondary outcomes included coughing, bronchospasm, laryngospasm, Mean Blood Pressure (MAP), and Heart Rate (HR) levels.

RESULTS

Two hundred and seven participants were included in the final analysis: 102 in the metoprolol group and 105 in the placebo group. Patients who received metoprolol had a significantly lower risk of bucking (43.1% vs. 64.8%, Relative Risk [RR = 0.66], 95% Confidence Interval [95% CI 0.51-0.87], p = 0.003). In the metoprolol group, 6 (5.9%) patients had moderate/severe coughing compared with 33 (31.4%) in the placebo group (RR = 0.19; 95% CI 0.08-0.43, p < 0.001).

CONCLUSION

Metoprolol reduced the risk of bucking at extubation in patients undergoing general anesthesia compared to placebo.

Coronary Artery Vasospasm After Mechanical Aortic Valve Replacement: A Case Report

Coronary artery vasospasm is a rare but fatal postoperative complication of cardiothoracic surgery. This phenomenon can occur directly after surgery or several hours postoperatively. Most reported cases have occurred after CABG surgery and less commonly after valve replacement. Patients can present with various symptoms, and physicians must be familiar with the indications to suspect coronary artery vasospasm to avoid adverse outcomes. We present a case of a 60-year-old female who suffered a cardiac arrest with refractory ventricular fibrillation due to coronary artery vasospasm following aortic valve replacement. During resuscitation, she underwent central veno-arterial extracorporeal membrane oxygenation (VA-ECMO) cannulation for hemodynamic support. She subsequently underwent urgent left heart catheterization, revealing vasospasm of the left anterior descending artery, early first diagonal, early first obtuse marginal, and non-dominant right coronary artery. Vasospasm was successfully treated with intracoronary nitroglycerin and nicardipine. This case report demonstrates the importance of early consideration of coronary artery vasospasm as a cause of postoperative arrest following cardiac 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.

Comparative study of the effect of two different doses of intravenous labetalol on the cardiovascular response to endotracheal extubation

Introduction

Providing a stable hemodynamic in extubation is important. We aimed to compare the effect of two different doses of intravenous labetalol on the cardiovascular response to endotracheal extubation.

Methods

This double-blind randomized trial was performed in 2019-2020 in Isfahan on 72 patients under general anesthesia. Patients using Random Allocation software were divided into three groups and received 0.1 mg/ kg or 0.2 mg/kg labetalol and normal saline intravenously 10 min before extubation. Hemodynamic variables including heart rate (HR), Systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), and peripheral blood oxygen saturation(SPO2) was measured for each patient before induction of anesthesia and 1, 3, 5 and 10 minutes after extubation.

Results

SBP changes were significantly different between the three groups at 1, 3, 5 minutes after extubation (P=0.036, P=0.009, P=0.005 respectively) unlike the other two groups, patients who received 0.2 mg/kg labetalol did not have an increase in DBP after extubation (P>0.05). DBP was significantly different between the three groups one minute after extubation (P=0.03). At minutes 1 and 3 following extubation, there was a significant difference in the MAP between the three groups. (P=0.029 and P=0.012 respectively). There was no significant difference between the three groups regarding heart rate (P>0.05).

Conclusion

Tracheal extubation is usually associated with an increase in hemodynamic variables. Both doses of labetalol attenuate the hemodynamic response accompanying tracheal extubation. But labetalol 0.2 mg/kg in reducing hemodynamic response to extubation acted more effectively than labetalol 0.1mg/kg.

Effect of Different Concentrations of Esmolol on Perioperative Hemodynamics and Analgesia in Patients Undergoing Colectomy: A Prospective, Randomized Controlled Study

Purpose

The aim of this study was to investigate the efficacy of esmolol on intraoperative hemodynamic and perioperative analgesic management.

Methods

Totally, 125 patients undergoing colectomy were randomly divided into three groups. Group S (saline group) was administered 0.75 mL/kg/h of normal saline for 5 min before anesthesia induction and maintenance of 0.25 mL/kg/h; Group E₁ and Group E₂ were administered 0.5 mg/kg and 1.0 mg/kg esmolol for 5 min before anesthesia induction, and maintained of 0.5 mg/kg/h and 2.0 mg/kg/h, respectively. Several parameters including indexes of hemodynamics variation (primary outcome), intra- and postoperative analgesic usage, and pain score were measured.

