Perioperative Management PBlockers

Several recent trials have evaluated the benefit of medical therapy initiated in the preoperative setting in reducing cardiac events. Mangano and colleagues (1995) conducted a randomized controlled trial of atenolol versus placebo in

200 patients with or at risk for CAD undergoing noncar-diac surgery and followed them for 2 years. They found that, although there was no difference in perioperative MI or death during initial hospitalization, ischemic episodes were significantly lower in the atenolol group (24% vs 39%). In addition, mortality at 2 years was 10% in the atenolol group versus 21% in controls (p = .019). The principal effect of atenolol was a decrease in mortality during the first 6 to 8 months. Of note, there was no difference in P-blocker use between groups over the follow-up period (approximately 15% in each treatment group).

Poldermans and colleagues (1999) randomized 173 patients undergoing major vascular surgery who had positive DSE on preoperative testing to bisoprolol versus standard care. Patients were excluded if (1) they had extensive wall motion abnormalities at rest or with dobutamine or (2) they were already on P-blocker therapy. Patients in the treatment group received bisoprolol for at least 1 week pre-operatively (mean 37 days) and were continued on bisoprolol for 30 days. The primary endpoints of cardiac death and nonfatal MI occurred in only 3.4% of patients in the bisoprolol group versus 34% in the standard care group (p <.001). The majority of events occurred during the first 7 days after surgery. The study was subsequently extended to follow long term outcomes in 101 of 112 surviving patients remaining on bisoprolol compared with those receiving standard care (Poldermans et al, 2001). During a median follow-up period of 22 months, the bisoprolol group had a markedly decreased risk of MI and cardiac death versus standard care group (12% vs 32%).

Current recommendations suggest starting oral P-blocker therapy days to weeks before elective surgery and continuing for a week to a month postoperatively (Eagle et al, 2002). The dose should be titrated to achieve a resting heart rate of 50 to 60 bpm. There may even be benefit to starting therapy intraoperatively if it has not been initiated beforehand; evidence comes from a small study showing a decreased incidence and duration of ischemic events with intraoperative esmolol followed by postoperative metoprolol in patients undergoing total knee artho-plasty (Urban et al, 2000).

Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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