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LETTERS TO THE EDITOR

Esmolol is Not an Alternative to Remifentanil for Fast-Track Outpatient Gynecologic Laparoscopic Surgery

Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Dresden, Germany

To the Editor:

Coloma et al. (1) were unable to demonstrate an advantage of esmolol but recommended it as an alternative for remifentanil. Their recommendation does not reflect state-of-the-art anesthetic technique. Coadministration of analgesics is usually viewed as essential for a modern concept of balanced anesthesia. Not surprisingly, esmolol attenuated the effects of sympathetic activation but effects on pituitary hormones were ignored (2). This endocrine response is activated by afferent neuronal impulses. Opioids can suppress the following hypothalamic stimulation when they are administered before the surgical stress (3). The authors do not comment on the high variation in esmolol requirements to achieve hemodynamic stability (SD > mean); furthermore, patients of the Esmolol group required significantly more muscle relaxants. This suggests that the provided anesthesia was insufficient. The use of Bispectral Index for monitoring the depth of anesthesia is questionable because the accuracy of the method has not yet been validated for desflurane (4). Neuroplastic changes in the spinal cord after noxious injury have been demonstrated and assumed to be important for the magnitude and the duration of postoperative pain (5). The larger requirement for postoperative analgesics in the Esmolol group was therefore not surprising.

References

1. Coloma M, Chiu JW, White PF, Armbuster SC. The use of esmolol as an alternative to remifentanil during desflurane anesthesia for fast-track outpatient gynecologic laparoscopic anesthesia. Anesth Analg 2001; 92: 352–7.[Abstract/Free Full Text]
2. Desborough JP. The stress response to trauma and surgery. Br J Anaesth 2000; 85: 109–17.[Free Full Text]
3. Bent JM, Paterson JL, Mashiter K, Hall GM. Effects of high-dose fentanyl anaesthesia on the established metabolic and endocrine response to surgery. Anaesthesia 1978; 39: 19–23.
4. Kissin I. Depth of anesthesia and bispectral index monitoring. Anesth Analg 2000; 90: 1114–7.[Free Full Text]
5. Katz J, Kavanagh BP, Sandler AN, et al. Preemptive analgesia: clinical evidence of neuroplasticity contributing to postoperative pain. Anesthesiology 1992; 77: 439–46.[Web of Science][Medline]

Response

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

In Reply:

We feel that Dr. Hubler and colleagues did not correctly characterize the article by Coloma et al. (1) comparing esmolol and remifentanil as adjuvants during gynecologic laparoscopic surgery. Although a less frequent incidence of nausea (4% vs 35% in the remifentanil group) may not be considered an advantage in Germany, patients in this country consider it to be one of the most important adverse outcomes after surgery (2) and are willing to pay "out of pocket" to avoid this uncomfortable side effect (3,4). These findings also confirm our earlier study comparing esmolol to alfentanil during propofol-based anesthesia (5). Therefore, we stand by our published conclusion that "an esmolol infusion was an acceptable alternative to remifentanil infusion for maintaining hemodynamic stability during desflurane-based fast-track anesthesia."

We do not understand the basis for their statement that our technique does not "reflect state-of-the-art anesthetic technique." Balanced anesthesia involves hypnosis (unconsciousness), analgesia, and muscle relaxation. In fact, in the original literature, the analgesic component was provided by local anesthesia, not opioid (narcotic) analgesics. We used acetaminophen 1.3 g per rectum, ketorolac 30 mg IV, and local anesthetic infiltration for analgesia in all study patients. Previous studies have demonstrated that it makes no difference with respect to patient outcome whether acute hemodynamic responses during surgery are controlled with hypnotics, opioid analgesics, adenosine, or sympatholytic drugs (6–8). Where is the evidence supporting these authors’ suggestion that intraoperative changes in "pituitary hormones" affect patient outcome?

The argument that opioids are obviously superior because they can suppress "hypothalamic stimulation" (9) when administered in large doses is irrelevant in this clinical situation. Administering large doses of opioids to outpatients undergoing gynecologic laparoscopic surgery seems inappropriate. Importantly, in the study by Coloma et al. (1), there was no significant difference in the incidence of postoperative pain from the end of surgery until the time of discharge (Table 3).

