Use of beta blockers in the perioperative period as an opioid-sparing technique can have positive short- and long-term effects, a study has concluded.
A study examining the use of esmolol for sympathetic blockade, as part of a multimodal approach to pain management in patients undergoing arthroscopic shoulder procedures with continuous brachial plexus blockade, has shown significant improvement in several outcome measures. When fentanyl was replaced with esmolol in an enhanced recovery after surgery (ERAS) pathway, unanticipated admissions fell from 11.4% to 2.27% and 30-day emergency department visits decreased from 12.5% to 3.41%.
“These findings support the hypothesis that opioid avoidance utilizing beta blockade as part of a multimodal approach to pain management can have long-term beneficial results,” said Emily Buckley, a certified registered nurse anesthetist at Phelps County Regional Medical Center, in Rolla, Mo. “We conclude that 30-day quality measures can be improved by simple modification of intraoperative anesthesia techniques, as demonstrated in this study.”
Strategy Is to Reduce Opioids
Although opioids remain an integral part of postoperative management, adverse side effects associated with their use can affect the immediate and long-term postoperative course. As Ms. Buckley reported, multimodal pain management, which involves the use of nonsteroidal anti-inflammatory drugs, peripheral nerve blockade and adjuncts (e.g., beta blockers), is a proven strategy of opioid reduction.
The ERAS protocol for shoulder arthroscopic procedures implemented by Ms. Buckley and her colleagues consisted of a continuous interscalene block with a 5-mL bolus of 0.5% ropivacaine and a 5-mL continuous infusion of 0.2% ropivacaine. In addition, esmolol was substituted for fentanyl and supported with a multimodal approach that included ketorolac, dexamethasone and ondansetron.
Along with colleague Michael Burns, also a CRNA, Ms. Buckley conducted a retrospective chart review of scheduled outpatient shoulder arthroscopic procedures performed by a single surgeon at Phelps County Regional Medical Center between November 2014 and December 2016. The procedures included arthroscopic surgical procedures on the sternoclavicular, acromioclavicular and shoulder joints. A total of 200 charts were reviewed, with 24 excluded due to noncompliance with the ERAS protocol.
As Mr. Burns reported at the 2017 annual Spring meeting of the American Society of Regional Anesthesia and Pain Medicine (abstract 3775), the control (n=88) and experimental (n=88) groups were homogeneous with regard to age, sex, American Society of Anesthesiologists physical status, body mass index, and chronic beta-blocker and opioid consumption (P=0.8748, P=0.8801, P=0.5194, P=0.5346, P=0.1553 and P=0.6945, respectively).
Findings Significant After First Day
In the immediate postoperative period, Mr. Burns said, the two groups showed similar opioid consumption and recovery times. Beyond the initial 24-hour time frame, however, findings diverged. The control group had a 12.5% emergency department visit rate, whereas the experimental group demonstrated a significantly lower rate, 3.41% (P=0.0401). The control group also had an unanticipated admission rate of 11.36% compared with a rate of 2.27% in the experimental group (P=0.0031).
According to Mr. Burns, when charts were reviewed for possible factors affecting the difference in unanticipated admissions and emergency department visits, Pvalues were significant for intraoperative and total opioids required.
“Patients receiving a large dose of opioids intraoperatively were at higher risk of failing the OSA [obstructive sleep apnea] protocol, which kept you in-house longer,” said Ms. Buckley, who noted that the most common reasons that patients were admitted to the ER were failure of the OSA protocol, nausea and vomiting, and pain.
“Many of our patients were leaving the medical center and quickly re-entering the health care system,” Mr. Burns said. “ With the initiation of this protocol, however, we had a risk change from one out of four patients being readmitted within 30 days or unanticipated admission the day of surgery to one out of 16.”
As to how esmolol might have influenced these outcomes, Ms. Buckley speculated that both the sparing of fentanyl and the addition of esmolol to the multimodal regimen could have an indirect effect on opioid consumption.
“By decreasing the overall consumption of opioids, we’re reducing both the short- and long-term adverse effects related to that,” Ms. Buckley said. “More and more research is being published regarding opioid-induced hyperalgesia and the long-term effects of the opioids that we give intraoperatively.”
Daniel Sessler, MD, the Michael Cudahy Professor and Chair of the Department of Outcomes Research at the Cleveland Clinic, in Ohio, underscored a strong association in the literature between hypotension and postoperative myocardial infarction, which is the leading cause of 30-day mortality. He inquired whether patients on esmolol were at increased risk for hypotension.
“Anecdotally, we saw less hypotension with esmolol compared to fentanyl,” Ms. Buckley said. “With esmolol, because it’s so short-ac ting, patients do get some breakthrough stimulation that keeps their blood pressure up, whereas with fentanyl, which is longer acting, you get more of a plateaued sedation synergistic effect. I actually think hypotension was improved with esmolol in comparison to fentanyl, but we hope to have results on that later.”
“Very interesting,” Dr. Sessler said. “I look forward to it.”