|Year : 2015 | Volume
| Issue : 2 | Page : 189-193
Oral propranolol premedication and hypotensive anesthesia in shoulder arthroscopic surgery: a randomized controlled double-blind study
Sahar M Talaat, Hanaa A El Gendy MD
Department of Anesthesiology, Intensive Care, and Pain Management, Faculty of Medicine, Ain Shams University, Cairo, Egypt
|Date of Submission||13-Dec-2013|
|Date of Acceptance||20-Jan-2014|
|Date of Web Publication||8-May-2015|
Hanaa A El Gendy
Department of Anesthesiology, Intensive Care, and Pain Management, Faculty of Medicine, Ain Shams University, Cairo
Source of Support: None, Conflict of Interest: None
The current study tested whether premedication with oral propranolol (10 mg) before hypotensive anesthesia in shoulder arthroscopic surgery could diminish reflex tachycardia following endotracheal intubation and nitroglycerine (NTG) infusion, the amount of NTG used, and the minimum alveolar concentration (MAC) values of inhalational anesthetic used during hypotensive anesthesia for shoulder arthroscopic surgery.
Patients and methods
A total of 60 American Society of Anesthesiologists (ASA) I patients scheduled for shoulder arthroscopic surgery were included in this randomized controlled double-blinded study on oral propranolol (10 mg) or placebo as a premedication 1 h before the induction of anesthesia. Hemodynamic variables, the amount of NTG, and the MAC values of inhalational anesthetic used were recorded. Visual field visibility by the surgeon using visual analogue score was assessed.
The heart rate, amount of NTG, and the MAC values of sevoflurane used were highly significantly lower (P < 0.01) in the propranolol group; however, no significant difference (P > 0.05) was found in the visual analogue score of the surgeon between the two groups. No statistically significant complications were observed in either group.
Premedication with 10 mg of oral propranolol before shoulder arthroscopic surgery was effective in achieving hypotensive anesthesia. It reduced reflex tachycardia, decreased NTG, and sevoflurane consumption without recorded complications.
Keywords: hypotensive anesthesia, nitroglycerine, propranolol, sevoflurane, shoulder, arthroscopic surgery
|How to cite this article:|
Talaat SM, El Gendy HA. Oral propranolol premedication and hypotensive anesthesia in shoulder arthroscopic surgery: a randomized controlled double-blind study. Ain-Shams J Anaesthesiol 2015;8:189-93
|How to cite this URL:|
Talaat SM, El Gendy HA. Oral propranolol premedication and hypotensive anesthesia in shoulder arthroscopic surgery: a randomized controlled double-blind study. Ain-Shams J Anaesthesiol [serial online] 2015 [cited 2021 Apr 17];8:189-93. Available from: http://www.asja.eg.net/text.asp?2015/8/2/189/156677
| Introduction|| |
One of the anesthetic challenges for shoulder arthroscopic procedures is the need for hypotensive anesthesia to lessen intra-articular hemorrhage and thus provide adequate visualization to the surgeon. The bones bleed at normotension, and the shoulder joint is a highly vascular joint  . Hypotension is commonly induced to alter regional tissue perfusion using drugs such as systemic vasodilators, inhalational anesthetics, ganglionic blockers, and β-adrenergic blockers , . Propranolol is a nonselective β-blocker that blocks both β1 and β2-adrenergic receptors, causing decreased cardiac contractility, heart rate (HR), and cardiac output. The oral form of propranolol is rapidly and completely absorbed from the gastrointestinal tract. The onset of action of oral propranolol is within 20-30 min, with peak plasma concentration attained within 60-90 min  , and its elimination half-life is 3-6 h  . Some authors propose the preanesthetic administration of β-blockers in patients not using such drugs to control blood pressure and HR perioperatively  , and therefore we preferred to use the oral form to benefit from its effect as a preanesthetic medication to help in controlling blood pressure thereafter and to assess its effect on controlling blood pressure intraoperatively, on the amount of nitroglycerine (NTG) needed, on reducing reflex tachycardia following endotracheal intubation and NTG infusion, and on inhalational anesthetic consumption.
| Patients and methods|| |
This prospective, randomized double-blinded study was conducted in the Orthopedic Department of Ain Shams University Hospitals during the period of January 2012 to March 2013. The eligible patients were 60 healthy adults between 18 and 40 years of age with physical status I, according to the classification of the American Society of Anesthesiologists (ASA), undergoing elective shoulder arthroscopic surgery.
