intraoperative beta blockade

[brmc]

It has been my practice to beta block intermiddiate, to high risk patients for non-cardiac surgery. Browsing several studies have shown differing opinions of the effecacy of beta-blockade in prevention of mortality and morbidity.
I usually titrate metoprolol or labatelol for a target heart rate of 60-70. What are others doing or being taught?

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[coprolalia]

What are others doing or being taught?

If you prescribe a beta-blocker naive patient peri-op beta-blockers because of risk stratification, be prepared for badness. Blood pressure and flow are two interrelated but entirely different concepts. Not so much taught, but learned the hard way.

-copro

 

[Planktonmd]

Browsing several studies have shown differing opinions of the effecacy of beta-blockade in prevention of mortality and morbidity.

Beta blockade is the single most beneficial thing you can do to lower the likelihood of perioperative cardiac ischemia.
It would be great if every patient who has risk factors came to you already on oral beta blockers but we don't live in a perfect world, so you can start in the holding area with IV Metoprolol or Atenolol, the post operative regimen will depend on the institutional policy.

 

[brmc]

I usually give 5 mg metoprolol intraoperativley or labatelol, but I have not found any guidlines optimum dosage other then titrating to heart rate and BP. Metoprolol does not seem to do much so I wonder if it is the best choice or is labatelol?

 

[kraphtymac]

Maybe an interesting addition to this thread would be institutional recommendations for PACU or intra-op beta-blockade? Just an idea.

 

[Mman]

I don't think there is any data that a dose of intraoperative beta blocker makes any difference in outcomes. Perioperative beta blockade? It's good, but depends how you define it and many studies have looked at many different definitions.

I'll be interested to see the results of the POISE trial currently underway.

 

[Planktonmd]

I don't think there is any data that a dose of intraoperative beta blocker makes any difference in outcomes. Perioperative beta blockade? It's good, but depends how you define it and many studies have looked at many different definitions.

I'll be interested to see the results of the POISE trial currently underway.

I think that intraoperative beta blockade is better than no beta blockade at all and that beta blockers are excellent adjuncts to any anesthetic in the absence of contraindications.

 

[Lonestar]

I have to agree with planktonmd. I have actually seen the effects of intraop beta blockade on ST segments. I had a patient undergoing Lap Chole who had h/o CAD. Her HR climbed to 90s during the case and i started to notice ST segment depression. called my attentding and gave metoprolol 1mg at a time. Titrated in 10 mg total and saw the ST segement change back to baseline within 10 min. Did an EKG and consulted cardiology in the PACU. no changes and no MI. Thought this was interesting; pt most likely had intraop ischemia which was promptly treated.

 

[VentdependenT]

It would be great if the PMD set the patient up on beta-blockers a few weeks before and for a month or two after in patients with CAD risk factors.

Unfortunately this doesn't happen with any frequency. Hopefully one day there will be better coordination through a electronic infrastructure that will allow the Anesthesiologist to do this in coordination with the PMD.

I think its getting better though. Now if only we could get people to lose 10%BMI prior to surgery.

I was thinking about starting TNF infusions.

 

[Planktonmd]

It would be great if the PMD set the patient up on beta-blockers a few weeks before and for a month or two after in patients with CAD risk factors.

Unfortunately this doesn't happen with any frequency. Hopefully one day there will be better coordination through a electronic infrastructure that will allow the Anesthesiologist to do this in coordination with the PMD.

I think its getting better though. Now if only we could get people to lose 10%BMI prior to surgery.

I was thinking about starting TNF infusions.

That's a great idea!
A bit radical, but I love it!

 

[seinfeld]

This is not related to preop beta blockade in pts at Risk for CAD but...
I read a recent editorial in a throw away about the use of labetatol in pts in the beach chair position. Author made the connection between cerebral ischemic events and the use of labetalol for BP titration to orthopaedic surgeon comfort. THought being it impairs cerebral autoregulation. Any one else have thoughts about this connection?

 

[VentdependenT]

http://www.scahq.org/sca3/newsletters/2005feb/lit3.shtml

CCB's. Food for thought.

 

[VentdependenT]

This is not related to preop beta blockade in pts at Risk for CAD but...
I read a recent editorial in a throw away about the use of labetatol in pts in the beach chair position. Author made the connection between cerebral ischemic events and the use of labetalol for BP titration to orthopaedic surgeon comfort. THought being it impairs cerebral autoregulation. Any one else have thoughts about this connection?

Uhh...what?!

There are so many confounding factors that it is ridiculous to blame labetolol for cerebral damage. Last I checked Labetolol still can't push itself on someone with right shifted cerebral autoregulation and arteriosclerosis.

Bitching orthopods screaming for MAPS in the 50's/SBP in the 90's on an 80 year old grandma under GA in the sitting position. Whatever man.

 

[Nasty Gas]

I'm assuming that most people use a test dose with esmolol prior to pushing metoprolol? I ALWAYS do this in BB naive patients, and usually even in BB tolerant. Just my practice, but I've never been burned (not yet, anyway!!!)

