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Progress in Vascular Anesthesiology

Progress in Vascular Anesthesiology. Donald M. Voltz, M.D. Assistant Professor of Anesthesiology Case Western Reserve University/University Hospitals of Cleveland. Overview. Beta-blockers Fluid Therapy Regional Anesthesia. Beta-blockers in Vascular Patients . Are We Using Too Few?.

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Progress in Vascular Anesthesiology

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  1. Progress in Vascular Anesthesiology Donald M. Voltz, M.D. Assistant Professor of Anesthesiology Case Western Reserve University/University Hospitals of Cleveland

  2. Overview • Beta-blockers • Fluid Therapy • Regional Anesthesia

  3. Beta-blockers in Vascular Patients Are We Using Too Few?

  4. Вeta-Blockers • Cardioprotection • Hemodynamic Control • Anesthetic Modification

  5. B-blockers and Cardioprotection • Well studied in vascular patient population • Evolving evidence supports there use as a standard of care in at risk patients • Likely to find increasing role in the future

  6. B-blockers Evidence for Use

  7. Effect of Atenolol on Mortality and Cardiovascular Morbidity after Noncardiac Surgery Dennis T. Mangano, Ph.D., M.D., Elizabeth L. Layug, M.D., Arthur Wallace, Ph.D., M.D., Ida Tateo, M.S., for The Multicenter Study of Perioperative Ischemia Research Group

  8. Mangano, et al. 1996 • Randomized trial of esmolol vs. saline (n=99, n=101) • Patient followed for 2 years • Mortality decreased in esmolol group • 0% vs 8% at 6 months • 3% vs 14% at 1 year • 10% vs 21% at 2 years

  9. Wallace, et al. 1998 • 200 pts randomized to atenolol or saline • EKG, Holter monitor, and CPK w/ MB were followed 24 hr prior and 7 days after surgery • Atenolol 0,5, or 10 mg or placebo prior to induction and every 12 hours until po than qd for 1 week

  10. Wallace, et al. 1998 • Decreased perioperative myocardial ischemia • 17/99 esmolol vs 34/101 placebo (days 0-2) • 24/99 esmolol vs 39/101 placebo (days 0-7)

  11. Polderman, et al. 1999 • 846 pts with one or more cardiac risk factors; 173 positive dobutamine stress tests • Bisoprolol in 59; Placebo in 53 • Nonfatal MI • 0% bisoprolol • 17% placebo group • Cardiac Death • 3.4% bisoprolol group • 17% placebo group

  12. What Patients are at Risk

  13. B-blockers & At Risk Patients • Presence of CAD • History of Myocardial Infarction • Typical Angina or Atypical Angina with + Stress Test • At Risk for CAD (2 or more of the following) • Age >65 years • Hypertension • Active Smoker • Serum Cholesterol > 240 mg/dl • Diabetes Mellitus

  14. B-blockers and Cardioprotection • How well are we doing with at risk patients? • Not Very Well!

  15. Prophylactic beta-blockade to prevent myocardial infarction perioperatively in high-risk patients who undergoing general surgical procedures.Taylor RC, Pagliarello G.Can J Surg. 2003 Jun;46(3):216-22 • 236 pts for laparotomy • 143 pts at risk for CAD • 60.8% did not receive B-blockers pre-op • 33% pts had B-blockers discontinued

  16. The Effect of Heart Rate Control on Myocardial Ischemia Among High-Risk Patients After Vascular Surgery Khether E. Raby, MD, FACC*, Sorin J. Brull, MD, Farris Timimi, MD, Shamsuddin Akhtar, MD, Stanley Rosenbaum, MD, Cameron Naimi, BS, and Anthony D. Whittemore, MD Anesth Analg. 1999 Mar;88(3):477-82

  17. The Effect of Heart Rate Control on Myocardial Ischemia Among High-Risk Patients After Vascular Surgery • Vascular Pts at High Risk for CAD underwent 24 hrs Holter Monitoring • 26 of 150 pts had significant ischemia as measured by ST-depression – PreOp • Randomized to Esmolol gtt (n=15) or Placebo (n=11) • Titrated to HR 20% below ischemic threshold • Holter Monitoring for 48 hrs PostOp

  18. The Effect of Heart Rate Control on Myocardial Ischemia Among High-Risk Patients After Vascular Surgery • Ischemia Present PostOp • 73% in Placebo Group (8 of 11) • 33% in Esmolol Group (5 of 15) • Number of Hours HR < Ischemic Threshold • 9 of 15 pts in Esmolol group <20% and all without ischemia • 4 of 11 pts in Placebo group <20%. 3 of 4 without ischemia

  19. B-blockers - Types • Esmolol • Metoprolol • Labetelol • Atenolol

  20. Esmolol • Ultra-short acting • Quick onset (peak effect by 5 min) • Loading dose 0.5 mg/kg • Beta1 selective • IV route only • Expensive

  21. Metoprolol • Can be given IV or PO • Long acting (q6h dosing) • Beta1 selective • Large doses may decrease the selectivity

  22. Labetelol • Can be given PO and IV • Selective alpha1 and nonselective beta1,2 • Alpha:Beta blocking properties 3:1 oral and 7:1 IV. (not clinically seen)

  23. Atenolol • Beta1 selective • Can be given IV or PO

  24. B-blocker Adverse Reactions • Bradycardia – is it symptomatic??? • Bronchospasm in COPD/Asthma patients – no evidence to suggest problem in these patients with selective agents • Heart Failure – use carefully in patients with low EF, however, has been shown to improve function with ACEI in end-stage CHF

