Intraoperative Esmolol Infusion Research Articles

Efficacy of esmolol versus magnesium sulphate on quality of recovery in patients undergoing laparoscopic cholecystectomy: Randomized controlled study

ABSTRACT Background Ambulatory procedures have a universal objective of rapid, efficient and secure recovery and release. Preliminary advances utilizing intraoperative esmolol infusion have registered a postoperative opioid saving outcomes. In the current study, we compared intraoperative esmolol versus magnesium sulphate infusions on postoperative recovery profile and stay in the postanaesthesia care unit (PACU). Patients and methods Sixty patients, of both sexes, of ASA I or II planned for ambulatory laparoscopic cholecystectomy under general anaesthesia were engaged into two groups. Esmolol group was given loading dose (1 mg/kg) over a period of 10 minutes followed by (30 μg/kg/min) all through the surgery, whereas magnesium sulphate (MgSo4) group was given loading dose (40 mg/kg) over 10 minutes then maintenance dose (15 mg/kg/h) till end of surgery. General anaesthesia and postoperative analgesia were standardized for all patients. Variables denoting immediate recovery from anaesthesia, pain score and time for first call to analgesia were recorded. White-Song score ≥ 12 were employed as a tool to review the rapidity of recovery. Results Compared to MgSo4 group, the esmolol group exhibited statistically significant shorter times for sponteaous eye opening, tongue extension, extubation and patients’ capability to recall their names. Incidence of vomiting as well as the total amount of ondansetron consumed in the PACU were evidently less among the esmolol group, whereas pain scores and the time of recall for first rescue analgesia did not vary significantly among the two studied groups. Members of the esmolol group displayed significant higher White -Song score at all times of measurements except at 120 minutes compared to those of MgSo 4 group. Conclusions Perioperative esmolol infusion is accompanied by superior and fast-tracked recovery profile compared to MgSo4 infusion.

Intra-operative esmolol and pain following mastectomy: A randomised clinical trial.

Esmolol is a beta-1 selective blocker that has been shown to reduce postoperative pain. Its antinociceptive effects have not been tested following mastectomy. To evaluate the safety, efficacy and antinociception of intra-operative esmolol infusion after mastectomy. Randomised, double-blinded, placebo-controlled trial. Tertiary referral centre, Brasília, Brazil. Recruitment: July 2015 to July 2017. Seventy women scheduled for mastectomy, ASA I to III, aged 18 to 75 years. Four were excluded. All underwent general anaesthesia. The intervention group received a bolus of 0.5 mg kg-1 of esmolol over 10 min followed by a continuous infusion of 100 μg kg-1 min-1. The placebo group received saline. The primary outcome was pain at rest 24 h after mastectomy as measured by a 0 to 10 numeric rating scale. Pain scores at rest 24 h after mastectomy were lower in esmolol-treated patients compared with placebo (mean difference = -1.51, 95% confidence interval (CI), -2.36 to -0.65, P = 0.001). On arrival in the postanaesthesia care unit (PACU), the occurrence of pain was also lower in the esmolol group, at rest and on effort (P = 0.009 and P = 0.013, respectively), on discharge from PACU (P = 0.009 and P = 0.015), 12 h (P = 0.01 and P = 0.007) and on effort in the 24 postoperative hours (P = 0.003). Mean morphine consumption was reduced by 77% in the esmolol group compared with the placebo group (mean difference = -2.52 mg, 95% CI = -3.67 to -1.38, P < 0.001). The length of hospital stay was shorter for the esmolol group (mean difference = -6.9 h, 95% CI, -13.4 to -0.31, P = 0.040). Esmolol was well tolerated, allowed a notable reduction in the dose of rescue analgesics and demonstrated superior efficacy compared to placebo for pain management after mastectomy. ClinicalTrials/NCT02466542.

