Hier ein einfaches Schema zur perioperativen Betablockade, wie sie in Stanford, Kalifornien gehandhabt wird:
Perioperative Beta Blockade (PPBB) Guidelines
Cliff Schmeising, MD
Consider PPBB for patients with in least one of
the following categories:
Known coronary artery disease
Atherosclerotic vascular disease
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
Systolic blood pressure (SBP) < 100 mmHg
Heart rate < 60 beats per minute (bpm)
Acutely hemodynamically unstable patients
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 mg’s), or once
daily atenolol (50-100 mg’s) 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 mg’s 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 mg’s 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
PACU or ICU after surgery: If HR > 60 bpm,
and SBP > 100 mmHg, metoprolol 2.5 –5.0 mg’s 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 mg’s 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 mg’s), or once daily atenolol (50-100 mg’s)
with dosage adjusted to keep HR > 50 and
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.