Hier ein einfaches Schema zur perioperativen Betablockade, wie sie in Stanford, Kalifornien gehandhabt wird:

 

Prophylactic Perioperative Beta Blockade (PPBB) Guidelines
Cliff Schmeising, MD

All patients scheduled for major elective non-cardiac surgery requiring general anesthesia and a hospital stay qualify.  Patients for emergency surgery, hemodynamically unstable patients, and renal transplant patients need to be assessed individually.  These guidelines are intended to provide supplemental information for use with the perioperative beta blockade protocol order form.

 Consider PPBB for patients with in least one of the following categories:

 Known coronary artery disease
Atherosclerotic vascular disease
Diabetes
Any two of the following:
age > 65 years, hypertension, current smoker, hyperlipidemia

Patients with in any of the following categories should not receive PPBB:

 Known sensitivity to beta blockers
Second or third degree heart block
Acute congestive heart failure
Acute bronchospasm
Systolic blood pressure (SBP) < 100 mmHg
Heart rate < 60 beats per minute (bpm)
Acutely hemodynamically unstable patients

Care must be taken with administration to patients with a history of asthma or COPD.

Drug Choice:

Atenolol, bisoprolol and metoprolol may all been used.  They are all long-acting, Beta-1 selective and have similar efficacy in the prevention of death after myocardial infarction.  Other beta blockers without intrinsic sympathomimetic effect are probably equivalent, so if a patient is on another beta blocker it is unnecessary to change to a Beta-1 selective drug.  However, the dosage should be adjusted to keep the HR < 80 bpm.

 How should PPBB be initiated?

Preoperatively:  If Hr > 60 bpm and SBP > 100 mmHg, then oral dosing with twice daily metoprolol (25-50 mgs), or once daily atenolol (50-100 mgs) can be started several days before surgery.  Target HR is >50 and < 70 bpm.

In Holding Area prior to surgery: If HR > 60 bpm and SBP > 100 mmHg, metoprolol 2.5-5 mgs IV can be given while monitoring HR and BP.  For maximal beta blockade, consider additional dose(s) q 10 minutes if HR remains > 70 bpm and SBP > 100 mmHg.  Target HR is > 50 and < 70 bpm.

During Surgery: If HR > 60 bpm and SBP > 100 mmHg, metoprolol 2.5-5 mgs IV q 10 minutes may be given 30 minutes prior to emergence.   Target HR for maximal beta blockade is < 70 bpm.  Alternatively, esmolol infusion may be titrated to maintain HR < 70 during emergence.  

PACU or ICU after surgery:  If HR > 60 bpm, and SBP > 100 mmHg, metoprolol 2.5 5.0 mgs IV may be given while monitoring HR and BP.  For maximal beta blockade, consider additional dose(s) q 10 minutes if HR remains > 70 bpm and SBP > 100 mmHg.  Target HR is > 50 and < 70 bpm.  Consider use of PBBP order form.

Post Operative Care:  If the patient is to be kept NPO, metoprolol 2.5-5 mgs IV q 6 hours dosing should be continued with target HR> 50 and < 70 bpm while maintaining SBP > 100 mmHg.  When patient is able to take oral medications the patient may be switched to twice daily oral metoprolol (25-50 mgs), or once daily atenolol (50-100 mgs) with dosage adjusted to keep HR > 50 and < 70 bpm and SBP > 100 mmHg.  Consider use of PBBP order form.

PPBB should be continued for at least 7 days postoperatively. Patients with a history of coronary artery disease may benefit from indefinite beta blockade therapy.