Efficacy of a single dose of esmolol to prevent extubation-related complications during emergence from anesthesia: a randomized, double-blind, placebo-controlled trial
Eficácia de uma única dose de esmolol para prevenir complicações relacionadas à extubação durante a emergência da anestesia: um estudo randomizado, duplo-cego, controlado por placebo
Fabrício Tavares Mendonça, Jorge Humberto Barreto Filho, Matheus de Bastos Cerqueira Soares Hungria, Thiago Cavalcante Magalhães
Abstract
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.
Keywords
Resumo
Introdução
Poucos estudos examinaram a eficácia do esmolol para atenuar as respostas hemodinâmicas e respiratórias durante a extubação. No entanto, a dose mais adequada de esmolol e um protocolo ideal para administrar esse betabloqueador são incertos.
Métodos
Foram selecionados 90 pacientes com estado físico ASA I, II e III (idade entre 18 e 60 anos) agendados para procedimentos com anestesia geral e extubação traqueal. Os pacientes foram randomizados em grupo esmolol e placebo para avaliar a eficácia e segurança de uma única dose em bolus de esmolol (2mg.kg-1) nas respostas cardiorrespiratórias durante o período peri-extubação. O desfecho primário foi a taxa de taquicardia durante a extubação.
Resultados
A taxa de taquicardia foi significativamente menor em pacientes tratados com esmolol em comparação com pacientes tratados com placebo (2,2% vs. 48,9%, risco relativo (RR): 0,04, intervalo de confiança de 95% (95% CI) = 0,01 a 0,32, p= 0,002). A taxa de hipertensão também foi significativamente menor no grupo esmolol (4,4% vs. 31,1%, RR: 0,14, IC 95% 0,03 a 0,6, p=0,004). Os pacientes tratados com esmolol foram associados com maior qualidade de extubação em comparação com os pacientes que receberam placebo (p<0,001), com um aumento de aproximadamente duas vezes na taxa de pacientes sem tosse (91,1%) no grupo esmolol em comparação com o grupo placebo ( 46,7%). A taxa de bucking foi aproximadamente 5 vezes menor no grupo esmolol (8,9% vs. 44,5%, respectivamente, RR: 0,20 (95% CI, 0,1 a 0,5, p=0,002, com um NNT de 2,8).
Conclusão
Uma única dose em bolus de esmolol é uma estratégia terapêutica eficaz e segura para atenuar as respostas cardiorrespiratórias durante o período peri-extubação.
Palavras-chave
References
1. Asai T, Koga K, Vaughan RS. Respiratory complications associated with tracheal intubation and extubation. Br J Anaesth. 1998;80:767---75.
2. Gavel G, Walker R. Laryngospasm in anaesthesia. Contin Educ Anaesth Crit Care Pain. 2014;14:47---51.
3. Arar C, Colak A, Alagol A, et al. The use of esmolol and magnesium to prevent haemodynamic responses to extubation after coronary artery grafting. Eur J Anaesthesiol. 2007;24:826---31.
4. Miyazaki M, Kadoi Y, Saito S. Effects of landiolol, a short-acting beta-1 blocker, on hemodynamic variables during emergence from anesthesia and tracheal extubation in elderly patients with and without hypertension. J Anesth. 2009;23:483---8.
5. Mendonc¸a FT, de Queiroz LM, Guimaraes CC, et al. Effects of lidocaine and magnesium sulfate in attenuating hemodynamic response to tracheal intubation: single-center, prospective, double-blind, randomized study. Braz J Anesthesiol. 2017;67:50---6.
6. Kutlesic MS, Kutlesic RM, Mostic-Ilic T. Attenuation of cardiovascular stress response to endotracheal intubation by the use of remifentanil in patients undergoing Cesarean delivery. J Anesth. 2016;30:274---83.
7. Sharma J, Sharma V, Gupta S. Comparative study of magnesium sulphate and esmolol in attenuating the pressor response to endotracheal intubation in controlled hypertensive patients. J Anaesth Clin Pharmacol. 2006;22:255---9.
8. Gulabani M, Gurha P, Dass P, et al. Comparative analysis of efficacy of lignocaine 1.5 mg/kg and two different doses of dexmedetomidine (0.5 μg/kg and 1 μg/kg) in attenuating the hemodynamic pressure response to laryngoscopy and intubation. Anesth Essays Res. 2015;9:5---14.
9. Bosco F, Braz J. Beta-blockers in anesthesiology: clinical and pharmacological aspects. Rev Bras Anestesiol. 2001;51:431---47.
10. Garnock-Jones KP. Esmolol: a review of its use in the short-term treatment of tachyarrhythmias and the short-term control of tachycardia and hypertension. Drugs. 2012;72:109---32.
11. Alkaya MA, Sarac¸o˘glu KT, Pehlivan G, et al. Effects of Esmolol on the Prevention of Haemodynamic Responses to Tracheal Extubation after Craniotomy Operations. Turk J Anaesthesiol Reanim. 2014;42:86---90.
12. Dyson A, Isaac PA, Pennant JH, et al. Esmolol attenuates cardiovascular responses to extubation. Anesth Analg. 1990;71:675---8.
13. Tung A, Fergusson NA, Ng N, et al. Pharmacological methods for reducing coughing on emergence from elective surgery after general anesthesia with endotracheal intubation: protocol for a systematic review of common medications and network metaanalysis. Syst Rev. 2019;8:32.
14. Bostan H, Eroglu A. Comparison of the clinical efficacies of fentanyl, esmolol and lidocaine in preventing the hemodynamic responses to endotracheal intubation and extubation. J Curr Surg. 2012;2:24---8.
15. Shrestha S, Chand M, Vaidya P, et al. Attenuation of hemodynamic response to tracheal extubation: comparison of esmolol and lidocaine. Post-Grad Med J NAMS. 2013;13:26---30.
16. Prajwal Patel HS, Shashank MR, Shivaramu BT. Attenuation of Hemodynamic Response to Tracheal Extubation: A Comparative Study between Esmolol and Labetalol. Anesth Essays Res. 2018;12:180---5.
17. Bhatia RS, Nigam P. Atenolol induced hypotension. J Assoc Physicians India. 1991;39:297---8.
18. Fouad FM, Tarazi RC, Bravo EL. Relation of cardiovascular response to the hypotensive effect of metoprolol. Am Heart J. 1982;104:803---11.
19. Unal Y, Ozsoylar O, Sariguney D, et al. The efficacy of Esmolol to blunt the haemodynamic response to endotracheal extubation in lumbar disc surgery. Res J Med Sci. 2008;2:99---104.
20. Lee LY, Pisarri TE. Afferent properties and reflex functions of bronchopulmonary C-fibers. Respir Physiol. 2001;125:47---65.
21. Canning BJ. Anatomy and neurophysiology of the cough reflex: ACCP evidence-based clinical practice guidelines. Chest. 2006;129:33S---47S.
22. Roe N, Lundy F, Litherland G, et al. Therapeutic targets for the treatment of chronic cough. Curr Otorhinolaryngol Rep. 2019;7:128.
23. Tanahashi S, Iida H, Dohi S, et al. Comparative effects of ultrashort-acting beta1-blockers on voltage-gated tetrodotoxinresistant Na+ channels in rat sensory neurons. Eur J Anaesthesiol. 2009;26:196---200.
24. Fallouh HB, Bardswell SC, McLatchie LM, et al. Esmolol cardioplegia: the cellular mechanism of diastolic arrest. Cardiovasc Res. 2010;87:552---60.
Facebook
Google+
Twitter
LinkedIn
Mendeley
StumbleUpon
CiteULike
Reddit
Email