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    Beta Blocker Agents

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    kuncupcupu1368
    The document discusses the appropriate use of beta blockers in the perioperative period, including which patients should receive beta blockers based on their risk level, the optimal timing for administration and discontinuation, recommended beta blockers such as metoprolol, and strategies for titrating dosage and monitoring patients. It provides evidence that perioperative beta blocker use can reduce in-hospital mortality for high-risk patients undergoing surgery.

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    Beta Blocker Agents

    Uploaded by

    kuncupcupu1368
    138 views28 pages
    The document discusses the appropriate use of beta blockers in the perioperative period, including which patients should receive beta blockers based on their risk level, the optimal timing for administration and discontinuation, recommended beta blockers such as metoprolol, and strategies for titrating dosage and monitoring patients. It provides evidence that perioperative beta blocker use can reduce in-hospital mortality for high-risk patients undergoing surgery.

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    The document discusses the appropriate use of beta blockers in the perioperative period, including which patients should receive beta blockers based on their risk level, the optimal timing for administration and discontinuation, recommended beta blockers such as metoprolol, and strategies for titrating dosage and monitoring patients. It provides evidence that perioperative beta blocker use can reduce in-hospital mortality for high-risk patients undergoing surgery.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    138 views28 pages

    Beta Blocker Agents

    Uploaded by

    kuncupcupu1368
    The document discusses the appropriate use of beta blockers in the perioperative period, including which patients should receive beta blockers based on their risk level, the optimal timing for administration and discontinuation, recommended beta blockers such as metoprolol, and strategies for titrating dosage and monitoring patients. It provides evidence that perioperative beta blocker use can reduce in-hospital mortality for high-risk patients undergoing surgery.

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    of 28

    A A place for Beta Blocker Agents in Perioperative :

    When and How

    Ike Sri Redjeki


    Department of Anesthesiology and ICU
    Medical Faculty/ Padjadjaran University
    Bandung

    Introduction to -blockers
    Are a class of drugs used for
    Management of cardiac arrhythmia
    Cardioprotection after myocardial infarction
    Once first-line treatment for hypertension (their role was
    downgraded in June 2006 in the United Kingdom to fourth-line)
    Propanolol was the first clinically useful beta adrenergic receptor
    antagonist
    Direct sympatho adrenal inhibition reduction of heart rate
    play a major role in the therapeutic efficacy of beta-blockade in
    congestive heart failure
    In chronic heart failure the myocardium undergoes a
    phenotype change alterations of the activity of enzymes
    regulating calcium homoeostasis

    Site of action of beta blocker

    Indications
    Reduction of risk of cardiovascular mortality in the
    early phase following an acute MI in hemodynamically
    stable patients
    Treatment of mild to moderate hypertension (in which
    a cardioselective beta-blocker is preferred)
    Angina pectoris when oral therapy is not feasible
    Management of hypertensive urgencies
    Peri -operative, cardioselective beta blockade,
    when indicated
    Possible therapy in acute aortic dissection

    Indication of Beta Blocker Therapy

    Hypertension
    Arrhythmias
    Angina/Coronary artery disease
    Acute coronary syndromes
    Congestive Heart Failure
    Postmyocardial infarction
    Perioperative

    Role of Peri-operative Beta-Blockers


    Beta -blockers are used to correct the imbalance between
    myocardial oxygen demand and supply in times of stress
    Reduce HR: increase diastolic time and increase coronary artery
    perfusion
    Reduce myocardial oxygen consumption by suppressing
    lipolysis, causing myocardium to metabolize more glucose compared
    to free fatty acid
    May increase stability of coronary atherosclerotic plaques
    May increase the threshold for ventricular fibrillation in presence
    of ischemia

    Important question; the use of beta blocker in


    perioperative period
    Which patients should be targeted ?
    What is the optimal time to begin these agents, and when
    should they be stopped ?
    Which type of beta blocker should be used ?
    How can a practical and effective strategy be
    implemented at hospitals on the basis of this evidence ?

    Which patients should be targeted ?

