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Nicardipine is superior to esmolol for the management of postcraniotomy emergence hypertension : a randomized open-label study . BACKGROUND Emergence hypertension after craniotomy is a well-documented phenomenon for which natural history is poorly understood . 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 system have also been proposed . In this open-label study , we compared the monotherapeutic antihypertensive efficacy of the 2 most titratable drugs used to treat postcraniotomy emergence hypertension : nicardipine and esmolol . We also investigated the effect of preoperative hypertension on postcraniotomy hypertension and the natural history of postcraniotomy hypertension in the early postoperative period . METHODS Fifty-two subjects were prospectively randomized to receive either nicardipine or esmolol as the sole drug for treatment of emergence hypertension at the conclusion of brain tumor resection ( 40 subjects finally analyzed ) . After a uniform anesthetic , standardized protocols of these antihypertensive medications were administered for the treatment of systolic blood pressure ( SBP ) > 130 , with the goal of maintaining SBP < 140 throughout the first postoperative day . In the event of study medication " failure , " a " rescue " antihypertensive ( labetalol or hydralazine ) was used . The O'Brien-Fleming Spending Function was used to calculate the appropriate α value for each interim analysis of the primary outcome ; univariate analysis was performed otherwise , with a 2-sided P < 0.05 considered statistically significant . RESULTS The incidence of nicardipine failure ( 5 % , 95 % confidence interval [ CI ] 0.1 % -24.9 % ) was significantly less than that of esmolol ( 55 % , 95 % CI 31.5 % -76.9 % ) as a sole drug in controlling SBP after brain tumor resection ( difference 99 % CI 13.8 % -75.7 % , P = 0.0012 ) . The presence of preoperative hypertension or the approach to surgery ( open craniotomy versus endonasal transsphenoidal ) had no significant effect on the incidence of failure of the antihypertensive regimen used . We did not observe a difference in the need for opioid therapy for postcraniotomy pain between drug groups ( 99 % CI difference -39.2 % -30.2 % ) . Failure of the study drug predicted the need for rescue drug therapy in the initial 12 hours after discharge from the recovery room ( difference success versus failure = -41.7 % , 99 % CI difference -72.3 % to -1.8 % , P = 0.0336 ) but not during the period 12 to 24 hours after discharge from the recovery room ( difference success versus failure = -27.4 % , 99 % CI difference -63.8 % -9.2 % , P = 0.143 ) . However , in those patients carrying a preoperative diagnosis of hypertension , the need for rescue medication was only different during the period 12 to 24 hours after discharge from the recovery room ( difference normotensive versus hypertensive = -35.4 % , 99 % CI difference -66.9 % to -0.3 % , P = 0.0254 ) . CONCLUSIONS Nicardipine is superior to esmolol for the treatment of postcraniotomy emergence hypertension . This type of hypertension is thought to be a transient phenomenon not solely related to sympathetic activation and catecholamine surge but also possibly encompassing other physiologic factors . For treating postcraniotomy emergence hypertension , nicardipine is a relatively effective sole drug , whereas if esmolol is used , rescue antihypertensive medications should be readily available .
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Intervention_Pharmacological
Nicardipine
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Intervention_Pharmacological
esmolol
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Intervention_Pharmacological
nicardipine and esmolol
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Intervention_Pharmacological
nicardipine or esmolol
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Intervention_Pharmacological
( labetalol or hydralazine
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Outcome_Physical
hypertension
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Outcome_Physical
systolic blood pressure ( SBP )
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Outcome_Physical
SBP
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Outcome_Adverse-effects
The incidence of nicardipine failure
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Outcome_Physical
of preoperative hypertension
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Outcome_Other
the need for rescue drug therapy
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Outcome_Other
the need for rescue medication
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Participant_Condition
emergence hypertension
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Participant_Condition
hypertension
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Participant_Sample-size
Fifty-two subjects
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Participant_Sample-size
40
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Participant_Condition
hypertension