 

[CremeSickle]

I might be a bit off in left field.

I use esmolol on just about every induction I do for pts at risk. 50 on induction blunts any CV response and i dont give fent up front.

Intraop i like lopressor.

 

[Mman]

I have to agree with planktonmd. I have actually seen the effects of intraop beta blockade on ST segments. I had a patient undergoing Lap Chole who had h/o CAD. Her HR climbed to 90s during the case and i started to notice ST segment depression. called my attentding and gave metoprolol 1mg at a time. Titrated in 10 mg total and saw the ST segement change back to baseline within 10 min. Did an EKG and consulted cardiology in the PACU. no changes and no MI. Thought this was interesting; pt most likely had intraop ischemia which was promptly treated.

That was using a beta blocker to treat a specific problem, not just giving it to anybody for the heck of it.

I mean if you had a 45 year old guy with no hx of smoking or sig family hx and no PMH, would you give him a dose of metoprolol intraop (for some random ortho procedure) so long as his HR was above 60?

From all the data for all the trials on perioperative beta blockade I've looked at, the treatment group nearly always has a higher incidence of hypotension and/or bradycardia that required treatment. The treatment groups in high risk groups (patient, procedure, etc) tend to have some better outcomes depending on what you look at. The moral of the story is that you shouldn't just give beta blockers to patients because they don't have a contraindication. They should actually have an indication as well.

The POISE trial is investigating beta blockade (for a month I think) on patients having all sorts of noncardiac surgeries and it's impact on outcomes.

 

[Planktonmd]

That was using a beta blocker to treat a specific problem, not just giving it to anybody for the heck of it.

I mean if you had a 45 year old guy with no hx of smoking or sig family hx and no PMH, would you give him a dose of metoprolol intraop (for some random ortho procedure) so long as his HR was above 60?

From all the data for all the trials on perioperative beta blockade I've looked at, the treatment group nearly always has a higher incidence of hypotension and/or bradycardia that required treatment. The treatment groups in high risk groups (patient, procedure, etc) tend to have some better outcomes depending on what you look at. The moral of the story is that you shouldn't just give beta blockers to patients because they don't have a contraindication. They should actually have an indication as well.

The POISE trial is investigating beta blockade (for a month I think) on patients having all sorts of noncardiac surgeries and it's impact on outcomes.

The indication is: having risk factors.
I don't think anyone said let's give beta blockers to every patient or maybe I missed it.

 

[Mman]

I agree that they need indications. However, there is still zero evidence that intraoperative beta blockade improves outcomes for patients having noncardiac surgery.

Most "experts" I've heard speak on the subject feel that the benefits of beta blockers in the perioperative period are probably in helping prevent tachycardia and hypertension. Of course, they aren't the only drug we have that can do that. Is 5 mg of metoprolol better than 100 mcg of fentanyl?

I would be interested to see what the NNT is for preventing say post-op complications (a-fib, mi, cardiac arrest, length of stay, 30 day mortality, etc) for intermediate to high risk patients having noncardiac surgery that have not been on preoperative beta blockers. Anything from 50 to 50,000 wouldn't be a total shock. I think some decently powered studies should be done on this sort of thing.

 

[Noyac]

Beta-blockers are not only beneficial for cardiac pts. There is growing evidence they decrease post-op pain.

http://www.ncbi.nlm.nih.gov/sites/e...ez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

http://www.ncbi.nlm.nih.gov/sites/entrez

 

[Noyac]

I agree that they need indications. However, there is still zero evidence that intraoperative beta blockade improves outcomes for patients having noncardiac surgery.

Most "experts" I've heard speak on the subject feel that the benefits of beta blockers in the perioperative period are probably in helping prevent tachycardia and hypertension. Of course, they aren't the only drug we have that can do that. Is 5 mg of metoprolol better than 100 mcg of fentanyl?

Here's one:

http://www.ncbi.nlm.nih.gov/sites/e...ailView&TermToSearch=8929262&ordinalpos=1&ito

And if you consider recent evidence that the more narcotics you give during surgery the more pain the pts experiences post-op and therefore the more narcs they need post-op. Which means more tachycardia and hypertension which "may" lead to more cardiac events.

Now if you believe that the intraop beta blocker can decrease post-op pain then it may also benefit the pt in terms of cardiac status. I know, It hasn't been proven but it makes sense now doesn't it.

Just something to think about.

 

[CremeSickle]

am i the only one who uses esmolol?

 

[dhb]

am i the only one who uses esmolol?

it ain't cheap

 

[CremeSickle]

Really? I never actually asked about the cost of esmolol..

I love the drug.. great stuff.

it ain't cheap

 

[Mman]

Here's one:

http://www.ncbi.nlm.nih.gov/sites/e...ailView&TermToSearch=8929262&ordinalpos=1&ito

And if you consider recent evidence that the more narcotics you give during surgery the more pain the pts experiences post-op and therefore the more narcs they need post-op. Which means more tachycardia and hypertension which "may" lead to more cardiac events.

