Attenuation of surgical stress response

heartICU · Jun 28, 2005

I thought the anesthesia providers on this board might like to discuss something other than which school to get into or why AA's and CRNA's will never get along.
There was a recent conference hosted by the UNC medical school in South Carolina with some really interesting topics. One I wanted to get your opinions on (CRNA, SRNA, AA & -ologist) is whether or not you've noticed any pharmacologic changes in the preop care of surgical patients ... namely the addition of statins, beta-blockers &/or alpha2 agonists.
One of the presentations dealt with decreased postop morbidity and mortality in surgical patients by blunting their stress response (decreased NE levels, decreased ischemia & cardiac death with Clonidine ... decreased morbidity and mortality r/t statins during vascular surgery) with the addition of these agents. Since anesthetics suppress many elements of the stress response, most problems occur postop.
I'm hoping that the providers/students working in larger teaching hospitals have had a chance to utilize this and can give an opinion. And even if you haven't, it sounds like an novel approach to perioperative care. Any insights?

Our patients, if they have cardiac disease or the procedure is high-risk, get a PO dose of Lopressor the morning of surgery. Our pre-op clinic evaluates this and chooses which patients are appropriate. Haven't given clonidine pre-op with the exception of with a spinal. HAven't had any statins started specifically for surgery, but we continue them all the way up until and throughout hospitalization.

mwbeah · Jun 29, 2005

perioperative beta-blockade can reduce morbidity and mortality

by roger l. royster, md

the agency for healthcare research and quality (ahrq) recently identified the perioperative administration of beta-blockers as one of 11 specific practices with sufficient clinical-based evidence for patient safety to justify immediate and widespread implementation.1 a number of randomized, controlled trials support the use of beta-blockers to reduce the morbidity and mortality associated with non-cardiac surgery in patients at risk for cardiac events.2-5

randomized clinical trials involving more than 24,000 patients demonstrated that beta adrenergic blockade reduced post-myocardial infarction mortality, likely by a reduction in infarct size when administered early or by a reduction in ventricular arrhythmias when administered chronically.6 in randomized clinical trials involving over 15,000 patients, beta-blockade also reduced the morbidity and mortality in patients suffering from congestive heart failure.7 all beta-blockers except those with intrinsic sympathetic activity reduce mortality in both myocardial infarction and heart failure patients.

applying the above information from clinical trials to the perioperative care of the cardiovascular patient, it seems logical that beta-adrenergic blockers might be beneficial during the stressful surgical period. four randomized controlled trials concerning the effectiveness of perioperative beta-blockade in reducing perioperative cardiac events are the basis for the ahrq recommendations. in 1988, stone et al.2 demonstrated that in 128 hypertensive patients having elective surgery, beta-blockade reduced the incidence of holter monitored documented ischemia (2%) compared to a control group (28%) (p3 reported on patients undergoing elective noncardiac surgery who had received atenolol preoperatively and had this continued through the seventh postoperative day. the all-cause mortality at 2 years (p=0.019), cardiac death at 2 years (p=0.033), and postoperative ischemia (p=0.03) were significantly reduced in the atenolol treated patients compared to controls. critics of this study point out less coronary disease, more ace-inhibitors, and fewer incidents of discontinuing beta-blockers in the beta-blockade group. however, statistical analysis modeling for these differences upheld the overall conclusions of the study.

