Perioperative Beta-blockade Research Articles

Effects of perioperative beta-blockade and COX2-inhibition on 5-year disease-free-survival in colorectal cancer patients undergoing curative surgery: A pilot randomized controlled trial

Effects of perioperative beta-blockade and COX2-inhibition on 5-year disease-free-survival in colorectal cancer patients undergoing curative surgery: A pilot randomized controlled trial

Preoperative chronic beta-blocker prescription in elderly patients as a risk factor for postoperative mortality stratified by preoperative blood pressure: a cohort study

Background: Recent data suggest that beta blockers are associated with increased perioperative risk in hypertensive patients. We investigated whether beta blockers were associated with an increased risk in elderly patients with raised preoperative arterial blood pressure. MethodsWe conducted a propensity-score-matched cohort study of primary care data from the UK Clinical Practice Research Datalink (2004–13), including 84 633 patients aged 65 yr or over. Conditional logistic regression models, including factors that were significantly associated with the outcome, were constructed for 30-day mortality after elective noncardiac surgery. The effects of beta blockers (primary outcome), renin–angiotensin system (RAS) inhibitors, calcium-channel blockers, thiazides, loop diuretics, and statins were investigated at systolic and diastolic arterial pressure thresholds. ResultsBeta blockers were associated with increased odds of postoperative 30-day mortality in patients with systolic hypertension (defined as systolic BP >140 mm Hg; adjusted odds ratio [aOR]: 1.92; 95% confidence interval [CI]: 1.05–3.51). After excluding patients for whom prior data suggest benefit from perioperative beta blockade (patients with prior myocardial infarction or heart failure), rather than adjusting for them, the point estimate shifted slightly (aOR: 2.06; 95% CI: 1.09–3.89). Compared with no use, statins (aOR: 0.35; 95% CI: 0.17–0.75) and thiazides (aOR: 0.28; 95% CI: 0.10–0.78) were associated with lower mortality in patients with systolic hypertension. ConclusionsThese data suggest that the safety of perioperative beta blockers may be influenced by preoperative blood pressure thresholds. A randomised controlled trial of beta-blocker withdrawal, in select populations, is required to identify a causal relationship.

Management Strategies for Noncardiac Surgery Following a Coronary Artery Event.

Coronary artery event includes acute coronary syndrome (ACS), percutaneous coronary intervention (PCI), and coronary artery bypass graft (CABG) surgery. Following such an event, risk of noncardiac surgery is increased. Of major concern is what can make this surgery safer? High functional capacity improves cardiovascular (CV) risk; at least 4.0 metabolic equivalents (METs) on stress test are favorable. Risk scores can suggest need for further evaluation. Coronary angiography prior to surgery usually is not indicated since revascularization shows disappointing CV risk reduction results. Due to high association of peripheral arterial disease (PAD) with coronary artery disease (CAD), low ankle-brachial index (ABI) indicates increased CV risk. New perioperative beta blockade has shown disappointing benefit, but if ongoing should be continued. De novo perioperative beta blockade is for the highest CV risk patient undergoing noncardiac vascular surgery. Good evidence supports CV risk reduction from new or existing statin in the perioperative period, especially for the diabetic. Diabetics should also be on an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) secondarily, during the perioperative period to decrease 30-day perioperative mortality. Optimal timing of elective noncardiac surgery following a coronary artery event appears to be 180days with CV risk decreased by a statin and an ACEI or an ARB.

Effect of Beta-Blockers on Perioperative Outcomes in Vascular and Endovascular Surgery: A Systematic Review and Meta-Analysis