    Minor criteria
    Age > 65 years
    Current smoking
    Hypercholesterolemia
    Hypertension

    Major criteria
    History of MI, angina, or any
    revascularization, Q waves
    on ECG, current or past use
    of nitroglycerine
    History of transient ischemic
    attack or cerebrovascular
    accident
    Diabetes
    Vascular surgery planned for
    arteries of chest, abdomen, or
    pelvis
    Creatinin > 2mg/dl

    Patients at risk who should not received Beta Blockers


    2 type of patients :
    Focus primarily on the patients ability to handle fluids
    load and cardiac output : congestive heart failure caused
    by depressed ejection fraction and systolic dysfunction
    beta blocker therapy improves long term survival in
    these group but it should not be started in the
    perioperative period as part of routine practice
    Focus on improving myocardial perfusion patients with
    physiologically significant aortic valvular disease beta
    blocker should not be given

    What is the optimal time to begin these agents, and


    when should they be stopped ?
    Pre induction period still an unanswered question
    It seems sensible to try to developed an approach in which beta
    blocker started as far in advance as possible giving the
    opportunity to titrate the drug to an effective heart rate before surgery
    But last minute identification and administration on the day of
    surgery are likely to be effective
    Longer treatment with beta blocker appears to extend the protective
    benefit of adrenergic blockade
    For patients who do not require lifelong beta blocker therapy th/
    up to 30 days provides maximal protective benefit

    Which type of beta blocker should be used ?


    Metoprolol is probably the most common agent available
    the parenteral form can lead directly to oral
    administration for NPO ( R/ Farpressor )
    Short acting beta blocker esmolol for unstable
    patients
    Atenolol

    In hospital period and transition to oral medication


    Oneoral
    of medication
    the mostwho
    crucial
    Patients not taking
    are
    Prehospitalization / immediately following admission
    hemodynamically
    stable in the use of
    practices
    Preoperative
    Metoprolol 5 mg ivPeriod
    every 15 minute
    up
    to
    15
    mg
    titrate
    pre-anesthesia
    holding area )
    perioperative
    blocker
    Giving
    metoprolol 25 beta
    ( in100
    mg/
    PO bid
    to heart rate of 65/mnt repeat every 6 hour

    Begin
    as
    outpatient
    surgery
    up
    to
    30
    days
    prior
    Is
    monitoring
    All Patients
    :
    Give
    continuous
    ECG metoprolol 5 mg
    to surgery
    They
    be
    titrated
    in
    such
    a
    Alternatives

    clonidin
    iv
    10
    minute
    to
    reach
    target
    every
    Titrate new
    or
    pre-existing
    beta
    blocker
    to heart
    ICU patientsway
    HD
    unstable
    caused
    by rate
    blood loss or
    that
    a
    target
    heart
    raterate
    of < 65/minute
    heart
    prolonged surgerybefore induction
    is achieved
    Esmolol
    500micr/kg
    iv
    over
    1
    minute
    then
    infuse
    50

    anesthesia
    if
    needed
    200 micr/kg/min to target heart rate
    May also use metoprolol per floor protocol

    Important data -blockers


    for ICU and perioperative

    Metoprolol iv when it was infused over 10 minute in


    normal volunteers maximum beta blockade was
    achieved at approximately 20 minute
    Doses 5 15 mg reduced HR ( after stimulation )
    10% - 15%
    Half life of drug 2.8 hour
    Drug disappeared approximately after 5 8 hour ( 5
    15 mg administration)

    Potential Hazard of iv B-Blocker


    Cardiac failure
    Severe sinus bradycardia: antidote atropine
    Partial heart block antidote atropine; if
    unresponsive isoproterenol or temporary pacing
    Bronchospasm antidote salbutamol
    Profound beta-blockade antidote when other
    measures have failed glucagon

    Side Effect Management


    Beta blocker / Metoprolol only used in stable HD patients
    ( not shock state MAP and peripheral perfusion)
    AV Block if occur after drug administration Give
    SA 0.25 0.5 mg iv
    Hypotension : if systolic BP < 90 mmHg give fluids and
    positive inotropic, if associated with bradycardia SA
    Pheochromocytoma: B-Blocker should be used in combination
    with alpha blocker to avoid paradoxical increase in BP due
    to the attenuation of B-mediated vasodilatation in skeletal
    muscle
    In DM may mask tachycardia in hypoglycemia

