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• W2000646913 abstract "To the Editor: We read with interest the paper by Cork et al. [1] on esmolol effects during cardiopulmonary bypass (CPB). They are to be congratulated on their meticulous collection and analysis of data. In our opinion, however, their study suffers from a major flaw. The placement of an aortic cross-clamp and infusion of cardioplegic solution to arrest the heart makes esmolol administration from the time of cross-clamp irrelevant, because none is getting to the myocardium! We agree wholeheartedly with the statement in their discussion relating beta-adrenergic antagonism during CPB and potential myocardial protection, but what is the rationale for continued administration of esmolol with the aorta cross-clamped? If there are protective effects, surely it would be advisable rather to continue the infusion during reperfusion (i.e., after cross-clamp release) to prevent potential injury. No mention is made of the constituents and volume of the cardioplegic solution; the simple washout of this after release of the aortic cross-clamp could affect the parameters measured. Was blood cardioplegia used? This would result in some esmolol delivery to the myocardium during cross-clamp. Although the authors reference the association of hyperkalemia with beta-adrenergic blockade, the esmolol group had approximately 50% longer cross-clamp times. A simpler explanation for the hyperkalemia could be increased cardioplegic solution volume: this information is not provided. Furthermore, in their conclusion, the implication that esmolol improved left and right ventricular stroke work indices for the first hour after bypass is plainly misleading, because serum esmolol concentrations were negligible 20 min after cross-clamp removal and it can be read from Table 2 that approximately 50 min passed before weaning from bypass. In the absence of any data relating postoperative course and use of inotropic agents, hemodynamic data and derived indices must be interpreted with caution. Did the reperfusion times differ between the groups? A longer CPB support time after cross-clamp release might explain the improved left and right ventricular stroke work indices in the esmolol group. We are interested to know how the loading dose (500 micro gram centered dot kg-1 centered dot min-1 for 4 min) and the infusion (300 micro gram centered dot kg-1 centered dot min-1) were decided on, especially because no mention is made of the volume of the pump prime and the associated dilution effects. We wonder how the arbitrary period of 10 min after cross-clamp release to stop the infusion was decided on. Furthermore, in Table 2 total esmolol doses infused are quoted in milliliters; we assume this is the 10 mg/mL solution, but this is not stated. We agree with the effects produced by the unfortunate randomization. Surely a number of results presented could be due to preoperative beta blockers. What were these drugs and when were they discontinued before surgery? The later suggestion that chronic beta-adrenergic blockade could have caused patients to be more sensitive to the catecholamine surge at cross-clamp release is puzzling, because the authors have tabulated no major differences from baseline in the catecholamines measured with this event. Although the authors clearly demonstrate rapid elimination of esmolol (within 20 min of cross-clamp removal), they show significant differences in heart rate and mean arterial pressure 25 min after cross-clamp removal and in heart rate 4 and 8 h postoperatively. We question the conclusion that this might be due to the residual esmolol effect, particularly because the esmolol group had a lower preoperative heart rate; this could readily be explained by preoperative beta-adrenergic blockade. Although temperature is mentioned briefly, the method of myocardial temperature measurement is not stated. Because the authors describe the metabolism of esmolol as a metabolic process (and thus temperature dependent), it would be important to note the temperature of the patient after CPB when the samples were taken. David C. Abramson, MBChB, FFA Even G. Pivalizza, MBChB, FFA Uwe Mehlhorn, MD Department of Anesthesiology, University of Texas Health Science Center at Houston, Houston, TX 77030" @default.
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• W2000646913 date "1995-08-01" @default.
• W2000646913 modified "2023-10-03" @default.
• W2000646913 title "Esmolol During Cardiopulmonary Bypass" @default.
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• W2000646913 doi "https://doi.org/10.1097/00000539-199508000-00057" @default.
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