Abstract Background To investigate the role of perioperative beta-blocker use in vascular and endovascular surgery. Methods We performed a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards. The review protocol was registered with International Prospective Register of Systematic Reviews (registration number:CRD42016038111). We searched electronic databases to identify all randomized controlled trials and observational studies investigating outcomes of patients undergoing vascular and endovascular surgery with or without perioperative beta blockade. We used the Cochrane tool and the Newcastle-Ottawa scale to assess the risk of bias of trials and observational studies, respectively. Random-effects models were applied to calculate pooled outcome data. Results We identified three randomized trials, five retrospective cohort studies, and three prospective cohort studies, enrolling a total of 32,602 patients. Our analyses indicated that perioperative use of beta-blockers did not reduce the risk of all-cause mortality [odds ratio (OR) 1.10, 95% confidence interval (CI) 0.59-2.04, P = 0.77], cardiac mortality (OR 2.62, 95% CI 0.86-8.05, P = 0.09), myocardial infarction (OR 0.89, 95% CI 0.59-1.35, P = 0.58), unstable angina (OR 1.34, 95% CI 0.41- 4.38, P = 0.63), stroke (OR 2.45, 95% CI 0.89-6.75, P = 0.08), arrhythmias (OR 0.76, 95% CI 0.41-1.43, P = 0.40), congestive heart failure (OR 1.12, 95% CI 0.77-1.63, P = 0.56), renal failure (OR 1.48, 95% CI 0.90-2.45, P = 0.13), composite cardiovascular events (OR 0.88, 95% CI 0.55-1.40, P = 0.58), rehospitalisation (OR 0.86, 95% CI 0.48-1.52, P = 0.60), and reoperation (OR 1.17, 95% CI 0.42-3.27, P = 0.77) in vascular surgery. Conclusions Beta-blockers do not improve perioperative outcomes in vascular and endovascular surgery.

Morbidity and Mortality in Elective Total Hip Arthroplasty Following Surgical Care Improvement Project Guidelines

BackgroundFollowing evidence questioning the safety and efficacy of perioperative beta-blocker therapy in noncardiac surgery, the Surgical Care Improvement Project (SCIP) guidelines were retired in 2015. However, perioperative myocardial infarctions and cardiac complications remain leading causes of mortality following noncardiac surgery. The impact of the SCIP guidelines on reducing cardiac complications in patients undergoing elective total hip arthroplasty (THA) has not been evaluated. MethodsThe Nationwide Inpatient Sample was queried for 345,875 elective THA performed from 2003 to 2011. Patient demographics and morbidity as well as the incidence of nonfatal and fatal cardiac complications and overall mortality associated with cardiac complications were determined before and following SCIP implementation. ResultsFollowing the institution of the SCIP guidelines, the overall mortality following cardiac complications decreased by 41%. Although the incidence of nonfatal cardiac events after THA did increase 5% (primarily secondary to an increased incidence of nonfatal hypotension), the incidence of postoperative inpatient mortality, stroke, fatal hypotension, fatal myocardial infarction, and nonfatal and fatal cardiac arrest significantly decreased. ConclusionFollowing the implementation of SCIP guidelines, there was a 41% reduction in mortality and a significant decrease in fatal cardiac complications, postoperative hypotension, myocardial infarction, and cardiac arrest. Despite SCIP guidelines being retired in 2015, evidence supports continuation of perioperative beta-blockade in primary elective total adult hip and knee arthroplasty.

Beta-blockers in vascular surgery patients: is the debate still going on?

Patients undergoing vascular surgery are under increased risk for perioperative myocardial ischemia and cardiovascular complications, and optimal medical treatment is therefore imperative for these patients. Beta-blockade has been introduced as a cornerstone of optimal management, and standardized preoperative initiation has been recommended in the past. However, recent pooled data have questioned prior recommendations and have led to revision of international guidelines. This review aims to highlight the debate on perioperative beta-blockade for vascular surgery patients in order to produce useful conclusions for everyday clinical practice.

Antihypertensive drugs

Antihypertensive drugs

Perioperative stroke.

Perioperative stroke is associated with significant morbidity and mortality, with an incidence that may be underappreciated. In this review, we examine the significance, pathophysiology, risk factors, and evidence-based recommendations for the prevention and management of perioperative stroke. This is a narrative review based on literature from the PubMed database regarding perioperative stroke across a broad surgical population. The Society for Neuroscience in Anesthesiology and Critical Care recently published evidence-based recommendations for perioperative management of patients at high risk for stroke; these recommendations were analyzed and incorporated into this review. The incidence of overt perioperative stroke is highest in patients presenting for cardiac and major vascular surgery, although preliminary data suggest that the incidence of covert stroke may be as high as 10% in non-cardiac surgery patients. The pathophysiology of perioperative stroke involves different pathways. Thrombotic stroke can result from increased inflammation and hypercoagulability; cardioembolic stroke can result from disease states such as atrial fibrillation, and tissue hypoxia from anemia can result from the combination of anemia and beta-blockade. Across large-scale database studies, common risk factors for perioperative stroke include advanced age, history of cerebrovascular disease, ischemic heart disease, congestive heart failure, atrial fibrillation, and renal disease. Recommendations for prevention and management of perioperative stroke are evolving, though further work is needed to clarify the role of proposed modifiable risk factors such as perioperative anticoagulation, antiplatelet therapy, appropriate transfusion thresholds, and perioperative beta-blockade. Perioperative stroke carries a significant clinical burden. The incidence of perioperative stroke may be higher than previously recognized, and there are diverse pathophysiologic mechanisms. There are many opportunities for further investigation of the pathophysiology, prevention, and management of perioperative stroke.

