Minimising cardiac anaesthetic risk: the tortoise or the hare?

Pre-operative fasting and administration of regular medications in adult patients presenting for elective surgery. Has the new evidence changed practice?

“…There is also evidence of widespread inequalities in the prescription and administration of regular medications in the peri‐operative period [12]. The omission of cardiac medicines is of particular concern, as evidence suggests that omission of such medicines will increase the risk of peri‐operative myocardial ischaemia [13, 14]. Similar problems are possible with a number of drug classes.…”

Peri‐operative β‐blockade and haemodynamic optimisation in patients with coronary artery disease and decreasing exercise capacity presenting for major noncardiac surgery

“…Peri‐operative haemodynamic optimisation assists the cardiorespiratory unit in attaining the physiological requirements of the peri‐operative period [1]. Haemodynamic optimisation is a protocol‐driven resuscitation to improve cardiac output, oxygen delivery and oxygen consumption [12].…”

“…However, associated patient risk factors, such as congestive cardiac failure or emergency surgery, may increase peri‐operative mortality [18] to the extent that both peri‐operative haemodynamic optimisation and β‐blockade may be indicated. In addition, some of the indications used in studies of peri‐operative haemodynamic optimisation (previous cardiorespiratory illness, extensive surgery planned, age > 70 years with limited physiological reserve in one or more organs and/or late stage vascular disease [1]), overlap with indications for peri‐operative β‐blockade (Tables 1–3).…”

“…The anaerobic threshold has been used to predict the peri‐operative capacity of the cardiorespiratory unit [19]. The anaerobic threshold is that point during exercise at which anaerobic metabolism is required in addition to aerobic metabolism [1, 19]. There is a significant decrease in peri‐operative mortality once a pre‐operative anaerobic threshold of oxygen delivery of 11 ml.kg −1 .min −1 is achieved [19].…”

“…Since the article by Juste et al in 1996 [1], a number of studies have added to our understanding of peri‐operative β‐blockade and haemodynamic optimisation. These include the indications for peri‐operative β‐blockade and haemodynamic optimisation, the tolerance of acute β‐blockade in patients with both coronary artery disease (CAD) and poor exercise capacity, and issues regarding both acute and chronic β‐blockade during haemodynamic optimisation.…”