Editorials Bolus Dose Esmolol for Anesthesia: Is There a Need? John B. Leslie, MD* Department Durham,
*Associate Professor of Anesthesia (Head, Section on Critical Care) and Neurology TAssociate Surgery
Professor
of
Cardiothoracic
Address reprint requests to Dr. Prough at the Department of Anesthesia, Bowman Gray School of Medicine, 300 S. Hawthorne Road, Winston-Salem, NC 27103, USA. Supported by HL-33869 from the National Heart, Lung, and Blood Institute Received and accepted for publication April 3, 1990 0 1990 Butterworth-Heinemann
of Anesthesiology,
Duke University
School
of Medicine,
NC.
In this issue of the Journal of Clinical Anesthesia, two papers describe the safety and efficacy of bolus-dose esmolol in blunting the tachycardic and hypertensive responses to laryngoscopy and intubation.ls* A third paper describes the use of bolus-dose esmolol intraoperatively to rapidly and safely control tachycardic events .3 Each of these papers describes the potential use of a recently approved new pharmacologic drug class into the daily clinical practice of anesthesiology; specifically, the incorporation of the very short-acting, beta, cardioselective drug esmolol. As each group of authors note,‘-3 the unique properties of esmolol now permit the anesthesia clinician to produce varying degrees of beta, blockade with a titratability near that of our “gold standard vasodilator” sodium nitroprusside (SNP). Is there a need to provide the rapid and precise control of tachycardia and hypertension in patients undergoing anesthesia? No one dares question the answer! Is there a place for intravenous bolus-dose esmolol in providing the desired control of the cardiovascular system or the hyperdynamic autonomic responses to stress? Does the conclusion of each of these papers really imply that most clinicians will find a need to incorporate bolus-dose esmolol into their routine anesthetic drug armamentarium? Will clinicians administer esmolol rather than “anesthesia” to control increases in heart rate (HR) and blood pressure (BP)? In answering this question of the potential need for rapid beta,-blockade during anesthesia, 1 believe the clinician must consider some of the information relevant to the risks of tachycardia and hypertension. We have known for many years that the balance between myocardial oxygen (0,) supply and demand is critical. Any increased 0, demand exceeding the ability of the coronary arteries to provide the needed increase in coronary flow may precipitate ischemia or infarction (“demandinduced coronary flow deficit”). An increased postoperative morbidity may be associated with perioperative ischemia and infarction.4,5 Issues still remain concerning the “most important parameter” in predicting an inadequate supply-demand balance: BP, HR, double product, triple-product, or the “Buffington Index.“‘j Recent evidence continues to suggest
J. Clin. Anesth.,
vol. 2, July/August
1990
215
Editor-iulc
that patients with ST-segment demonstrated ischemia, whether with good (>40%) or reduced (
*Associate Professor of Anesthesia (Head, Section on Critical Care) and Neurology TAssociate Surgery
Professor
of
Cardiothoracic
Address reprint requests to Dr. Prough at the Department of Anesthesia, Bowman Gray School of Medicine, 300 S. Hawthorne Road, Winston-Salem, NC 27103, USA. Supported by HL-33869 from the National Heart, Lung, and Blood Institute Received and accepted for publication April 3, 1990 0 1990 Butterworth-Heinemann
of Anesthesiology,
Duke University
School
of Medicine,
NC.
In this issue of the Journal of Clinical Anesthesia, two papers describe the safety and efficacy of bolus-dose esmolol in blunting the tachycardic and hypertensive responses to laryngoscopy and intubation.ls* A third paper describes the use of bolus-dose esmolol intraoperatively to rapidly and safely control tachycardic events .3 Each of these papers describes the potential use of a recently approved new pharmacologic drug class into the daily clinical practice of anesthesiology; specifically, the incorporation of the very short-acting, beta, cardioselective drug esmolol. As each group of authors note,‘-3 the unique properties of esmolol now permit the anesthesia clinician to produce varying degrees of beta, blockade with a titratability near that of our “gold standard vasodilator” sodium nitroprusside (SNP). Is there a need to provide the rapid and precise control of tachycardia and hypertension in patients undergoing anesthesia? No one dares question the answer! Is there a place for intravenous bolus-dose esmolol in providing the desired control of the cardiovascular system or the hyperdynamic autonomic responses to stress? Does the conclusion of each of these papers really imply that most clinicians will find a need to incorporate bolus-dose esmolol into their routine anesthetic drug armamentarium? Will clinicians administer esmolol rather than “anesthesia” to control increases in heart rate (HR) and blood pressure (BP)? In answering this question of the potential need for rapid beta,-blockade during anesthesia, 1 believe the clinician must consider some of the information relevant to the risks of tachycardia and hypertension. We have known for many years that the balance between myocardial oxygen (0,) supply and demand is critical. Any increased 0, demand exceeding the ability of the coronary arteries to provide the needed increase in coronary flow may precipitate ischemia or infarction (“demandinduced coronary flow deficit”). An increased postoperative morbidity may be associated with perioperative ischemia and infarction.4,5 Issues still remain concerning the “most important parameter” in predicting an inadequate supply-demand balance: BP, HR, double product, triple-product, or the “Buffington Index.“‘j Recent evidence continues to suggest
J. Clin. Anesth.,
vol. 2, July/August
1990
215
Editor-iulc
that patients with ST-segment demonstrated ischemia, whether with good (>40%) or reduced (
