Yonsei Med J.  2015 Jul;56(4):1114-1121. 10.3349/ymj.2015.56.4.1114.

The Effects of Oral Atenolol or Enalapril Premedication on Blood Loss and Hypotensive Anesthesia in Orthognathic Surgery

• Kim NY
• Yoo YC
• Chun DH
• Lee HM
• Jung YS
• Bai SJ

• KMID: 2366355
• DOI: http://doi.org/10.3349/ymj.2015.56.4.1114

Abstract

PURPOSE
The aim of this study was to evaluate the effects of premedication with oral atenolol or enalapril, in combination with remifentanil under sevoflurane anesthesia, on intraoperative blood loss by achieving adequate deliberate hypotension (DH) during orthognathic surgery. Furthermore, we investigated the impact thereof on the amount of nitroglycerin (NTG) administered as an adjuvant agent.
MATERIALS AND METHODS
Seventy-three patients undergoing orthognathic surgery were randomly allocated into one of three groups: an angiotensin converting enzyme inhibitor group (Group A, n=24) with enalapril 10 mg, a beta blocker group (Group B, n=24) with atenolol 25 mg, or a control group (Group C, n=25) with placebo. All patients were premedicated orally 1 h before the induction of anesthesia. NTG was the only adjuvant agent used to achieve DH when mean arterial blood pressure (MAP) was not controlled, despite the administration of the maximum remifentanil dose (0.3 microg kg-1min-1) with sevoflurane.
RESULTS
Seventy-two patients completed the study. Blood loss was significantly reduced in Group A, compared to Group C (adjusted p=0.045). Over the target range of MAP percentage during DH was significantly higher in Group C than in Groups A and B (adjusted p-values=0.007 and 0.006, respectively). The total amount of NTG administered was significantly less in Group A than Group C (adjusted p=0.015).
CONCLUSION
Premedication with enalapril (10 mg) combined with remifentanil under sevoflurane anesthesia attenuated blood loss and achieved satisfactory DH during orthognathic surgery. Furthermore, the amount of NTG was reduced during the surgery.

Keyword

Atenolol; enalapril; premedication; blood loss; surgical; orthognathic surgery

MeSH Terms

Administration, Oral
Adrenergic beta-Antagonists/administration & dosage/*pharmacology
Adult
Aged
*Anesthesia, Inhalation
Atenolol/administration & dosage/*pharmacology
Blood Loss, Surgical
Blood Pressure/drug effects
Cardiac Output/drug effects
Double-Blind Method
Enalapril/administration & dosage/*pharmacology
Female
Heart Rate/drug effects
Humans
Intraoperative Care
Male
Methyl Ethers/*administration & dosage
Middle Aged
*Orthognathic Surgical Procedures
Piperidines/*administration & dosage
*Premedication
Treatment Outcome
Adrenergic beta-Antagonists
Atenolol
Enalapril
Methyl Ethers
Piperidines

Figure

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  Fig. 1 CONSORT flow diagram. Group A, angiotensin converting enzyme inhibitor group; Group B, β-blocker group; Group C, control group.

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  Fig. 2 Mean arterial blood pressures (MAP) in Group A, B, and C at each time point, as described in Table 1. Significant differences over time in MAP were observed among the three groups following analysis using a linear mixed model. The results of Bonferroni post-hoc comparisons for repeated measures indicated a pattern of significant difference in MAP at T1 between Group A and C (adjusted p=0.0561). In addition, MAP at T1 was statistically lower in Group B than Group C (adjusted p<0.001) and MAP at T7 was significantly higher in Group C than Group A (adjusted p<0.001). Group A, angiotensin converting enzyme inhibitor group; Group B, β-blocker group; Group C, control group. *,‡Adjusted p<0.05, †Adjusted p<0.1.

• 

  Fig. 3 (A) Heart rate (HR) and (B) cardiac index (CI) in Groups A, B, and C at each time point, as shown in Table 1. Analysis using a linear mixed model indicated significant overall differences among the three groups, regardless of time. After post-hoc analysis with Bonferroni correction, the HR of Group B was significantly lower than that of Group C (adjusted p=0.0213). Furthermore, there was no significant difference in CI among the three groups at any of the time points analyzed. Group A, angiotensin converting enzyme inhibitor group; Group B, β-blocker group; Group C, control group. *Adjusted p<0.05.

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