Although the Bispectral Index (BIS) monitor was used to ensure comparable depths of hypnosis in both treatment groups, the comment that the accuracy of the method has not been validated for desflurane reflects a failure to carefully review the literature (10) and a lack of understanding of the BIS concept. We did not suggest that the BIS was used to monitor the "depth of anesthesia."

Finally, the argument regarding "neuroplastic changes" is not supported by clinical outcome studies. Despite its logical appeal and support in the animal literature, a recent editorial by Eisenach (11) has correctly pointed out that there is little (if any) convincing clinical evidence that the phenomenon of "preemptive analgesia" is important in humans. Of interest, a recent study by Guignard et al. (12) demonstrated that use of remifentanil infusions during surgery can increase postoperative pain (and the requirement for opioid pain medication after surgery) by inducing acute opioid tolerance. In fact, a recent study by Célèrier et al. (13) confirms that we may be contributing to postoperative pain by the use of large doses of opioids during surgery.

In our opinion, esmolol (or other sympatholytic drugs) is an acceptable alternative to remifentanil (or other opioid analgesics).

References

1. Coloma M, Chiu JW, White PF, Armbruster SC. The use of esmolol as an alternative to remifentanil during desflurane anesthesia for fast-track outpatient gynecologic laparoscopic surgery. Anesth Analg 2001; 92: 352–7.
2. Macario A, Weinger M, Carney S, Kim A. Which clinical outcomes are important to avoid? The perspective of patients. Anesth Analg 1999; 89: 652–8.[Abstract/Free Full Text]
3. Tang J, Wang B, White PF, et al. The effect of timing of ondansetron administration on its efficacy, cost-effectiveness, and cost-benefit as a prophylactic antiemetic in the ambulatory setting. Anesth Analg 1998; 86: 274–82.[Abstract]
4. Gan TJ, Sloan F, de L Dear G, et al. How much are patients willing to pay to avoid postoperative nausea and vomiting? Anesth Analg 2001; 92: 393–400.[Abstract/Free Full Text]
5. Smith I, Van Hemelrijck J, White PF. Efficacy of esmolol versus alfentanil as a supplement to propofol-nitrous oxide anesthesia. Anesth Analg 1991; 73: 540–6.[Abstract/Free Full Text]
6. Monk TG, Mueller M, White PF. Treatment of stress response during balanced anesthesia: comparative effects of isoflurane, alfentanil, and trimethaphan. Anesthesiology 1992; 76: 39–45.[Web of Science][Medline]
7. Monk TG, Ding Y, White PF. Total intravenous anesthesia: effects of opioid versus hypnotic supplementation on autonomic responses and recovery. Anesth Analg 1992; 75: 798–804.[Abstract/Free Full Text]
8. Zárate E, Sá Rêgo MM, White PF, et al. Comparison of adenosine and remifentanil infusions as adjuvants to desflurane anesthesia. Anesthesiology 1999; 90: 956–63.[Web of Science][Medline]
9. Bent JM, Paterson JL, Mashiter K, Hall GM. Effects of high-dose fentanyl anaesthesia on the established metabolic and endocrine response to surgery. Anaesthesia 1984; 39: 19–23.[Web of Science][Medline]
10. Song D, Joshi GP, White PF. Titration of volatile anesthetics using bispectral index facilitates recovery after ambulatory anesthesia. Anesthesiology 1997; 87: 842–8.[Web of Science][Medline]
11. Eisenach JC. Preemptive hyperalgesia, not analgesic? Anesthesiology 2000; 92: 308–9.[Web of Science][Medline]
12. Guignard B, Bossard AE, Coste C, et al. Acute opioid tolerance: interoperative remifentanil increases postoperative pain and morphine requirement. Anesthesiology 2000; 93: 409–17.[Web of Science][Medline]
13. Célèrier E, Rivat C, Jun Y, et al. Long-lasting hyperalgesia induced by fentanyl in rats: preventive effect of ketamine. Anesthesiology 2000; 92: 465–72.[Web of Science][Medline]

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