Now if you believe that the intraop beta blocker can decrease post-op pain then it may also benefit the pt in terms of cardiac status. I know, It hasn't been proven but it makes sense now doesn't it.

Just something to think about.

My question about metoprolol vs fentanyl was mostly rhetorical. I'm not arguing that beta blockers are a bad thing. I'm merely pointing out that there is not really any evidence that an intraoperative dose of beta blocker has any positive outcome effects and that some so called experts feel that the things we normally do to avoid hypertension and tachycardia provide the same benefit as beta blockers.

I also wouldn't quote the Mangano atenolol study for much of anything. There are much, much better perioperative beta blocker studies out there. Some good, some bad.

Some of the bad (I don't have links)
-PJ Devereaux in 2005 had a metanalysis covering 22 RCTs and 2437 patients undergoing noncardiac surgery. There was no significant benefit to beta blockers, but a significant increase in bradycardia and hypotension requiring treatment. That was no benefit in mortality, no benefit in cardiac mortality, no benefit in nonfatal MI, no benefit in nonfatal cardiac arrest, no benefit in stroke, etc.
-Yang in 2004 looked at Metoprolol after vascular surgery RCT of metop vs placebo in 497 patients. Pretty high risk patients and they had no difference in any outcome.
-Juul in 2006 had an RCT of 921 patients with diabetes undergoing major noncardiac surgery randomized to toprol xl vs placebo started preop and continued through discharge. Once again found no significant difference in any outcome.

Now don't get me wrong. There have been some decently done smaller trials that have also shown some evidence for improved outcomes with "perioperative beta blockade". But perioperative can mean anything from started 30 days preop to started on the day of surgery and it is equally as variable as to how long in duration.

There just isn't a good answer right now, though. The largest trials tend to show no benefit and some harm while enough smaller trials show benefits to make you wonder. The POISE trial is attempting to enroll 10,000 patients randomized to metoprolol vs placebo for 3 weeks with 30 day and 1 year followup. It will have a lot more power than any of the other RCTs and actually might shed some more light on the subject.

But anybody that claims to know the answer right now is full of something.

 

[ZA_Gasman]

My feeling at the moment is that to beta block intermediate risk patients is a strategy fraught with problems. There are a number of issues i.e. when do you then stop the beta blockade? Are they then at increased risk on withdrawal?

I agree with Mman in that there is just no clear answer at the moment. Even the ACC/AHA focussed update on periop beta blockade didn't offer much clarity (surprising that )

I think we also need to clarify why we are using beta blockade. I agree that there are concrete indications for ultra short acting agents like esmolol in the peri-induction scenario in, for example intracranial aneurysm surgery or in the patient who simply won't tolerate an intubation response, but to use beta blockade intraoperatively and to say that we are ok because the HR is 70-90 doesn't make much sense to me. Decreasing risk is a multimodal approach of which beta blockade is only one component.

Ideally, in my mind anyway, one would want to start beta blockade pre op, continue intraoperatively prn and maintain postoperatively. For how long? Who knows. I know that studies say one month, but I'm real worried about withdrawing beta blockade in a patient who has had compelling indications for their use. We know that receptor populations change when their endogenous ligand is blocked, this is why we need to supplement beta blockade in the periop period in those patients already beta blocked. When we withdraw beta blockade after one month, you can bet those patients get a tachy.

Beta blockers are not a panacea for excellent intraoperative and perioperative management.

....Climbs off his soapbox, gets his coat.....

 

[Planktonmd]

All this talk about the lack of evidence on improved outcome is great but I can tell you from personal experience of many years:
Beta blockers make a huge difference and improve the quality of your anesthetic. They are particularly useful when the anesthesiologist is not personally monitoring the patient at all times and another type of provider is doing that.
Beta blockers go hand in hand with narcotics and should be used as frequently and aggressively as possible.
Sometimes in medicine you just have to use common sense and judgment even if statistical evidence is not very strong, Sometimes we still need to be artists as well as scientists.

 

[Mman]

All this talk about the lack of evidence on improved outcome is great but I can tell you from personal experience of many years:
Beta blockers make a huge difference and improve the quality of your anesthetic. They are particularly useful when the anesthesiologist is not personally monitoring the patient at all times and another type of provider is doing that.
Beta blockers go hand in hand with narcotics and should be used as frequently and aggressively as possible.
Sometimes in medicine you just have to use common sense and judgment even if statistical evidence is not very strong, Sometimes we still need to be artists as well as scientists.

I agree that clinical judgment is very important. However, isn't it interesting that you can randomize so many patients to beta blockers or not and find no difference in mortality or any morbidity you can think of?

I'm not saying don't give patients beta blockers intraop. I do it myself at times (right patient, right indication, etc). But we still need to think about it and what we are trying to accomplish. And I will be very interested to see what large, well conducted, RCTs have to say on the matter. If there is any real benefit to beta blockers intraop or periop (however you choose to define that), then it should be pretty easy to see evidence of.