Does esmolol infusion have an adjuvant effect on transversus abdominis plane block for pain control in laparoscopic cholecystectomy? A randomized controlled double-blind trial

ABSTRACT Background Both intraoperative esmolol and transversus abdominis plane (TAP) block facilitate postoperative analgesia after laparoscopic cholecystectomy as part of multimodal analgesia. Both strategies can minimize the use of postoperative opioids. In current study, our goal was to assess if intra-operative esmolol infusion in association with TAP block can overcome the deficits of TAP block alone after laparoscopic cholecystectomy. Methods This prospective, randomized and double-blinded clinical trial included 60 patients of either sex who scheduled for elective laparoscopic cholecystectomy; received either ultrasound-guided TAP block alone or in association with intravenous esmolol bolus (0.5 mg/kg) before induction followed by a maintenance infusion (0.05 mg/kg/min) till the end of operation. Intra-operative hemodynamic parameters were followed up. Postoperatively, in order to maintain visual analogue scale (VAS) scores ≤3, patients received IV morphine. The primary outcome was amount of opioid consumption during the first 24 hours postoperative. Pain scores, mean arterial pressure (MAP), heart rate (HR) and occurrence of nausea/vomiting were secondary outcomes. Results The mean morphine consumption after surgery in patients receiving esmolol was (5.83) mg compared to (7.5) mg in TAP only group (p = 0.204). The mean pain scores at early postoperative hours were significantly lower in esmolol group (p < 0.05). MAP and HR were significantly lower in esmolol group intraoperative; however, no variance was detected later. Conclusion In the first 24 hours following surgery, esmolol infusion increased the analgesic impact of TAP block in terms of opioid demand and pain severity.

The effect of perioperative esmolol infusion on the postoperative pain and nausea vomiting after middle ear surgeries

Background: Pain and postoperative nausea and vomiting are the most common postoperative complications in middle ear surgeries. Amongst the beta-blockers, esmolol is ultrashort acting cardio selective β1 receptor antagonist used for management of postoperative pain. It also contributes to the significant decrease in PONV and reduces patient distress and facilitates earlier discharge. Objective: To evaluate the effectiveness of perioperative esmolol infusion on postoperative pain relief and postoperative nausea vomiting after middle ear surgeries. Methods: After obtaining approval from Institution Ethics Committee, 70 patients of age 15 and 65 years of ASA I,II and III were allocated with randomization into two groups of 35 each. Group C: 30 ml normal saline loading dose and thereafter continuous infusion of 1ml/min and Group E:0.5mg/kg esmolol in 30ml NS loading dose and 30ug/kg/min as infusion. Results: Average duration of analgesia was about 535 min in group E as compared to 187 min in group C. For PONV requirement of inj. ondansetron in group E was after 145 min and in group C it was 20 min. Group E patients had significantly less variations in blood pressure and heart rate intraoperatively and the response to intubation was masked as compared to group C. Conclusion: Intraoperative esmolol infusion is a newer justified method to reduce postoperative pain and PONV with advantage of hemodynamic stability.

Effect of Intraoperative Esmolol Infusion on Haemodynamics and Surgical Field in FESS Under General Anaesthesia

Introduction: Functional endoscopic sinus surgery (FESS) is a commonly performed operation. Endoscopic sinus surgery allows enhanced illumination and visualization and it has dramatically improved surgical dissection. However major complications such as excess bleeding and poor visibility can arise do to work in a confined space.Due to poor visibility longer time to perform the surgery may arise. Material and Methods: This study was performed on randomly selected 60 patients, in a randomized placebo controlled double blind prospective study. We evaluated the hypotensive efficacy of intravenous Esmolol in FESS, reduction in blood pressure and Quality of surgical field and complications under general anaesthesia. Conclusions: Esmolol produces a lower surgical bleeding scores and better quality of operative field for the surgeon as well as less adverse effects.

