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AMBULATORY ANESTHESIA

The Use of Esmolol as an Alternative to Remifentanil During Desflurane Anesthesia for Fast-Track Outpatient Gynecologic Laparoscopic Surgery

Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas

Address correspondence to Paul F. White, PhD, MD, Professor and McDermott Chair of Anesthesiology, Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center at Dallas, 5323 Harry Hines Boulevard, F2.208, Dallas, TX 75390-9068. Address e-mail to paul.white @utsouthwestern.edu.

We compared esmolol and remifentanil infusions with respect to their effect on intraoperative hemodynamic stability and early recovery after outpatient laparoscopic surgery when administered as IV adjuvants during desflurane anesthesia. After premedication with midazolam 2 mg IV, anesthesia was induced with propofol 2 mg · kg^-1 IV in combination with either esmolol 1 mg · kg^-1 IV (n = 27) or remifentanil 1 µg · kg^-1 IV (n = 26) and succinylcholine 1 mg · kg^-1 IV according to a randomized, double-blinded protocol. Anesthesia was initially maintained with des- flurane 2.5% (subsequently titrated to maintain an electroencephalogram-bispectral index value of 60) and nitrous oxide 65% in oxygen. Before skin incision, an infusion of either esmolol (5 µg · kg^-1 · min^-1) or remifentanil (0.05 µg · kg^-1 · min^-1) was started and titrated to maintain the heart rate within 25% of the baseline value. Mivacurium, 0.04 mg/kg IV, bolus doses were administered to maintain a stable peak inspiratory pressure. Esmolol (12.8 ± 13.1 µg · kg^-1 · min^-1) and remifentanil (0.04 ± 0.02 µg · kg^-1 · min^-1) infusions were equally effective in maintaining a stable heart rate during these laparoscopic procedures. Although the mivacurium requirement was larger in the Esmolol group (7 ± 5 vs 3 ± 4 mg), the Esmolol group reported a smaller incidence of postoperative nausea and vomiting (4% vs 35%). Both drugs were associated with frequent "postanesthesia care unit bypass" rates (78–81%), short times to "home readiness" (119–120 min), excellent patient satisfaction (81–85%), and rapid resumption of normal activities (2.6–3.2 d). Fast-tracked patients were ready for discharge home significantly earlier (112 ± 46 vs 151 ± 50 min). We concluded that esmolol infusion is an acceptable alternative to remifentanil infusion for maintaining hemodynamic stability during desflurane-based fast-track anesthesia for outpatient gynecologic laparoscopic surgery.

Implications: Adjunctive use of a variable-rate infusion of esmolol during outpatient anesthesia with desflurane-nitrous oxide was associated with less postoperative nausea and vomiting than a remifentanil infusion. However, both adjuvants facilitated fast-tracking and lead to early discharge after laparoscopic tubal ligation surgery.

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