The Effect of beta-blockade on objectively measured physical fitness in patients with abdominal aortic aneurysms – A blinded interventional study

Perioperative beta-blockade is widely used, especially before vascular surgery; however, its impact on exercise performance assessed using cardiopulmonary exercise testing (CPET) in this group is unknown. We hypothesized that beta-blocker therapy would significantly improve CPET-derived physical fitness in this group. We recruited patients with abdominal aortic aneurysms (AAA) of <5.5 cm under surveillance. All patients underwent CPET on and off beta-blockers. Patients routinely prescribed beta-blockers underwent a first CPET on medication. Beta-blockers were stopped for one week before a second CPET. Patients not routinely taking beta-blockers underwent the first CPET off treatment, then performed a second CPET after commencement of bisoprolol for at least 48 h. Oxygen uptake (.VO2) at estimated lactate threshold and .VO2 at peak were primary outcome variables. A linear mixed-effects model was fitted to investigate any difference in adjusted CPET variables on and off beta-blockers. Forty-eight patients completed the study. No difference was observed in .VO2 at estimated lactate threshold and .VO2 at peak; however, a significant decrease in .VE/.VCO2 at estimated lactate threshold and peak, an increase in workload at estimated lactate threshold., O2 pulse and heart rate both at estimated lactate threshold and peak was found with beta-blockers. Patients taking beta-blockers routinely (chronic group) had worse exercise performance (lower .VO2 ). Beta blockade has a significant impact on CPET-derived exercise performance, albeit without changing .VO2 at estimated lactate threshold and.VO2 at peak. This supports performance of preoperative CPET on or off beta-blockers depending on local perioperative practice. NCT 02106286.

ACP Journal Club. Review: Perioperative β-blockade reduces nonfatal MI but increases mortality in noncardiac surgery.

Source Citation Wijeysundera DN, Duncan D, Nkonde-Price C, et al. Perioperative beta blockade in noncardiac surgery: a systematic review for the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. J Am Coll Cardiol. 2014;64:2406-25. 25091545*

The Genetic Basis of Coronary Artery Disease and Atrial Fibrillation: A Search for Disease Mechanisms and Therapeutic Targets.

ORONARY ARTERY disease (CAD) and arrhythmias such as atrial fibrillation (AF) significantly contribute to perioperative mortality and morbidity. The 30-day postoperative mortality rate is increased significantly in patients with AF (6.4%) and (CAD) (2.9%). 1 The VISION trial found that 11.6% of patients undergoing noncardiac surgery had increased troponin levels postoperatively, and these patients had an increased 30-day mortality compared with the reference group. 2 Postoperative AF patients have longer hospital stays and increased mortality. 3–6 Postoperative AF is common not only after cardiac surgery, but is seen after major noncardiac surgery as well. As anesthesiologists continue to focus on perioperative care for surgical patients, they must examine all options for decreasing mortality and morbidity for patients with coronary artery disease and arrhythmias undergoing noncardiac surgery. The genetic predisposition for CAD and AF has garnered more attention in the past decade due to innovative technology and ready access to human genomic information that has improved the ability to identify single nucleotide polymorphisms in the genome. Although advances continue to be made in the management of CAD and AF, prevention likely will be the most effective way to decrease ischemic heart disease and atrial fibrillation in the patient population. Medical management has an important role for perioperative prevention of major adverse cardiac events; however, the 2014 ACC/AHA guidelines reflect important contributions from recent studies regarding the safety and efficacy of perioperative beta-blockade. The only class I recommendation for perioperative beta-blockade is the continuation of beta-blockers for patients who have been taking them chronically. 1 The initiation of beta-blockers for patients with high-risk myocardial ischemia or for patients with multiple risk factors is a class IIb recommendation. There is continued concern about the risk of perioperative stroke related to betablockers and the safest time to initiate beta-blockers before surgery. Perioperative myocardial revascularization has been examined as a method to decrease major perioperative adverse cardiac events. The CARP trial showed that at medial longterm follow-up, there was no difference in mortality between revascularized and nonrevascularized patients undergoing vascular surgery even in high-risk groups such as those with multivessel coronary artery disease 7 Therefore, medical and surgical interventions have limited ability to decrease perioperative risk when there is a clear unmet need for better risk assessment and management strategy. This review will focus on the recent progress made in establishing the genetic basis for coronary artery disease and atrial fibrillation. The clinical relevance of CAD and perioperative myocardial infarction are closely linked; however, they do not share many genetic variants. These genetic differences will be highlighted using specific genes as examples, including 9p21. A thorough understanding of the genes and their contribution to these disease processes may lead to improved risk stratification and prevention of these common perioperative complications.