The effect of intraoperative lidocaine versus esmolol infusion on postoperative analgesia in laparoscopic cholecystectomy: a randomized clinical trial

BackgroundAs a part of multimodal analgesia for laparoscopic cholecystectomy, both intraoperative lidocaine and esmolol facilitate postoperative analgesia. Our objective was to compare these two emerging strategies that challenge the use of intraoperative opioids. We aimed to assess if intraoperative esmolol infusion is not inferior to lidocaine infusion for opioid consumption after laparoscopic cholecystectomy.MethodsIn this prospective, randomized, double-blind, non-inferiority clinical trial, 90 female patients scheduled for elective laparoscopic cholecystectomy received either intravenous (IV) lidocaine bolus 1.5 mg/kg at induction followed by an infusion (1.5 mg/ kg/h) or IV bolus of esmolol 0.5 mg/kg at induction followed by an infusion (5–15 μg/kg/min) till the end of surgery. Remaining aspect of anesthesia followed a standard protocol apart from no intraoperative opioid supplementation. Postoperatively, patients received either morphine or tramadol IV to maintain visual analogue scale (VAS) scores ≤3. The primary outcome was opioid consumption (in morphine equivalents) during the first 24 postoperative hours. Pain and sedation scores, time to first perception of pain and void, and occurrence of nausea/vomiting were secondary outcomes measured up to 24 h postoperatively.ResultsTwo patients in each group were excluded from the analysis. The postoperative median (IQR) morphine equivalent consumption in patients receiving esmolol was 1 (0–1.5) mg compared to 1.5 (1–2) mg in lidocaine group (p = 0.27). The median pain scores at various time points were similar between the two groups (p > 0.05). More patients receiving lidocaine were sedated in the post-anesthesia care unit (PACU) than those receiving esmolol (p < 0.05); however, no difference was detected later.ConclusionInfusion of esmolol is not inferior to lidocaine in terms of opioid requirement and pain severity in the first 24 h after surgery. Patients receiving lidocaine were more sedated during their stay in PACU than those receiving esmolol.Trial registrationClinicalTrials.gov- NCT02327923. Date of registration: December 31, 2014.

The Effects of Intraoperative Esmolol Infusion on the Postoperative Pain and Hemodynamic Stability after Rhinoplasty

ABSTRACTBackground: Esmolol an ultrashort acting cardioselective β1-adrenergic receptor antagonist), has been successfully employed for perioperative sympatholysis. In this study, we tested the hypothesis that perioperative esmolol administration resulted in decreased postoperative pain and improves the hemodynamic balance in patients with rhinoplasty. Methods: In this clinical trial study, fifty-six patients (56) undergoing rhinoplasty surgery were randomly distributed into two groups (Group E and Group C). Patients in the Group E were administered 5–10 µg/kg/min of esmolol in combination with propofol and remifentanil titrated to hemodynamic response. Patients in the Group C were administered normal saline, having same volume as the esmolol in addition to propofol and remifentanil. The mean blood pressure, opioid requirement, pain score, and heart rate were evaluated 30 min, 1 h and 3 h, respectively, after surgery. Results: Postoperative pain was reduced significantly in the first 3 postoperative hours, and the need to use morphine was decreased in the group receiving esmolol. Group E patients had significantly less variations in blood pressure and heart rate postoperatively. Conclusions: Intraoperative esmolol infusion is a valid method to reduce postoperative pain, it provide lesser need to analgesics and hemodynamic stability in first 3 hours of post rhinoplasty surgery.

Recent trends in the anesthetic management of craniotomy for supratentorial tumor resection.

The article reviews the recent evidence on the anesthetic management of patients undergoing craniotomy for supratentorial tumor resection. A rapid recovery of neurological function after craniotomy for supratentorial tumor allows for the prompt diagnosis of intracranial complications and possibly an early hospital discharge. Intraoperative esmolol infusion was shown to reduce the anesthetic requirements, and may facilitate a more rapid recovery of neurological function. Outpatient craniotomy for supratentorial tumor resection has been associated with several clinical and economic benefits, but has not gained widespread use because of skepticism and medical-legal concerns. Awake craniotomy is associated with advantageous outcomes compared with surgery under general anesthesia, and is regarded as the standard of care for tumors that reside in or in close proximity to the eloquent brain. Recent studies have demonstrated that intraoperative electroacupuncture, dexmedetomidine, pregabalin, and lidocaine may facilitate postcraniotomy pain management. The use of volatile anesthetic agents in cancer surgery is associated with a worse survival compared with intravenous anesthetics, possibly by hindering immunologic defenses against cancer cells. Recent evidence has yielded valuable information regarding anesthetic management of patients undergoing supratentorial tumor craniotomy. Despite a plethora of studies that compare short-term outcomes using different anesthetic and analgesic regimens, randomized controlled trials that examine the long-term outcomes (i.e., neurocognitive function, quality of life, tumor recurrence, and survival) that are of particular interest to patients are needed.

