Abstract SNACC-73

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Nicardipine is Superior to Esmolol for the Management of Emergence Hypertension after Craniotomy

Badri A, Bebawy J, Kosky J, Hemmer L, Moreland N, Carabini L, Koht A, Gupta D
Northwestern University, Chicago, IL, USA

Background
Emergence hypertension following craniotomy is a well-described, poorly understood, phenomenon. Most clinicians attribute this phenomenon to an acute and transient increase in catecholamine release, but other mechanisms such as neurogenic hypertension or activation of the Renin-Angiotensin-Aldosterone (RAA) system have also been proposed. We compared, in a prospective and randomized fashion, the antihypertensive efficacy of the two most titratable agents used to control blood pressure following craniotomy, nicardipine and esmolol. We also describe the relationship between preoperative hypertension and post-craniotomy hypertension, as well as describe the natural history of post-craniotomy hypertension in the early postoperative period.
Methods
With IRB approval, 52 subjects were prospectively randomized to receive either nicardipine or esmolol as sole agents for the treatment of emergence hypertension at the conclusion of brain tumor resection (40 subjects finally analyzed). Following a uniform anesthetic, standardized protocols of these antihypertensive medications were administered for the treatment of SBP > 130, with the goal of maintaining SBP < 140 throughout the first postoperative day. In the event of study medication failure, a “rescue” antihypertensive and/or opioid was employed.
Results
Nicardipine is superior to esmolol as a sole agent in controlling systolic blood pressure following brain tumor resection (P = 0.0012). The presence of preoperative hypertension or the approach to surgery (open craniotomy versus endonasal transphenoidal) had no significant effect on the incidence of failure of the antihypertensive regimen used. When stratifying for the study groups, it appears that failure occurs primarily in the PACU (P = 0.0033), where rescue medication is most often required (P = 0.0012). We did not observe a difference in the need for opioid rescue for post-craniotomy pain between the study groups. Of those subjects who failed their antihypertensive (primarily esmolol) infusion postoperatively, the need for rescue medication during the first 12 hours was significant (P = 0.0336), but was not significant at 24 hours. However, in those patients carrying a preoperative diagnosis of hypertension, the need for rescue medication was significant at 24 hours (P = 0.0254).
Conclusions
Nicardipine is superior to esmolol in the treatment of post-craniotomy emergence hypertension. This type of hypertension appears to be a transient phenomenon not solely related to sympathetic activation and catecholamine surge, but also encompassing other post-craniotomy factors. For treating post-craniotomy emergence hypertension, nicardipine is a relatively effective sole agent, while if esmolol is used, rescue antihypertensive medications should be readily available.

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