Perioperative beta blockade in noncardiac surgery: a systematic review for the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.

To review the literature systematically to determine whether initiation of beta blockade within 45 days prior to noncardiac surgery reduces 30-day cardiovascular morbidity and mortality rates. PubMed (up to April 2013), Embase (up to April 2013), Cochrane Central Register of Controlled Trials (up to March 2013), and conference abstracts (January 2011 to April 2013) were searched for randomized controlled trials (RCTs) and cohort studies comparing perioperative beta blockade with inactive control during noncardiac surgery. Pooled relative risks (RRs) were calculated under the random-effects model. We conducted subgroup analyses to assess how the DECREASE-I (Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography), DECREASE-IV, and POISE-1 (Perioperative Ischemic Evaluation) trials influenced our conclusions. We identified 17 studies, of which 16 were RCTs (12 043 participants) and 1 was a cohort study (348 participants). Aside from the DECREASE trials, all other RCTs initiated beta blockade within 1 day or less prior to surgery. Among RCTs, beta blockade decreased nonfatal myocardial infarction (MI) (RR: 0.69; 95% confidence interval [CI]: 0.58 to 0.82) but increased nonfatal stroke (RR: 1.76; 95% CI: 1.07 to 2.91), hypotension (RR: 1.47; 95% CI: 1.34 to 1.60), and bradycardia (RR: 2.61; 95% CI: 2.18 to 3.12). These findings were qualitatively unchanged after the DECREASE and POISE-1 trials were excluded. Effects on mortality rate differed significantly between the DECREASE trials and other trials. Beta blockers were associated with a trend toward reduced all-cause mortality rate in the DECREASE trials (RR: 0.42; 95% CI: 0.15 to 1.22) but with increased all-cause mortality rate in other trials (RR: 1.30; 95% CI: 1.03 to 1.64). Beta blockers reduced cardiovascular mortality rate in the DECREASE trials (RR: 0.17; 95% CI: 0.05 to 0.64) but were associated with trends toward increased cardiovascular mortality rate in other trials (RR: 1.25; 95% CI: 0.92 to 1.71). These differences were qualitatively unchanged after the POISE-1 trial was excluded. Perioperative beta blockade started within 1 day or less before noncardiac surgery prevents nonfatal MI but increases risks of stroke, death, hypotension, and bradycardia. Without the controversial DECREASE studies, there are insufficient data on beta blockade started 2 or more days prior to surgery. Multicenter RCTs are needed to address this knowledge gap.

Perioperative Beta Blockade in Noncardiac Surgery: A Systematic Review for the 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery

To review the literature systematically to determine whether initiation of beta blockade within 45 days prior to noncardiac surgery reduces 30-day cardiovascular morbidity and mortality rates.PubMed (up to April 2013), Embase (up to April 2013), Cochrane Central Register of Controlled Trials (up to March 2013), and conference abstracts (January 2011 to April 2013) were searched for randomized controlled trials (RCTs) and cohort studies comparing perioperative beta blockade with inactive control during noncardiac surgery. Pooled relative risks (RRs) were calculated under the random-effects model. We conducted subgroup analyses to assess how the DECREASE-I (Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography), DECREASE-IV, and POISE-1 (Perioperative Ischemic Evaluation) trials influenced our conclusions.We identified 17 studies, of which 16 were RCTs (12,043 participants) and 1 was a cohort study (348 participants). Aside from the DECREASE trials, all other RCTs initiated beta blockade within 1 day or less prior to surgery. Among RCTs, beta blockade decreased nonfatal myocardial infarction (MI) (RR: 0.69; 95% confidence interval [CI]: 0.58 to 0.82) but increased nonfatal stroke (RR: 1.76; 95% CI:1.07 to 2.91), hypotension (RR: 1.47; 95% CI: 1.34 to 1.60), and bradycardia (RR: 2.61; 95% CI: 2.18 to 3.12). These findings were qualitatively unchanged after the DECREASE and POISE-1 trials were excluded. Effects on mortality rate differed significantly between the DECREASE trials and other trials. Beta blockers were associated with a trend toward reduced all-cause mortality rate in the DECREASE trials (RR: 0.42; 95% CI: 0.15 to 1.22) but with increased all-cause mortality rate in other trials (RR: 1.30; 95% CI: 1.03 to 1.64). Beta blockers reduced cardiovascular mortality rate in the DECREASE trials (RR:0.17; 95% CI: 0.05 to 0.64) but were associated with trends toward increased cardiovascular mortality rate in other trials (RR: 1.25; 95% CI: 0.92 to 1.71). These differences were qualitatively unchanged after the POISE-1 trial was excluded.Perioperative beta blockade started within 1 day or less before noncardiac surgery prevents nonfatal MI but increases risks of stroke, death, hypotension, and bradycardia. Without the controversial DECREASE studies, there are insufficient data on beta blockade started 2 or more days prior to surgery. Multicenter RCTs are needed to address this knowledge gap.

Abstract 12444: Outcomes After Starting Beta-Blockade Within a Clinically Sensible Period Before Major Elective Noncardiac Surgery

INTRODUCTION: Guidelines recommend that perioperative beta-blockade be started days to weeks before surgery. Nonetheless, all randomized trials except for the controversial DECREASE trials started treatment ≤1 day before surgery, while most observational studies did not distinguish between long-term beta-blockade versus beta-blockers started for perioperative reasons. We thus conducted a population-based cohort study of the effectiveness of beta-blockade started within a clinically sensible period (8-60 days) before surgery. METHODS: Following research ethics approval, we conducted a cohort study of patients (≥66 years) who underwent major elective noncardiac surgery from 2003 and 2012 in Ontario, Canada. Propensity-score methods were used to form a matched cohort that reduced important differences between patients who started beta-blockers 8-60 days before surgery versus controls (no beta-blockers within 1 year before surgery). We measured the association of beta-blockade with 30-day (death, MI, stroke) and 1-year (death) outcomes post-surgery. Subgroup analyses were performed based on Revised Cardiac Risk Index class and history of prior CAD. RESULTS: The cohort included 4268 beta-blocked patients and 154,357 controls. Metoprolol (median daily dose 50 mg) was prescribed to 36% of beta-blocked patients, atenolol (median 25 mg) to 26%, and bisoprolol (median 5 mg) to 37%. In the matched cohort (n=8492), beta-blockade was not associated with death (RR 0.96; CI 0.70-1.32), MI (RR 0.92; CI 0.72-1.17), and stroke (RR 1.31; CI 0.68-2.52) at 30-days, or death at 1-year (Figure). Associations with outcomes did not differ significantly across subgroups. CONCLUSIONS: Outcomes were not altered in patients who start perioperative beta-blockade within a clinically sensible period before surgery. A large randomized trial is needed to determine if the continued use of perioperative beta-blockade in clinical practice is justified.

Perioperative Beta-Blockade Improves CEA Outcomes

Perioperative beta-blockade for patients with coronary artery disease (CAD) who are undergoing carotid endarterectomy (CEA) appeared to prevent cardiac damage, resulting in a low mortality rate and no stroke events. This article presents data from a study evaluating the role of beta-blockage in asymptomatic cardiac damage in patients with CAD undergoing CEA.