All patients in this study were anesthetized by the same anesthesiologists and operated upon by the same surgery team. Patients with bronchial asthma, cardiac, renal, hepatic, hematologic, diabetes mellitus, and other endocrine diseases; those on β-adrenergic blockers; those receiving any antihypertensive therapy; or pregnant females were excluded from the study. After obtaining approval from the Institutional Review Board and informed written consent from patients, the patients were allocated to one of the two study groups by simple randomization. All patients in the current study underwent all routine preoperative investigations. One hour before the induction of anesthesia, the patient was given propranolol tablet (10 mg, P group) or placebo (C group) by a nurse anesthetist blinded to the study. The baseline systolic blood pressure (SBP), mean arterial blood pressure (MABP), and pulse rate were measured before the patient received propranolol or placebo and before the induction of anesthesia. In the operating room, an intravenous access was established using 20- or 18-G intravenous cannula. All patients were monitored with five-lead ECG, invasive blood pressure in the nonoperative arm, pulse oximetry, and end-tidal CO2. Intravenous midazolam (2 mg) was administered to the patients for sedation.
All patients were anesthetized by a standardized anesthetic technique consisting of intravenous induction with 2 mg/kg of 1% propofol and 2 μl/kg of fentanyl. Orotracheal intubation was performed after the patient had received atracurium (0.5 mg/kg). The anesthesia was maintained with 1-3% sevoflurane in oxygen air mixture and atracurium, as required. Ventilation was controlled to maintain an end-tidal CO 2 at 35-40 mmHg. Patients received 10 ml/kg/h of acetated Ringer's fluid infusion intraoperatively. The patients were placed in the semisitting position. The duration of surgery was considered from the time of skin incision to closure of skin incision. Hemodynamic parameters (MABP and HR) were measured every minute after intubation for 5 min, and then continuously recorded at 3-min intervals till the end of surgery.
Before skin incision, controlled hypotension was started to reach the MABP within the target range of 55-60 mmHg by titrating NTG infusion from 0.5 to 10 μg/kg/min. NTG was turned off when the surgeon started hemostasis. The total amount of NTG used and the duration of hypotension (MABP within the target range of 55-60 mmHg) were recorded.
Bradycardia was defined as HR less than 50 beats/min and treated with 0.3 mg atropine intravenous injection. Sustained hypotension was defined as MABP less than 55 mmHg for more than two successive readings and was treated by 10 mg ephedrine single bolus dose and bolus administration of 250 ml of acetated Ringer's solution over 10 min. Intraoperative bradycardia and sustained hypotension were recorded. The minimum alveolar concentration (MAC) values of sevoflurane used were also recorded. The visual analogue score (excellent = 4, good = 3, adequate = 2, poor = 1) was used to grade the visual field visibility of the shoulder joint space during surgery by the surgeon. Emergence time (the time from the end of surgery to opening the eyes on calling the patient's name) was recorded. After recovery, the patient was transported to the postanesthetic care unit.
Primary outcomes of the study was the HR changes following endotracheal intubation and NTG infusion, whereas secondary outcomes were the total amount of NTG, the MAC values of sevoflurane used, and visual field visibility by the surgeon using visual analogue score.
IBM SPSS statistics (v. 22.0, 2013; IBM Corp., Chicago, Illinois, USA) was used for data analysis. Data were expressed as mean ± SD for quantitative parametric measures in addition to median percentiles for quantitative nonparametric measures and both number and percentage for categorized data. Comparison between two independent mean groups for parametric data was done using Student's t-test. χ2 -Test was used to study the association between two variables or comparison between two independent groups with regard to the categorized data. The probability of error at 0.05 was considered significant, whereas the probability at 0.01 and 0.001 was considered highly significant.
Sample size calculations
The sample size was calculated using HR changes following endotracheal intubation and NTG infusion as the primary variables. On the basis of a previous study, 30 patients would be required in each group to achieve an α-error of 5% and a β-error of 1%. Thus, 30 patients in each group were considered sufficient  .
| Results|| |
All 60 adult patients scheduled for elective shoulder arthroscopic surgery completed the study. Of them, 30 patients received oral propranolol (10 mg), and 30 received placebo 1 h before the induction of anesthesia. There were no significant differences between the two groups in terms of their age, sex, weight, operative time, hypotensive time, emergence time, baseline SBP, MABP, and HR ([Table 1]).