Effects of esmolol infusion on recovery profile and discharge from postanesthesia care unit after ambulatory gynecologic laparoscopic surgeries

Context Ambulatory surgery has a target of rapid recovery and discharge. Esmolol has sparing effects on inhalational anesthetics and opioids. Aim The aim of the study was to demonstrate effects of esmolol infusion on recovery profile and discharge from postanesthesia care unit (PACU). Settings and design This study was a randomized, double-blind, and controlled study. Patients and methods Sixty female patients scheduled for elective gynecologic laparoscopic surgery under general anesthesia were divided into two groups. Patients were given either esmolol loading and maintenance doses (the esmolol group) or equivalent volume of normal saline (the control group). Esmolol was given as a loading dose of 1 mg/kg just before induction of anesthesia followed by an infusion of 30 mg/kg/min. Depth of anesthesia was controlled by bispectral index monitoring and variable dose propofol infusion, whereas fentanyl and sevoflurane doses were fixed throughout the procedure. Times denoting recovery from anesthesia were recorded. Patients who reached White-Song score of 12 plus pain numerical rating scale below 4 were discharged from PACU. Time needed for PACU discharge was recorded. Results Compared with the control group, the esmolol group had following statistically significant results: lower blood pressure and heart rate, less fluctuant bispectral index values, lower amount of propofol infusion used, shorter times for immediate postoperative eye opening, extubation, tongue protrusion, and ability of the patient to mention her name, lower pain scores, fewer patients needed analgesics and earlier discharge from PACU. Conclusion Intraoperative esmolol infusion is associated with hemodynamic stability and antinociceptive properties. Recovery profile was excellent and helped early discharge from PACU.

Effect of intraoperative esmolol infusion on anesthetic, analgesic requirements and postoperative nausea-vomitting in a group of laparoscopic cholecystectomy patients

PurposePostoperative pain and nausea/vomitting (PNV) are common in laparoscopic cholecystectomy patients. Sympatholytic agents might decrease requirements for intravenous or inhalation anesthetics and opioids. In this study we aimed to analyze effects of esmolol on intraoperative anesthetic-postoperative analgesic requirements, postoperative pain and PNV. MethodsSixty patients have been included. Propofol, remifentanil and vecuronium were used for induction. Study groups were as follows; I – Esmolol infusion was added to maintenance anesthetics (propofol and remifentanil), II – Only propofol and remifentanil was used during maintenance, III – Esmolol infusion was added to maintenance anesthetics (desflurane and remifentanil), IV – Only desflurane and remifentanil was used during maintenance. They have been followed up for 24h for PNV and analgesic requirements. Visual analog scale (VAS) scores for pain was also been evaluated. ResultsVAS scores were significantly lowest in group I (p=0.001–0.028). PNV incidence was significantly lowest in group I (p=0.026). PNV incidence was also lower in group III compared to group IV (p=0.032). Analgesic requirements were significantly lower in group I and was lower in group III compared to group IV (p=0.005). Heart rates were significantly lower in esmolol groups (group I and III) compared to their controls (p=0.001) however blood pressures were similar in all groups (p=0.594). Comparison of esmolol groups with controls revealed that there is a significant decrease in anesthetic and opioid requirements (p=0.024–0.03). ConclusionUsing esmolol during anesthetic maintenance significantly decreases anesthetic-analgesic requirements, postoperative pain and PNV.