International RCT-based guidelines for use of preoperative stress testing and perioperative beta-blockers and statins in non-cardiac surgery

BackgroundCardiologists frequently advise on perioperative care for non-cardiac surgery and require guidance based on randomised controlled trials that are not discredited by misconduct or misreporting. Regional political bodies currently do not provide this. We therefore examined the credible randomised controlled trial (RCT) evidence on key cardiac perioperative questions which currently have 14 recommendations. MethodsThree aspects of perioperative measures were considered: perioperative statins, preoperative stress-testing and perioperative beta-blockade. One author searched PubMed for RCTs considering these topics. All authors independently assessed the RCTs and then collaboratively composed guidelines. ResultsPerioperative statin therapy has been examined by three RCTs, DECREASE III and IV, which are discredited and a third containing serious inconsistencies undermining its validity.Preoperative stress testing has been examined by two RCTs: one discredited trial, DECREASE II, and a second which found no benefit.Perioperative beta-blockade has been examined by eleven RCTs, two of which are discredited. The nine remaining trials together suggest that perioperative beta-blockade increases mortality. ConclusionsWhen the non-credible RCTs are omitted, the evidence base on these three subjects is much smaller than previously believed: 14 recommendations can be replaced by 3.Current guideline arrangements collectively paralyse the numerous signatories from making urgent amendments after initial publication, even when important new information comes to light. Clinicians simply have to wait for the routine five-year expiry.We present a concise scientifically based guideline and commit to updating it responsibly.

Back to the future: medical reversals and perioperative medicine

While most of us were enjoying the pleasures of an idle summer, a publication in Mayo Clinic Proceedings created a stir in the esoteric world of evidence-based medicine. The subject of interest was medical reversal, a phenomenon in which ‘‘a medical practice is found to be inferior to some lesser or prior standard of care’’. Prasad et al. reviewed original articles published in the New England Journal of Medicine from 2001 to 2010 in their endeavour to determine if new evidence advanced, confirmed, or rejected current medical practices. Seven hundred fiftysix (56%) of the 1,344 manuscripts reviewed found a new therapy superior to an older treatment, 138 (10%) confirmed the utility of a current therapy, and 165 (12%) found new practices inferior to present care. One hundred forty-six (40%) of the 363 studies evaluating an existing medical practice found the current therapy inferior to a lesser or earlier standard of care. These rejections of current practice for an older treatment (or no treatment at all) cut across classes of medical care, including anesthesia. Cited examples from perioperative medicine included bispectral index monitoring, mild hypothermia for an intracranial aneurysm clipping, use of a pulmonary artery catheter for high-risk surgical patients, coronary revascularization before elective vascular surgery, epidurals in early labour, and use of aprotinin in cardiac surgery. The reaction to Prasad’s findings was swift and critical. An accompanying editorial stated, ‘‘[T]he proportion of medical reversals seems alarmingly high. At a minimum, it poses major questions about the validity and clinical utility of a sizeable portion of everyday medical care.’’ The blog, Science-Based Medicine, noted, ‘‘[T]his highlights the fact that some current practices are useless or less than optimal and need to be reexamined.’’ Even the New York Times got in on the action by leading with the headline, ‘‘Medical Procedures May Be Useless, or Worse.’’ Both the evidence base for medical practice and the practice itself were under attack. Patients and clinicians alike could be left wondering how a supposedly science-based practice could have been wrong so frequently. Prasad identified a common narrative among the reversals noting that, ‘‘[a]lthough there is a weak evidence base for some practice, it gains acceptance largely through vocal support from prominent advocates and faith that the mechanism of action is sound. Later, future trials undermine the therapy, but removing the contradicted practice often proves challenging.’’ Does this sound familiar? Let us consider the saga of perioperative beta-blockade from Prasad’s perspective of medical reversal. In 1996, Mangano published results of a 200-patient placebo-controlled trial evaluating a seven-day perioperative course of atenolol on a composite outcome of cardiac mortality and morbidity. Six patients who died in hospital were excluded. Of those surviving to hospital discharge, 12 of 99 placebo patients died within six months of surgery compared with four of 95 patients receiving atenolol (crude relative risk [RR] 0.35; 95% confidence interval [CI] 0.1 to 1.0). Several years later, Poldermans G. L. Bryson, MD (&) Department of Anesthesiology, The Ottawa Hospital, The University of Ottawa, 1053 Carling Avenue, Box 249C, Ottawa, ON K1Y 4E9, Canada e-mail: glbryson@ottawahospital.on.ca