On administering oral propranolol (10 mg) 1 h before the induction of anesthesia, there was a highly significant decrease in the HR during the preinduction period, first 5 min after endotracheal intubation, before, and during NTG infusion (P < 0.001). With regard to MABP, there were no significant changes (P > 0.05) between both groups during the preinduction period, last 2 min after endotracheal intubation, before, and during NTG infusion (P > 0.05). However, there was a highly significant decrease in the MABP (P < 0.001) during the first 2 min after endotracheal intubation, and a significant decrease in the MABP (P < 0.05) 3 min after endotracheal intubation ([Table 2]). There were no recorded cases of intraoperative hypotension or bradycardia. There was a highly significant decrease in the total amount of NTG used (P < 0.01) in the propranolol group to achieve the targeted MABP. Of the patients, 80% in the propranolol group required less than 0.5 μg/kg/min in comparison with 40% in the placebo group ([Table 3]). Mean values of sevoflurane used were significantly less in the propranolol group (1.56 ± 0.2554) than in the placebo group (2.407 ± 0.4425) (P < 0.001), whereas there was no significant difference (P > 0.05) between both groups with regard to the visual field visibility by the surgeon using visual analogue score ([Table 4]). Propranolol may cause bradycardia in the postoperative period, and therefore patients were monitored with pulse oximeter up to 6 h of drug use, and there were no recorded cases of HR less than 55 beats/min.
| Discussion|| |
During shoulder arthroscopic surgery, reduction in SBP or MABP (20-25% of baseline in a normotensive individual) decreases bleeding from joint space and optimizes visual field , .
NTG is one of the most commonly used agents in hypotensive anesthesia, has a direct vasodilator effect on the peripheral capacitance, and resistance vessels cause hypotension and baroreceptor-induced reflex tachycardia, which are common occurrences with NTG therapy , . Plasma renin activity, plasma epinephrine, and aldosterone concentrations were also increased after NTG administration  .
β-Adrenergic blockers blunt the reflex tachycardia, which may be effective in decreasing stress response because of laryngoscopy and baroreceptor-induced reflex tachycardia produced by NTG, although additional hypotensive effects may occur. Operative bleeding may be arterial, dependent on MABP and capillary blood flow or venous, and dependent on venous return and venous tone  .
The current study revealed that administering 10 mg oral propranolol premedication 1 h preoperatively for adult patients scheduled for elective shoulder arthroscopic surgery significantly decreased HR following endotracheal intubation and NTG infusion. Moreover, in the present study, 80% of the patients required a small dose of NTG infusion (0.5-0.7 μg/kg/min) to induce hypotension in comparison with 40% only in the placebo group. In addition, there was a highly significant decrease in the total amount of NTG used (P < 0.01) in the propranolol group to achieve the targeted MABP.
In accordance with our study, several previous studies revealed that propranolol is a well-established simple technique to inhibit catecholamine and renin release, minimize reflex tachycardia, and minimize sodium nitroprusside (SNP) and NTG dose requirement during hypotensive anesthesia ,, .
In humans, sevoflurane has a negative inotropic effect in the isolated myocardium  . In animals, sevoflurane decreases myocardial contractility to ~40-45% of control values at greater than or equal to 1.75 MAC  . In the current study, sevoflurane consumption was found to be less in the propranolol group than in the placebo group, which might be cost effective. There was no significant change (P > 0.05) between both groups with regard to the surgeon visual analogue score.
In the present study, the quality of the surgical field assessed by surgeon visual analogue score was satisfactory in both groups, with no statistical difference in between. This is attributed to targeting optimization of the surgical field by optimum hypotensive anesthesia. On the contrary, a study conducted by Amr and Amin  on hypotensive anesthesia for spine surgeries showed better surgical field in the β-adrenergic blocker group in comparison with the placebo group.
In this study, emergence time showed no significant difference between the two groups. There were no recorded cases of rebound hypertension, intraoperative hypotension, or bradycardia. No clinically significant complications were recorded in both groups. In concomitance with our study, previous studies reported the safety and effectiveness of β-adrenergic blockers in hypotensive anesthesia in orthognathic and endoscopic sinus surgery , .