Intraoperative esmolol infusion reduces postoperative analgesic consumption and anaesthetic use during septorhinoplasty: a randomized trial

Background and objectivesEsmolol is known to have no analgesic activity and no anaesthetic properties; however, it could potentiate the reduction in anaesthetic requirements and reduce postoperative analgesic use. The objective of this study is to evaluate the effect of intravenous esmolol infusion on intraoperative and postoperative analgesic consumptions as well as its effect on depth of anaesthesia. MethodsThis randomized-controlled double blind study was conducted in a tertiary care hospital between March and June 2010. Sixty patients undergoing septorhinoplasty were randomized into two groups. History of allergy to drugs used in the study, ischaemic heart disease, heart block, bronchial asthma, hepatic or renal dysfunction, obesity and a history of chronic use of analgesic or β-blockers were considered cause for exclusion from the study. Thirty patients received esmolol and remifentanil (esmolol group) and 30 patients received normal saline and remifentanil (control group) as an intravenous infusion during the procedure. Mean arterial pressure, heart rate, and bispectral index values were recorded every 10min. Total remifentanil consumption, visual analogue scale scores, time to first analgesia and total postoperative morphine consumption were recorded. ResultsThe total remifentanil consumption, visual analogue scale scores at 0, 20 and 60min, total morphine consumption, time to first analgesia and the number of patients who needed an intravenous morphine were lower in the esmolol group. ConclusionsIntravenous infusion of esmolol reduced the intraoperative and postoperative analgesic consumption, reduced visual analogue scale scores in the early postoperative period and prolonged the time to first analgesia; however it did not influence the depth of anaesthesia.

Comparison of effects of intraoperative esmolol and ketamine infusion on acute postoperative pain after remifentanil-based anesthesia in patients undergoing laparoscopic cholecystectomy.

BackgroundRemifentanil is a short-acting drug with a rapid onset that is useful in general anesthesia. Recently, however, it has been suggested that the use of opioids during surgery may cause opioid-induced hyperalgesia (OIH). Researchers have recently reported that esmolol, an ultra-short-acing β1 receptor antagonist, reduces the postoperative requirement for morphine and provides more effective analgesia than the administration of remifentanil and ketamine. Hence, this study was conducted to determine whether esmolol reduces early postoperative pain in patients who are continuously infused with remifentanil for anesthesia during laparoscopic cholecystectomy.MethodsSixty patients scheduled to undergo laparoscopic cholecystectomy were randomly divided into three groups. Anesthesia was maintained with sevoflurane and 4 ng/ml (target-controlled infusion) of remifentanil in all patients. Esmolol (0.5 mg/kg) was injected and followed with a continuous dosage of 10 µg/kg/min in the esmolol group (n = 20). Ketamine (0.3 mg/kg) was injected and followed with a continuous dosage of 3 µg/kg/min in the ketamine group (n = 20), while the control group was injected and infused with an equal amount of normal saline. Postoperative pain score (visual analog scale [VAS]) and analgesic requirements were compared for the first 6 hours of the postoperative period.ResultsThe pain score (VAS) and fentanyl requirement for 15 minutes after surgery were lower in the esmolol and ketamine groups compared with the control group (P < 0.05). There were no differences between the esmolol and ketamine groups.ConclusionsIntraoperative esmolol infusion during laparoscopic cholecystectomy reduced opioid requirement and pain score (VAS) during the early postoperative period after remifentanil-based anesthesia.

L’esmolol versus l'association kétamine-rémifentanil pour une analgésie postopératoire précoce après cholécystectomie par laparoscopie: une étude randomisée contrôlée

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. 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 0.5mg·kg(-1) iv at induction followed by an infusion of 5-15μg·kg(-1)·min(-1), and Group R-K patients received a bolus of ketamine 0.5mg·kg(-1) iv and remifentanil 0.5μg·kg(-1) iv at induction followed by a remifentanil infusion titrated over a range of 0.1-0.5μg·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. Median consumption of morphine was higher in Group R-K than in Group E (5mg [4-6] vs 0mg [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. 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.