Results

Group E₁ and Group E₂ had significantly lower intubation response than Group S (P = 0.007, P = 0.001), and extubation response of Group E₂ was significantly lower than Group S (P = 0.007). The opioid consumption in Group E₁ and Group E₂ was significantly lower than in Group S intraoperatively (P = 0.020 and 0.007). The incidence of postoperative adverse reactions among the three groups was not statistically significant (P = 0.368 and 0.772).

Conclusion

Esmolol 0.5 mg/kg and 1.0 mg/kg infusion before intubation both can effectively inhibit the intubation response, while only maintenance with 2.0 mg/kg/h of esmolol can reduce the incidence of extubation response. At the same time, esmolol can decrease intraoperative opioid requirement without increasing the risk of adverse reactions.

Trial Registration

ChiCTR1900024538 and the date of registration was July 15, 2019 at http://www.chictr.org.cn.

Efficacy of a single dose of esmolol to prevent extubation-related complications during emergence from anesthesia: a randomized, double-blind, placebo-controlled trial

BACKGROUND

Few trials have examined the efficacy of esmolol to attenuate hemodynamic and respiratory responses during extubation. However, the most appropriate dose of esmolol and an optimal protocol for administering this beta-blocker are uncertain.

METHODS

Ninety patients ASA physical status I, II, and III (aged 18-60 years) scheduled to procedures with general anesthesia and tracheal extubation were selected. Patients were randomized into esmolol and placebo group to evaluate the efficacy and safety of a single bolus dose of esmolol (2 mg.kg^-1) on cardiorespiratory responses during the peri-extubation period. The primary outcome was the rate of tachycardia during extubation.

RESULTS

The rate of tachycardia was significantly lower in esmolol-treated patients compared to placebo-treated patients (2.2% vs. 48.9%, relative risk (RR): 0.04, 95% confidence interval (95% CI) = 0.01 to 0.32, p = 0.002). The rate of hypertension was also significantly lower in the esmolol group (4.4% vs. 31.1%, RR: 0.14, 95% CI 0.03 to 0.6, p = 0.004). Esmolol-treated patients were associated with higher extubation quality compared to patients who received placebo (p < 0.001), with an approximately two-fold increase in the rate of patients without cough (91.1%) in the esmolol group compared to the placebo group (46.7%). The rate of bucking was approximately 5-fold lower in the esmolol group (8.9% vs. 44.5%, respectively, RR: 0.20 (95% CI, 0.1 to 0.5, p = 0.002, with an NNT of 2.8).

CONCLUSION

A single bolus dose of esmolol is an effective and safe therapeutic strategy to attenuate cardiorespiratory responses during the peri-extubation period.

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.

Efficacy of a Bolus Dose of Esmolol and Bolus Dose of Lignocaine for Attenuating the Pressor Response to Laryngoscopy and Endotracheal Intubation in General Anesthesia: A Comparative Study

Context:

Laryngoscopy and endotracheal intubation result in an increase in heart rate and blood pressure; they evoke life-threatening complications. The esmolol is short-acting cardioselective beta-blocker and brings advantages to the perioperative management of tachycardia and hypertension.

Aims:

The aim of this study was to compare the efficacy of a bolus dose of esmolol and bolus dose of lignocaine for attenuation of the pressor response to laryngoscopy and intubation.

Settings and Design:

Sixty patients of both sex, aged 20–50 years, belonging to the American Society of Anesthesiologists physical Status I and II randomly allocated into two groups (n = 30).

Materials and Methods:

The study drugs diluted in 10-ml normal saline. Group I received esmolol 1.5 mg/kg and Group II received lignocaine 1.5 mg/kg 2 min before inducing the patients with thiopentone 5 mg/kg and suxamethonium 1.5 mg/kg. The heart rate, systolic blood pressure, and diastolic blood pressure were measured at basal, during intubation, and 1, 2, 3, and 5 min after intubation, and based on these values, the mean arterial pressure (MAP) and rate pressure product (RPP) was calculated.

Statistical Analysis Used:

The Student's t-test and data were represented by mean standard deviation and graphs.

Results:

The mean pulse rate, mean of MAP, and mean of RPP at intubation and at 1, 2, 3, and 5 min after intubation in lignocaine group showed a significant rise in these values but in esmolol group it remained nearer to or less than baseline values.

Conclusions:

Esmolol 1.5 mg/kg is effective in attenuating the pressor response in comparison with lignocaine 1.5 mg/kg during laryngoscopy and intubation.