Beta Blockade. Andre P. Marshall, PGY2 8/14/09 VANDERBILT SURGERY

Transcription

1 Beta Blockade Andre P. Marshall, PGY2 8/14/09

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3 Beta Blockade Who are the Betas anyway? When, why, and how do we block them?

4 The Beta Receptor B 1 : cardiac chronotropic and inotropic B 2 : bronchodilation, vasodilation, and uterine relaxation (non gravid) B 3 : lipolysis in adipose tissue

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6 Take Home Messages Periop Risk reduction Stay on B Blocker if already on Start if vascular Sx + documented ischemia. Debate about other use. Use in isolated blunt head trauma Use for aortic dissection / trauma Use for postop HTN Use for postop Atrial Fib

7 The Drugs 1. Non-selective - B 1 + B 2 (CI in Asthma) Propanolol, tomolol, pindolol, nadolol, labetolol (also blocks A 1 ) 2. Selective - B 1 Acebutolol, Betaxolol, Esmolol (short acting), Atenolol, Metoprolol

8 Contraindications Sinus bradycardia Heart block Cardiogenic shock Overt cardiac failure SBP < 100 mm Hg

9 Side Effects Common side effects: Drowsiness or fatigue. Cold hands and feet. Weakness or dizziness. Dry mouth, eyes, and skin. Less common side effects: Wheezing, trouble breathing, or shortness of breath. Slow heartbeat. Trouble sleeping or vivid dreams while asleep. Swelling of the hands and feet. Rare side effects: Abdominal cramps. Throwing up. Diarrhea. Constipation. Back or joint pain. Skin rash. Sore throat.depression. Memory loss, confusion, or hallucinations. Impotence.

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11 Surgical Indications Periop cardiac risk reduction Isolated blunt head trauma. Aortic dissection - traumatic and otherwise Atrial Fibrillation HTN, Tachycardia Rule out other reasons i.e. pain, anastomotic leak

12 Perioperative Risk Reduction Lot of enthusiasm 50-90% reduction of periop cardiac death in patients at risk undergoing noncardiac surgery

13 Perioperative Risk Reduction ACC/AHA guidelines Class I 1. Continue BB in those who are on them 2. Give to those undergoing vascular surgery who are at high cardiac rish owing to the finding of ischemia on preoperative testing Class IIa Probably recommended for pts undergoing vascular surgery in whom periop assement reveals CHD Probably recommended for pts undergoing vascular surgery with more than 1 cardiac risk factor

14 Perioperative Risk Reduction ACC/AHA guidelines cont. Class IIb: Uncertain of usefulness in intermediate risk or vasc surgery with single cardiac risk factor Uncertain in vasc surgery patients with no clinical risk factors Class III: Do not give to patients undergoing surgery who have absolute contraindications.

15 Cautions To Periop Risk Reduction POISE Trial: May The Lancet 8351 patients Gave 100 mg metoprolol xl preop followed by 100 mg post op then up to 200 mg daily x 30 days Decreased MI and A-Fib related mortalities Significantly increased hypotension and CVA Overall more morbidity and mortality

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17 Bottom Line Pt on beta blockers - do not stop Pt having vascular surgery and has evidence of ischemia - start beta blockade

18 Blunt Head Injury Beta Blockade in isolated head injury causes increased survival There is a catecholamine surge associated with traumatic brain injury Recent study of 1156 patients: Showed B blocker use to be independent predictor of survival

19 Blood Pressure Useful for post op hypertension Can be given IV for pt with ileus. (only on 9n or units) Easy to titrate.

20 Arrhythmia Atrial fibrillation May give trial of Metoprolol 5 mg IV x 3 to see if can rate control rapid atrial fibrillation. Sometimes will convert new onset afib.

21 Aortic Dissection Medical treatment - Minimize change in pressure over time Control BP Usual Goal SBP <110 Nitroprusside Control HR - Goal HR = 60 Esmolol or Labetolol Transtion to Metoprolol or Propanolol PO

22 I Can t Remember All That! Periop: If on - keep, If vasc and documented ischemia start, pref at least 7 days before OR TBI - consider centrally acting B-blocker HTN - consider metoprolol, propanolol A-fib - metoprolol, propanolol Nonop Aortic dissection - Nipride + Esmolol for HR and BP control, Transition to PO.

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