The current study has potential limitations including subjective evaluation of the surgical field, which may lead to inaccurate data and lack of recording cost effectiveness with regard to sevoflurane consumption.
| Conclusion|| |
Premedication with oral propranolol (10 mg) before shoulder arthroscopic surgery was effective in achieving hypotensive anesthesia. It reduced reflex tachycardia, decreased NTG requirement, and diminished sevoflurane consumption without recorded complications.
| Acknowledgements|| |
Conflicts of interest
| References|| |
Tantry TP, Muralishankar BG, Adappa KK, et al.
Target-controlled infusion (propofol) versus inhaled anaesthetic (sevoflurane) in patients undergoing shoulder arthroscopic surgery. Indian J Anaesth 2013; 57:35-40.
Gallagher DM, Milliken RA. Induced hypotension for orthognathic surgery. J Oral Surg 1979; 37:47-51.
Rodrigo C. Induced hypotension during anesthesia, with special reference to orthognathic surgery. Anesth Prog 1995; 42:41-58.
Apipan B, Rummasak D. Efficacy and safety of oral propranolol premedication to reduce reflex tachycardia during hypotensive anesthesia with sodium nitroprusside inorthognathic surgery: a double-blind randomized clinical trial. J Oral Maxillofac Surg 2010; 68:120-124.
Piriou V, Aouifi A, Lehot JJ. Beta-bloquants Perioperative beta-blockers. Part one: fundamentals: indications thérapeutiques. Can J Anesth 2000; 47: 653-663.
Bosco FAP, Braz JRC. Beta-blockers in anesthesiology: clinical and pharmacological aspects. Rev Bras Anestesiol 2001; 51:431-447.
Duralde XA. Bleeding problems during shoulder arthroscopy, chapter 1. In Duralde XA editors. Shoulder arthroscopy: complications in orthopaedics. USA: American Academy of Orthopaedic Surgeons 2009;65:1-7.
Bussmann WD, Kenedi P, von Mengden HJ, et al.
Comparison of nitroglycerin with nifedipine in patients with hypertensive crisis or severe hypertension. J Clin Invest 1992; 70:1085-1088.
Varon J, Marik PE. Perioperative hypertension management. Vasc Health Risk Manag 2008; 4:615-627.
Muiesan ML, Agabiti-Rosei E, Romanelli G, et al.
Transdermal nitroglycerin efficacy in patients with chronic stable angina pectoris as related to sympathetic and renin-angiotensin-aldosterone activity. Eur Heart J 1992; 13:15-21.
Degoute CS. Controlled hypotension: a guide to drug choice. Drugs 2007; 67:1053-1076.
Marshall WK, Bedford RF, Arnold WP, et al.
Effects of propranolol on cardiovascular and renin angiotensin system during hypotension produced by sodium nitroprusside in humans. Anesthesiology 1981; 55:277-80.
O'Rourke ST. Antianginal actions of beta-adrenoceptor antagonists. Am J Pharm Educ 2007 Oct 15;71:95.
Damle NA, Pardeshi SR, Kelkar KV, et al.
Pretreatment with propranolol and captopril for hypotensive anaesthesia with sodium nitroprusside. Anaesth J Clin Pharmacol 1994; 10:195.
Pagel PS, Farber NE, Pratt PF, Warltier DC. Cardiovascular pharmacology, chapter 23. In: Miller RD editors. Miller's anaesthesia
. 7th ed. Philadelphia: Churchill Livingstone 2010;1:595-632.
Eger EI. Inhaled anesthetics: uptake and distribution, chapter 21. In: Miller RD editors. Miller's anaesthesia
. 7th ed. Philadelphia: Churchill Livingstone 2010;1:531-559.
Amr YM, Amin SM. Effects of preoperative β-blocker on blood loss and blood transfusion during spinal surgeries with sodium nitroprusside-controlled hypotension. Saudi J Anaesth 2012; 6:263-267.
Nair S, Collins M, Hung P, et al.
The effect of beta-blocker premedication on the surgical field during endoscopic sinus surgery. Laryngoscope 2003; 114:1042-1046.
[Table 1], [Table 2], [Table 3], [Table 4]