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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

Progress in Vascular Anesthesiology

Donald M. Voltz, M.D.

Assistant Professor of Anesthesiology

Case Western Reserve University/University Hospitals of Cleveland

overview
Overview
  • Beta-blockers
  • Fluid Therapy
  • Regional Anesthesia
eta blockers
Вeta-Blockers
  • Cardioprotection
  • Hemodynamic Control
  • Anesthetic Modification
b blockers and cardioprotection
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
slide7

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

mangano et al 1996
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
wallace et al 1998
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
wallace et al 199810
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)
polderman et al 1999
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
b blockers at risk patients
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
b blockers and cardioprotection14
B-blockers and Cardioprotection
  • How well are we doing with at risk patients?
    • Not Very Well!
slide15

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
slide16

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

slide17
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
slide18
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
b blockers types
B-blockers - Types
  • Esmolol
  • Metoprolol
  • Labetelol
  • Atenolol
esmolol
Esmolol
  • Ultra-short acting
  • Quick onset (peak effect by 5 min)
  • Loading dose 0.5 mg/kg
  • Beta1 selective
  • IV route only
  • Expensive
metoprolol
Metoprolol
  • Can be given IV or PO
  • Long acting (q6h dosing)
  • Beta1 selective
  • Large doses may decrease the selectivity
labetelol
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)
atenolol
Atenolol
  • Beta1 selective
  • Can be given IV or PO
b blocker adverse reactions
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
summary for at risk patients
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
esmolol promotes electroencephalographic burst suppression during propofol alfentanil anesthesia

Esmolol Promotes Electroencephalographic Burst Suppression During Propofol/Alfentanil Anesthesia

Jay W. Johansen

Anesth Analg 2001; 93:1526-31

esmolol promotes electroencephalographic burst suppression during propofol alfentanil anesthesia29
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
esmolol promotes electroencephalographic burst suppression during propofol alfentanil anesthesia30
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
efficacy of esmolol versus alfentanil as a supplement to propofol nitrous oxide anesthesia

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

efficacy of esmolol versus alfentanil as a supplement to propofol nitrous oxide anesthesia32
Efficacy of esmolol versus alfentanil as a supplement to propofol-nitrous oxide anesthesia
  • N=97 patients for arthroscopy
  • Compared esmolol to alfentanil
efficacy of esmolol versus alfentanil as a supplement to propofol nitrous oxide anesthesia33
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
esmolol potentiates reduction in minimal alveolar isoflurane concentration

Esmolol Potentiates Reduction in Minimal Alveolar Isoflurane Concentration

Jay W. Johansen, et al.

Anesth Analg 1998; 87:671-6

esmolol potentiates reduction in minimal alveolar isoflurane concentration35
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)
esmolol potentiates reduction in minimal alveolar isoflurane concentration36
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%**
slide37

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

beneficial effects from b adrenergic blockade in elderly patients undergoing noncardiac surgery
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
beneficial effects from b adrenergic blockade in elderly patients undergoing noncardiac surgery39
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
beta blockers and bariatric surgery
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
fluid therapy for vascular patients

Fluid Therapy for Vascular Patients

Are We Using Way Too Much?

aaa change in anesthetic care
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
fluid therapy in vascular patients
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.
benefits of regional anesthesia
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
regional anesthesia and cardiac protection
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
regional anesthesia and cardiac protection50
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
regional anesthesia and cardiac protection51
Regional Anesthesia and Cardiac Protection
  • Problems with regional anesthesia studies and cardiac protection
    • Groups not normalized to heart rate?
    • Is the benefit only from cardiac accelerator fibers being blocked?
    • Are there other benefits of beta-blockers not being used because of a high epidural level?
slide52

Is Reduced Cardiac Performance the Only Mechanism for Myocardial Infarction Size Reduction During beta-Adrenergic Blockade?

Stangeland, L. Grong, K. Vik-Mo, H. Anderson, K. Levken, J.