    Perioperative Beta Blocker


    The stress induced by surgery can cause an asymptomatic
    coronary plaque unstable and rupture resulting
    complete occlusion of a portion of the coronary artery
    The perioperative risk associated with unstable plaque can
    be reduced pharmacologically with : aspirin, statin and
    chronic beta blocker therapy
    POISE trial ( 2008 )
    9298 patients , RCT, > 45 years old patients, non cardiac surgery,
    at high risk of atherosclerotic disease
    Intervention : metoprolol 2 4 hour start preoperatively and
    continued for 30 days

    Risk Stratification


    Revised Cardiac Index ( RCI )
    Risk Factors
    High risk surgery (intraperitoneal, intrathoracic, aortic)
    Ischemic heart disease (prior MI, angina, nitrate use)
    History of CHF
    History of cerebrovascular disease
    Insulin therapy for diabetes
    Preoperative serum Cr >2.0 mg/dl

    Points
    1
    1
    1
    1
    1
    1

    (Lee et al, Circula.on 1999; 100: 1043)

    Risk Stratification
    Revised Cardiac Index





    Class

    # Factors

    Cardiac Complication
    Rate*

    0.5%

    II

    1.3%

    III

    3.6%

    IV

    3-6

    9.1%

    *Cardiac Complication: MI, CHF, VF, complete heart block



    (Lee et al, Circulation 1999; 100: 1043)

    Risk Stratification
    Clinical Markers





    Major
    "
    "
    "
    "

    Intermediate

    ACS
    Decompensated CHF
    Significant arrhythmia
    Severe valvular disease

    "
    "
    "
    "

    Mild angina
    Prior MI
    Compensated CHF
    Diabetes Mellitus

    Minor
    "
    "
    "
    "
    "
    "

    Advanced age
    Abnormal ECG
    Rhythm other than sinus
    Low functional capacity
    Prior CVA
    Uncontrolled HTN

    (ACC/AHA Guidelines JACC, 2002)

    Risk Stratification
    Functional Capacity





    1-4 METs

    4-10 METs

    " ADLs

    >10 METs

    " climb flight of stairs " sports


    " Heavy house work
    " Exercise, golf,dance

    (ACC/AHA Guidelines JACC, 2002)

    Risk Stratification
    Surgery Specific Risk

    High

    > 5% Risk of MI/Death

    " Emergent surgery
    " Aortic or other major vascular
    surgery
    " Peripheral vascular
    rolonged
    surgery
    " P


    (ACC/AHA Guidelines JACC, 2002)

    "
    "
    "
    "
    "
    "

    Intermediate

    Low

    < 5% Risk of MI/Death

    < 1% Risk of MI/


    Death

    Carotid endarterectomy
    Head and Neck
    Intraperitoneal
    Intrathoracic
    Orthopedic
    Prostate

    "
    "
    "
    "

    Endoscopic
    Superficial
    Cataract
    Breast

    NEJM 2005 ; 349-61

    Conclusion :
    Perioperative B blocker therapy is associated
    with a reduced risk of in hospital mortality
    among the High Risk patients
    But not in low risk patients
    Patient safety may be enhanced by increasing
    the use of B blockers in high risk patients

    Normalization of
    cellular
    metabolsm
    Decrease
    cardiac
    dysfunction

    Cytokine
    effect

    Improved glucose
    metabolism

    Preeclampsia with immediate post operative


    hypertension
    Post operative post SC patients HR increase to 170x/
    mnt and BP increase to 190/99 mmHg
    ECG ST depression in Lead I, II, III
    SpO2 99% with nasal catheter 2l/mnt
    Conscious cm, with no other symptoms
    NRS 1, no pain only not comfortable

    Preeclampsia with immediate post operative


    hypertension
    Metoprolol iv ( R/ Farpressor) strart with 2,5 mg 15
    minute, in 10 minute BP decrease to 170/87 mmHg
    HR 160 x/ mnt
    Another 2,5 mg iv was given in 5 minute HR
    decrease to 100/ mnt and BP 160/80 mmHg
    Patients was observed for 2 hours HR 105/mnt with BP
    163/78 mmHg
    Another 2,5 mg metoprolol iv was given and patients
    HR 76 84 / mnt with PB around 130 140 systolic /
    75 80 mmhg diastolic

    Conclusions
    If you want to use beta blocker use them
    sensibly, carefully, and act directly for
    complication

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