two studies in 1999 continued the search for clinical data to validate the use of perioperative beta-blockade. poldermans et al.4 randomized 112 patients with positive dobutamine stress echocardiograms having vascular surgery procedures to receive bisoprolol starting an average of 37 days before surgery and continuing for 30 days after surgery. patients already taking beta-blockers were excluded. cardiac death was 3.4% in the beta-blocker group and 17% in controls (p=0.02), and nonfatal mi was 0% in the beta-blocker group and 17% in controls (p5 randomized 26 patients with holter monitor documented preoperative ischemia undergoing vascular surgery to either a control group or to receive esmolol for 48 hours postoperatively, titrated to keep the heart rate at 20% below the individual ischemic threshold. postoperative ischemia occurred in 33% of the beta-blocker group and in 73% of the controls (p8 or inadequate sample size.9

are there problems with administering beta-blockers perioperatively? most would agree that in the patient already receiving beta-blockers, therapy should be continued postoperatively. the failure to maintain these drugs during this period may generate serious side effects secondary to withdrawal and an upregulated beta receptor state. sinus bradycardia, heart failure, and bronchospasm are rare reported side effects in the clinical studies, but do occur. esmolol, a short-acting beta-blocker, is therefore very attractive in patients who may have an increased risk for adverse effects but who would appear to benefit from therapy because of a high risk for cardiac complications. furthermore, ahrq recommends that beta-blockers be continued for 1 week postoperatively.

does perioperative beta-blockade preclude preoperative screening and risk stratification? this remains a difficult question to answer. certainly the use of beta-blockade perioperatively appears effective and could generate significant cost savings if preoperative testing is reduced. however, improved outcomes in high-risk patients may still result if critical coronary lesions (e.g., left main disease) are identified preoperatively. the various patient subgroups which might yield a positive cost-benefit analysis from aggressive preoperative testing remain to be identified.

the ahrq stance on perioperative beta-blockade is clear. additionally, further randomized, controlled clinical studies may be limited because of the reluctance of researchers to place patients in a placebo group due to patient safety concerns. therefore, the perioperative use of beta-blocker therapy to prevent cardiac events and to reduce associated cardiac mortality may evolve to become a standard of care. even though post-myocardial infarction beta-blockade is considered standard of care, it too remains disturbingly underutilized.10 a recent study in vascular surgery patients in europe revealed that only 27% received perioperative beta-blockade.11 one can hope the ahrq position will increase anesthesiologists' and surgeons' awareness of the benefits of perioperative beta-blockade in high-risk patients. widespread implementation of this perioperative therapy will likely improve patient safety.

dr. royster is professor and vice chair of the department of anesthesiology at wake forest university school of medicine, winston-salem, nc.

hope this helps,

mike

subee, MSN, CRNA · Jun 29, 2005

I thought the anesthesia providers on this board might like to discuss something other than which school to get into or why AA's and CRNA's will never get along.
There was a recent conference hosted by the UNC medical school in South Carolina with some really interesting topics. One I wanted to get your opinions on (CRNA, SRNA, AA & -ologist) is whether or not you've noticed any pharmacologic changes in the preop care of surgical patients ... namely the addition of statins, beta-blockers &/or alpha2 agonists.
One of the presentations dealt with decreased postop morbidity and mortality in surgical patients by blunting their stress response (decreased NE levels, decreased ischemia & cardiac death with Clonidine ... decreased morbidity and mortality r/t statins during vascular surgery) with the addition of these agents. Since anesthetics suppress many elements of the stress response, most problems occur postop.
I'm hoping that the providers/students working in larger teaching hospitals have had a chance to utilize this and can give an opinion. And even if you haven't, it sounds like an novel approach to perioperative care. Any insights?

You don't have to be in a "big city" hospital to already be prescribing pre-op beta blockers for pts. with cardiac hx. It is the standard of care for my smallist community hospital. Sometimes the slow pulse is a pain when doing joint replacements with associated blood loss but have had no major problems.

versatile_kat · Jun 29, 2005

You don't have to be in a "big city" hospital to already be prescribing pre-op beta blockers for pts. with cardiac hx. It is the standard of care for my smallist community hospital. Sometimes the slow pulse is a pain when doing joint replacements with associated blood loss but have had no major problems.

Thanks for the reply ... I was mainly talking to the alpha2 agonists and statins. I think beta blockers are now given to a majority of at risk patients in most hospitals (there was a post not so long ago about this).