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

Abstract

SummaryPatients with coronary artery disease presenting for major noncardiac surgery may have indications for both peri-operative b-blockade and haemodynamic optimisation. The combination of peri-operative cardiorespiratory failure and myocardial ischaemia has a grave prognosis. Recent investigations have shown that in patients with coronary artery disease, b-blockade does not depress cardiac output as much as originally thought. There may, therefore, be a place for both peri-operative b-blockade and haemodynamic optimisation. The indications for peri-operative b-blockade and haemodynamic optimisation, the effect of acute b-blockade on cardiac output in patients with coronary artery disease, and the interaction of peri-operative b-blockade and haemodynamic optimisation are discussed.Keywords Sympathetic nervous system; beta-adrenergic blockade. anaesthesia. myocardial ischaemia. Since the article by Juste et al. in 1996 [1], a number of studies have added to our understanding of peri-operative b-blockade and haemodynamic optimisation. These include the indications for peri-operative b-blockade and haemodynamic optimisation, the tolerance of acute b-blockade in patients with both coronary artery disease (CAD) and poor exercise capacity, and issues regarding both acute and chronic b-blockade during haemodynamic optimisation.Indications for peri-operative b-blockade

Landiolol has a less potent negative inotropic effect than esmolol in isolated rabbit hearts

“…The administration of β-blockers plays an important role in preventing perioperative myocardial ischemia in patients with coronary artery diseases [24]; however, tachycardia should be avoided without reducing blood pressure, because an adequate blood pressure level is required to maintain coronary perfusion [25]. In the present study, we used a denervated rabbit model, and there are several potential limitations in explaining the clinical effectiveness of landiolol in such a model.…”

Use of the AnaConDa™ anaesthetic delivery system in ICU

“…If one were to rely on just the original article without referring to the erratum subsequently reported, it is possible to get the wrong clinical message. We came across one such erratum [1] which had the potential to change the message in the original article [2]. We searched, therefore, all the issues of Anaesthesia from 1996 to 2006 and found 37 errata published.…”

“…Agitated patients are younger, have longer ICU stays, have more ventilator days and are more likely to self-extubate [2]. Intravenous haloperidol has been extensively used to manage agitated patients in the ICU and to control delirium in patients with…”

“…The article cited above [2] is one of the 20 most read articles in the last 12 months. Yet, on the contents page there is no indication of the erratum published in a later issue of the journal, which has the potential to change the clinical message.…”

“…Both the use of volatile agent and the AnaConDa have been described for ICU sedation [2,3] but in the light of the practicalities, familiarity, efficacy, cost and safety of intravenous sedation regimes in the ICU, we wanted to be able to justify volatile use. Suffice to say the only valid alternative we have come up with so far was its use for postoperative sedation following cardiac surgery.…”