Cardiovasc Res 1986;20: 322-30

stangeland et al
Stangeland, et al.
  • Anaesthetized cats to elucidate if decreased heart rate was the mechanism for cardiac protection.
  • Treated groups with either timolol or alinidine (clonidine derivative that decreases HR independently of Beta-receptors)
  • Induced regional ischemia (LAD occlusion for 6 hours)
stangeland et al54
Stangeland, et al.
  • Alinidine Group:
    • Decreased Necrotic Area to 77% of control
  • Timolol Group:
    • Decreased Necrotic Area to 65% of control
    • This data suggested another mechanism for beta-blocker cardioprotection other than heart rate control
regional anesthesia and pulmonary function
Regional Anesthesia and Pulmonary Function
  • FRC is decreased due to
    • Diaphragmatic dysfunction of upper abdominal or thoracic incisions
    • Decreased chest wall compliance
    • Incisional Pain Limitations
regional anesthesia and pulmonary function56
Regional Anesthesia and Pulmonary Function
  • Advantages for thoracic and upper abdominal surgery
  • Unclear benefits in lower abdominal and peripheral surgery
  • No Change in hospital LOS
  • Time and Post-Op labor intensive
    • Time to place
    • Requires pain service to follow
regional anesthesia and pulmonary function57
Regional Anesthesia and Pulmonary Function
  • Currently are not using thoracic epidurals for AAA surgery
  • Pain control in ICU and on Floor is adequate
  • Surgeon’s and Anesthesiologist’s are in agreement to post-operative pain control
regional anesthesia and pulmonary function58
Regional Anesthesia and Pulmonary Function
  • No increased incidence in pneumonia
  • No delay in extubation for elective aortic or lower extremity surgery
regional anesthesia and graft thrombosis
Regional Anesthesia and Graft Thrombosis
  • Improvement in lower extremity blood flow
  • Decrease sympathetic activation and stimulation of coagulation system
  • Systemic absorption of local anesthetics block thromboxane A2, platelet aggregation and reduce blood viscosity
  • Large meta-analysis done in orthopedics looking at DVT.
  • Abdominal surgery patients had a less significant effect
  • Minimization of blood loss.
regional anesthesia and los
Regional Anesthesia and LOS
  • No increase in LOS at our institution
  • Unclear in literature if LOS is improved with regional anesthesia
norris e j et al anesthesiology 2001 95 1054 67

Double-masked Randomized Trial Comparing Alternate Combinations of Intraoperative Anesthesia and Postoperative Analgesia in Abdominal Aortic Surgery

Norris, E.J. et al.

Anesthesiology 2001;95:1054-67

norris et al
Norris et al.
  • N=168 pts for elective aortic surgery
  • Randomized to either epidural with light GA vs. GA alone
  • Pts either with PCA or PCEA for 72h postoperatively
norris et al63
Norris et al.
  • Postoperative outcomes were similar in groups
    • MI, reoperation, renal failure, pneumonia
    • LOS and direct medical costs
    • VAS Pain Scores
  • Epidural groups with shorter
    • Time to extubation (19 vs. 13 hours)
    • ICU discharge (46 vs. 43 hours)
    • Return of Bowel Function (111 vs. 102 hours)
regional anesthesia and bowel function
Regional Anesthesia and Bowel Function
  • Thought to relate to narcotic use as well as sympathetic reflex arcs
  • Thought is decreased sympathetic slowing while maintaining parasympathetic peristalis
  • Problems with randomized studies are higher amounts of narcotics.
  • Lower narcotic usage has impacted post-operative ileus in out institution
regional anesthesia and vascular surgery summary
Regional Anesthesia and Vascular Surgery - Summary
  • Not presently known if regional superior to beta-blockade for cardioprotection
  • Regional may be beneficial in severely reduced pulmonary function patients
  • Pain control is similar with IVPCA vs PCEA
  • Unclear if additional factors are significant in vascular patients
the end
THE END

Vascular Anesthesia at University Hospitals of Cleveland