Neuroanesthesia can be frustrating. You give a perfect anesthetic for excision of a frontal tumor, the surgeon even comments on the excellent operating conditions, and the patient awakes pain-free and without a neurologic deficit. Then a call comes in from the PACU telling you that the patient is hypertensive and asking what drug you want given to control blood pressure. Postcraniotomy hypertension occurs commonly and untreated may result in surgical site bleeding, remote cerebral hematomas, cerebral edema, and raised ICP.
Dr. John F. Bebawy and colleagues from the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, compared nicardipine versus esmolol for the treatment of hypertension after craniotomy. Their results are published in this month’s issue of Anesthesia and Analgesia and discussed in the article titled “Nicardipine is Superior to Esmolol for the Management of Post-Craniotomy Emergence Hypertension: A Randomized Open-Label Study.”
The investigators used infusions of either esmolol or nicardipine to maintain SBP < 140 mmHg on the first postoperative day. Nicardipine only failed to control hypertension in 1 out of 20 patients (5%) compared with failure in 11 out of 20 patients (55%) in the esmolol group. Preoperative hypertension did not affect the failure rate of the antihypertensive drugs but was associated with an increased incidence of hypertension and the need for rescue therapy 12-24 hours after discharge from the PACU.
Although this was a small study and not blinded, the results are striking. Labetalol and hydralazine were given as rescue medication, and a study of their efficacy as monotherapy compared with nicardipine would be valuable. This research has yielded important clinical data. Next time there is a call from the PACU to say that the craniotomy patient has become hypertensive, the response is clear: administer nicardipine.