Beta-Blocking Agents for Surgery: Influence on Mortality and Major Outcomes. A Meta-Analysis

To re-evaluate the effects of perioperative beta-blockade on mortality and major outcomes after surgery. A meta-analysis of parallel randomized, controlled trials published in English. A university-based electronic search. Patients undergoing surgery. Two interventions were evaluated: (1) Stopping or continuing a β-blocker in patients on long-term β-blocker therapy; and (2) Adding a β-blocker for the perioperative period. Stopping a β-blocker before the surgery did not change the risk of myocardial infarction (3 studies including 97 patients): risk ratio (RR), 1.08 (95% confidence interval 0.30, 3.95); I(2), 0%. Adding a β-blocker reduced the risk of death at 1 year: RR, 0.56 (0.31, 0.99); I(2), 0%; p = 0.046; number needed to treat 28 (19, 369) (4 studies with 781 patients). Adding a β-blocker reduced the 0-to-30 day risk of myocardial infarction: RR, 0.65 (0.47, 0.88); I(2), 12.9%; p = 0.006 (15 studies with 12,224 patients), but increased the risk of a stroke: RR, 2.18 (1.40, 3.38); I(2), 0%; p = 0.001 (8 studies with 11,737 patients); number needed to harm 177 (512, 88). β-blockers reduced the 1-year risk of death, and this effect seemed greater than the risk of inducing a stroke.

Improving Documentation of a Beta-Blocker Quality Measure Through an Anesthesia Information Management System and Real-Time Notification of Documentation Errors

Continuation of perioperative beta-blockers for surgical patients who are receiving beta-blockers prior to arrival for surgery is an important quality measure (SCIP-Card-2). For this measure to be considered successful, name, date, and time of the perioperative beta-blocker must be documented. Alternately, if the beta-blocker is not given, the medical reason for not administering must be documented. Before the study was conducted, the institution lacked a highly reliable process to document the date and time of self-administration of beta-blockers prior to hospital admission. Because of this, compliance with the beta-blocker quality measure was poor (-65%). To improve this measure, the anesthesia care team was made responsible for documenting perioperative beta-blockade. Clear documentation guidelines were outlined, and an electronic Anesthesia Information Management System (AIMS) was configured to facilitate complete documentation of the beta-blocker quality measure. In addition, real-time electronic alerts were generated using Smart Anesthesia Messenger (SAM), an internally developed decision-support system, to notify users concerning incomplete beta-blocker documentation. Weekly compliance for perioperative beta-blocker documentation before the study was 65.8 +/- 16.6%, which served as the baseline value. When the anesthesia care team started documenting perioperative beta-blocker in AIMS, compliance was 60.5 +/- 8.6% (p = .677 as compared with baseline). Electronic alerts with SAM improved documentation compliance to 94.6 +/- 3.5% (p < .001 as compared with baseline). To achieve high compliance for the beta-blocker measure, it is essential to (1) clearly assign a medical team to perform beta-blocker documentation and (2) enhance features in the electronic medical systems to alert the user concerning incomplete documentation.

Can anaesthetic technique effect postoperative outcome?

Conventional wisdom maintains that multiple aspects of surgical technique and management may affect postoperative outcome, while anaesthetic technique has little long-term effect on patient outcomes. There is accumulating evidence that, on the contrary, anaesthetic management may in fact exert a number of longer-term effects in postoperative outcome. Here, we review the most topical aspects of anaesthetic management which may potentially influence later postoperative outcomes. There is strong evidence that administration of supplemental oxygen and the avoidance of perioperative hypothermia, allogeneic blood transfusion, hyperglycaemia or large swings in blood glucose levels reduces postoperative infection rates. There is also some evidence that the use of regional anaesthesia techniques reduces chronic postsurgical pain and that avoidance of nitrous oxide reduces the long-term risk of myocardial infarction. Current evidence is equivocal regarding the effects of anaesthesia techniques and cancer recurrence. The instigation of perioperative beta-blockade in noncardiac surgery may not reduce perioperative adverse events or improve postoperative cardiovascular risk. Further prospective, large-scale human trials with long-term follow-up are required to clarify the association between anaesthesia and cancer recurrence, neurotoxicity and the developing brain and long-term postoperative cognitive dysfunction in the elderly.