  25. Summary for At Risk Patients • Preemptive Bradycardia • Think about heart rate as separate from blood pressure • Be aggressive with heart rate control • Incorporate into preoperative and postoperative care. • Involve Primary Care Physician • Involve Vascular Surgeon and Nursing

  26. Balanced Anesthesia andBeta-blockers

  27. B-blockers and Anesthetic Reduction

  28. Esmolol Promotes Electroencephalographic Burst Suppression During Propofol/Alfentanil Anesthesia Jay W. Johansen Anesth Analg 2001; 93:1526-31

  29. Esmolol Promotes Electroencephalographic Burst Suppression During Propofol/Alfentanil Anesthesia • N=20 patients • Alfentanil Groups (50 or 150 ng/ml) • Saline vs Esmolol infusion • Monitored BIS output and Suppression Ratio

  30. Esmolol Promotes Electroencephalographic Burst Suppression During Propofol/Alfentanil Anesthesia • BIS Output • Esmolol – 40% reduction (37→22) • Saline – no change • Suppression Ratio • Esmolol – 13.4 fold increase (5 → 67) • Saline – no change

  31. Efficacy of esmolol versus alfentanil as a supplement to propofol-nitrous oxide anesthesia Smith, J. Van Hemelrijck, and P. White Anesth Analg 2003;97:1633-1638

  32. Efficacy of esmolol versus alfentanil as a supplement to propofol-nitrous oxide anesthesia • N=97 patients for arthroscopy • Compared esmolol to alfentanil

  33. Efficacy of esmolol versus alfentanil as a supplement to propofol-nitrous oxide anesthesia • Esmolol decreased time to eye opening (7.2 vs 9.8 min) • Esmolol reported more pain in PACU • Esmolol required more opiods in PACU

  34. Esmolol Potentiates Reduction in Minimal Alveolar Isoflurane Concentration Jay W. Johansen, et al. Anesth Analg 1998; 87:671-6

  35. Esmolol Potentiates Reduction in Minimal Alveolar Isoflurane Concentration • N=100; divided into 5 groups • Isoflurane alone • Isoflurane with large dose esmolol (250 mcg/kg/min) • Isoflurane with Alfentanil • Isoflurane, Alfentanil, small dose esmolol (50 mcg/kg/min) • Isoflurane, Alfentanil, large dose esmolol (250 mcg/kg/min)

  36. Esmolol Potentiates Reduction in Minimal Alveolar Isoflurane Concentration • MAC levels after steady state • Isoflurane – 1.28% • Iso + large dose Esmolol – 1.23% • Iso + Alfentanil – 0.96%* • Iso + Alfentanil + small dose Esmolol – 0.96% • Iso + Alfentanil _ large dose Esmolol – 0.74%**

  37. Michael Zaugg, M.D.; Thomas Tagliente, M.D., Ph.D.; Eliana Lucchinetti, M.S.; Ellis Jacobs, Ph.D.; Marina Krol, Ph.D.; Carol Bodian, Dr.P.H.; David L. Reich, M.D.; Jeffrey H. Silverstein, M.D. ANESTHESIOLOGY 1999;91:1674-1686

  38. Beneficial Effects from B-Adrenergic Blockade in Elderly Patients Undergoing Noncardiac Surgery • N=63 patients for noncardiac surgery • Monitored – Neuropeptide Y, epinephrine, norepinephrine, cortisol, and ACTH • Randomly assigned • Group 1: no atenolol • Group 2: Pre- and Post-operative atenolol • Group 3: Intraoperative Atenolol

  39. Beneficial Effects from B-Adrenergic Blockade in Elderly Patients Undergoing Noncardiac Surgery • Beta-blockade did not change neuroendocrine stress response • Lower Narcotic Requirement • Groups II and III – 27.7% less fentanyl • Lower Anesthetic Requirements • Group III – 37.5% less isoflurane (BIS same in all groups) • Lower PACU Morphine requirements • Shorter PACU times

  40. Beta-blockers and Bariatric Surgery • Randomized Study of Morbidly Obese Patients Undergoing Gastric Bypass • Metoprolol vs. Placebo • Evaluate • Intraoperative Volatile Requirements • PACU Pain Requirement • PCA Usage

  41. Fluid Therapy for Vascular Patients Are We Using Way Too Much?

  42. AAA Change in Anesthetic Care • Retrospective study of AAA and anesthesia • Patients for elective infra-renal AAA in 1991 and 2001 • End-Points • Time to extubation • Intraoperative Fluid Administration • Time to return of Bowel Function

  43. AAA and Crystaloid Use

  44. AAA Length of Stay

  45. AAA and Bowel Function

  46. Fluid Therapy in Vascular Patients • Ensure adequate end-organ perfusion • Treat hypotension of reperfusion with a combination of fluid and vasopressors • Replace blood loss with blood, not crystaloid • Question replacing insensible losses and NPO deficits by formulas.

  47. Vascular Surgery and Regional Anesthesia

  48. Benefits of Regional Anesthesia • Cardiac Protection • Preservation of Pulmonary Function • Lower graft thrombosis • Decrease postoperative hypercoagulable state • Faster return of bowel function • Superior postoperative analgesia • Better immune function

  49. Regional Anesthesia and Cardiac Protection • Thoracic epidural a must, no benefit from lumbar catheter • High level to block cardiac accelerator fibers • Maintain an infusion or PCEA post-operatively for maximal benefits • Low risk of bleeding if placed 1 hour prior to systemic heparinization

  50. Regional Anesthesia and Cardiac Protection • Still not clear • Some studies show no difference • The role of beta-blockers to control sympathetic response confounding • No clear evidence regional is superior

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