A Comparison of the Effects of Intraoperative Administration of Metoprolol or Esmolol on General Anesthetic Requirement

Study Overview
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Brief Summary
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We will compare three study groups receiving metoprolol, esmolol, or placebo. Level of anesthesia will be titrated to achieve the same range of BIS value in all groups. Our hypothesis is that the metoprolol and esmolol groups will require a lower level of anesthetic agent to achieve the targeted BIS range, compared to the placebo group. Our objective is to clarify if metoprolol, in a dose range used for perioperative cardiac protection, decreases anesthetic requirement.

Detailed Description
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Beta-receptor antagonists are commonly used in the perioperative setting. These agents have been shown to decrease the incidence of perioperative myocardial ischemia and are recommended by a recent practice guideline in certain patient groups.1 Besides protection from ischemia, there are other situations where beta-receptor antagonists are used intraoperatively such as control of the sympathetic response to tracheal intubation and certain types of surgical stimuli. There is new evidence suggesting that administration of esmolol, a short-acting beta-receptor antagonist, might reduce the actual anesthetic requirement. This was initially shown by studies in which esmolol decreased the amount of anesthetic required to prevent movement after skin incision.2;3 Subsequent studies used bispectral index (BIS) as an endpoint and demonstrated decreased BIS values in subjects receiving esmolol during general anesthesia. 4;5 This anesthetic-sparing effect observed with esmolol has not been prospectively studied with other beta-receptor antagonists. Since perioperative beta-blockade is commonly achieved using longer acting agents such as metoprolol or atenolol, it is clinically relevant to understand the effects of these medications on anesthetic requirement. We aim to conduct a prospective, randomized, controlled, double-blind study to compare the anesthetic-sparing effect of metoprolol and esmolol administered intraoperatively.

Official Title
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A Comparison of the Effect of Intraoperative Administration of Metoprolol or Esmolol on General Anesthetic Requirement

Conditions
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Myocardial Ischemia

Intervention / Treatment
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* Drug: Metoprolol
* Drug: Esmolol
* Drug: P-Group


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Being older than 18 but, not older than 75 Scheduled for surgery under general anesthesia Duration of surgery scheduled as 2 hours or longer Exclusion Criteria: Intracranial or intrathoracic surgery (due to difficulty using a BIS monitor or frequent need for beta-receptor antagonism) Indication for perioperative beta-receptor antagonism Current use of calcium-channel antagonists History of coronary artery disease History of reactive airway disease History of diabetes or other disorders of glucose metabolism Reported allergy to any of the study drugs Reported substance abuse (except nicotine and caffeine) Use of monoamine oxidase (MAO) inhibitor drugs Hypersensitivity to metoprolol, esmolol and related derivatives, or to any of the excipients of either. Hypersensitivity to other beta-blockers (cross-sensitivity between beta-blockers can occur). Sick-sinus Syndrome. Heart block greater than first degree, cardiogenic shock, and overt cardiac failure. Significant first-degree heart block (P-R interval greater than or equal to 0.24 sec; systolic pressure < 100mmHg; or moderate- to-severe cardiac failure). Severe peripheral arterial circulatory disorders. Pheochromocytoma. Baseline heart rate of < 60 Systolic pressure less than 100 mm Hg Pregnant women Prisoners

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 75 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Other
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Quadruple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: M-Group<br>Patients were randomly assigned to Metoprolol Group. The drug was dispensed in 60ml & 5ml syringes of 0.9% NaCl and 1mg/ml Metoprolol. Investigators and patients were blinded to the group assignment. | Drug: Metoprolol<br>* 60ml syringes of 0.9% NaCl, 5ml syringes of metoprolol at 1mg/ml concentration<br>* Other names: M-Group;|
| Experimental: E-Group<br>Patients were randomly assigned to Esmolol Group. The drug was dispensed in 60ml & 5ml syringes of 0.9% NaCl and 10mg/ml Esmolol. Investigators and patients were blinded to the group assignment. | Drug: Esmolol<br>* 60ml syringes of esmolol at 10 mg/ml concentration, 5ml syringes of 0.9% of NaCl<br>* Other names: E-Group;|
| Placebo Comparator: P-Group<br>Patients were randomly assigned to this group. Patients received 0.9% NaCl only. To maintain the blind, 0.9% NaCl was also dispensed in 60ml & 5ml syringes. | Drug: P-Group<br>* 0.9%NaCl dispensed in 60ml & 5ml syringes<br>* Other names: Placebo Comparator;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Area Under the Curve of etSEV Over the First Hour | We will measure the amount of Sevoflurane used to achieve the same level Bispectral Index. Each patient will have their percentage of sevoflurane in expired breath measured every 5 minutes for 2 hours, resulting in 24 data points per person. The primary endpoint will be area under the curve (AUC) for each subject for the first hour. | Every 5 minutes for 2 hours |