title: Esmolol versus ketamine-remifentanil combination for early postoperative analgesia after laparoscopic cholecystectomy: a randomized controlled trial.
abstract: OBJECTIVE
  Controversy surrounds the optimal technique to moderate pain after laparoscopic cholecystectomy (LC). Opioid analgesics, sympatholytic drugs, and adjuvants, such as ketamine, have all been used. We compared esmolol with a combination of remifentanil plus ketamine in patients undergoing LC to determine the impact of these drugs on morphine requirements and pain control.
  
  
  METHODS
  Sixty American Society of Anesthesiologists physical status I-II patients undergoing LC and anesthetized with sevoflurane were randomized to one of two groups. Group E patients received a bolus of esmolol 0.5 mg·kg(-1)                            iv at induction followed by an infusion of 5-15 μg·kg(-1)·min(-1), and Group R-K patients received a bolus of ketamine 0.5 mg·kg(-1)                            iv and remifentanil 0.5 μg·kg(-1)                            iv at induction followed by a remifentanil infusion titrated over a range of 0.1-0.5 μg·kg(-1)·min(-1). All patients received paracetamol, dexketoprofen, and levobupivacaine via infiltration of laparoscopic port sites. After surgery, a predetermined bolus of morphine was administered according to a verbal numerical rating scale (VNRS) for pain intensity. The primary outcome of interest was postoperative morphine requirement.
  
  
  RESULTS
  Median consumption of morphine was higher in Group R-K than in Group E (5 mg [4-6] vs 0 mg [0-2], respectively; P < 0.001). In the postanesthesia care unit, patients in Group R-K had higher pain scores than patients in Group E (difference in maximum VNRS, -11; 95% confidence interval (CI), -19 to -3). The concentration of sevoflurane to maintain a bispectral index~40 was higher in Group E than in Group R-K (between-group difference 0.3%; 95% CI, 0.15 to 0.40). The incidence of postoperative nausea and vomiting was similar between the two groups.
  
  
  CONCLUSIONS
  Intraoperative esmolol infusion reduces morphine requirements and provides more effective analgesia compared with a combination of remifentanil-ketamine given by infusion in patients undergoing LC.
authors.affiliation: Department of Anesthesiology, Hospital Abente y Lago, Complexo Hospitalario Universitario, A Coruña, Spain.
authors.forename: Servando
authors.initials: S
authors.lastname: López-Álvarez
authors.forename: Monica
authors.initials: M
authors.lastname: Mayo-Moldes
authors.forename: Matilde
authors.initials: M
authors.lastname: Zaballos
authors.forename: Belen García
authors.initials: BG
authors.lastname: Iglesias
authors.forename: Rafael
authors.initials: R
authors.lastname: Blanco-Dávila
mesh_terms: D058671:Adrenergic beta-1 Receptor Antagonists / Q000627:therapeutic use; D000328:Adult; D000368:Aged; D000700:Analgesics / Q000008:administration & dosage / Q000627:therapeutic use; D000701:Analgesics, Opioid / Q000008:administration & dosage / Q000627:therapeutic use; D017081:Cholecystectomy, Laparoscopic / Q000379:methods*; D004311:Double-Blind Method; D004359:Drug Therapy, Combination; D005260:Female; D006801:Humans; D007262:Infusions, Intravenous; D007649:Ketamine / Q000008:administration & dosage / Q000627:therapeutic use*; D008297:Male; D008875:Middle Aged; D009020:Morphine / Q000008:administration & dosage; D010149:Postoperative Pain / Q000188:drug therapy*; D010880:Piperidines / Q000008:administration & dosage / Q000627:therapeutic use*; D011412:Propanolamines / Q000627:therapeutic use*; D000077208:Remifentanil
chemical_list: D058671:Adrenergic beta-1 Receptor Antagonists; D000700:Analgesics; D000701:Analgesics, Opioid; D010880:Piperidines; D011412:Propanolamines; D007649:Ketamine; D009020:Morphine; C036604:esmolol; D000077208:Remifentanil