Effects of preoperative oral beta blocker versus intraoperative nitroprusside or esmolol on quality of surgical field during tympanoplasty

Study Objective To determine whether orally administered atenolol provides an optimal surgical field in comparison to intravenous sodium nitroprusside or esmolol during tympanoplasty. Design Randomized, double-blinded study. Setting Operating room in a university hospital. Patients 105 ASA physical status 1 and 2 adult patients undergoing tympanoplasty. Interventions Patients were randomized to three groups to receive either oral atenolol 50 mg twice daily for one day prior to surgery (Group I), intraoperative nitroprusside infusion (Group II), or intraoperative esmolol infusion (Group III). Measurements Quality of the operative field, mean arterial pressure, and heart rate were assessed. Blood gases, liver enzymes, cardiac troponin I, creatine kinase isoenzyme-MB release, blood urea nitrogen, and creatinine concentrations also were measured. Main Results Time to achieve target surgical field was significantly reduced in the atenolol group versus the other groups (8.3 ± 3.2, 28.2 ± 6.4, and 17.2 ± 5.3 min, respectively). Heart rate significantly decreased in the atenolol and esmolol groups versus the nitroprusside group ( P < 0.0001). Mean arterial pressure after extubation and frequency of rebound hypertension were comparable in the groups. No significant changes in cardiac enzymes, renal and hepatic function, or acid-base status were noted. Conclusions Although the three drugs are acceptable for obtaining an optimum surgical field, preoperative oral beta blocker appeared to be rapid in onset and was simpler to implement.

The Sparing Effect of Low-Dose Esmolol on Sevoflurane during Laparoscopic Gynaecological Surgery

This double-blind, randomized, placebo-controlled study evaluated the sparing effect of esmolol on sevoflurane during laparoscopic gynaecological surgery in 54 patients between December 2009 and May 2010. The concentration of sevoflurane required to maintain adequate anaesthesia was determined. Patients received either a 0.5 mg/kg esmolol intravenous loading dose followed by infusion of 30 μg/kg per min or an identical volume of normal saline (placebo). During surgery the input concentration of sevoflurane was adjusted every 5 min to maintain systolic blood pressure within 15% of baseline and bispectral index at 50 - 60. Infusion of esmolol resulted in an 18.2% decrease in mean sevoflurane input concentration. Patients receiving esmolol had an earlier discharge from the postanaesthetic care unit and a lower mean fentanyl dose. In conclusion, intraoperative esmolol infusion decreased both the requirement for sevoflurane and postoperative administration of fentanyl.

Intraoperative Esmolol Infusion in the Absence of Opioids Spares Postoperative Fentanyl in Patients Undergoing Ambulatory Laparoscopic Cholecystectomy

The use of opioids during ambulatory surgery can delay hospital discharge or cause unexpected hospital admission. Preliminary studies using an intraoperative continuous infusion of esmolol in place of an opioid have inconsistently reported a postoperative opioid-sparing effect. In this study, we compared esmolol versus either intermittent fentanyl or continuous remifentanil on postoperative opioid-sparing, side effects, and time of discharge. Ninety patients (consisting of three groups) were enrolled in this prospective, randomized, and observer-blinded study. The control group (n = 30) received intermittent doses of fentanyl, the esmolol group (n = 30) received a continuous infusion of esmolol (5-15 microg x kg(-1) x min(-1)) and no supplemental opioids during surgery, and the remifentanil group (n = 30) received a continuous infusion of remifentanil (0.1-0.5 mixrog x kg(-1) x min(-1)). General anesthesia was standardized, and adjuvant medications included acetaminophen, ketorolac, local anesthetics in the skin incisions, dexamethasone, and droperidol. Postoperative analgesia included fentanyl. The amount of fentanyl in the postanesthesia care unit was significantly less in the esmolol group, 91.5 +/- 42.7 microg, compared with the other two groups, remifentanil, 237.8 +/- 54.7 microg, control, 168.1 +/- 96.8 microg (P < 0.0001). The incidence of nausea was more frequent in the control (66.7%) and remifentanil (67.9%) groups compared with the esmolol group (30%) (P < 0.01). The esmolol group reached the White-Song score of 12 of 14 faster than the remifentanil group (P < 0.01), and left the hospital 45-60 min earlier (P < 0.004). Intraoperative IV infusion of esmolol contributes to a significant decrease in postoperative administration of fentanyl and ondansetron and facilitates earlier discharge.