Saturday, October 24, 2009

The resurgence of perioperative betablockers

Exciting news for all the hospitalists and perioperative medicine specialists. A large study done between 1996 and 2008 by Dr. Wallace, an anesthesiologist from the VA Hospital (UCSF)
(http://www.cardiacengineering.com/bbac/) showed survival benefits of perioperative beta blockers for patients with cardiovascular risk.

He uses a protocol called PCRRT that stands for Perioperative Cardiac Risk Reduction Therapy and can be accessed at http://www.cardiacengineering.com/bbac/PCRRT.pdf.

The protocol uses up-titrating dose of oral atenolol if the HR is >60x' or SBP > 120mmHg. They use iv metoprolol on the day of surgery and until the patient is able to take po, and then resume atenolol postoperatively at a dose of 100 mg once a day for 7 days. They advocate the indefinite use of betablockers in patients with CAD or PAD.

Fascinating is the fact that in the patients that betablockers were contraindicated, they used the alpha 2 agonist agent clonidine at a dose of 0.2 mg the night before surgery, a clonidine patch at a dose of 0.2 mg/24h and an additional oral dose of 0.2 mg in the AM of surgery.

The mortality at 30 days and 1 year was:
- Addition of betablocker:
30 days - O.R. 0.52 (95%CI, 0.33 - 0.83; P =.0055) ---> Reduction of almost 50%
1 year - O.R. 0.64 (95% CI, 0.51 - 0.79; P =.0001) ----> Reduction of almost 40%

- Continuation of previous betablocker:
30 days - 0.68 (95% CI, 0.47 - 0.98; P =.037) ---> Reduction of 32%
1 year - 0.82 (95% CI, 0.67 - 1.0; P =.05) ---> Reduction of almost 20%

- Withdrawal of previous betablocker:
30 days - increase in mortality 4-fold (P < .0001) 1 year - doubled mortality (P > .0001)

This information is very exciting, and supports the value of perioperative betablockers. The POISE trial brought a lot of noise in the perioperative medicine world; they used a very supraphysiologic dose of metoprolol in a very rapid fashion with no titration. This is a major caveat considered by the detractors of its results, mainly Dr. Poldermans.

The recently published European Society of Cardiology guidelines for Perioperative cardiac risk reduction in non-cardiac surgery (which were lead by Dr. Poldermans), advocate the use of perioperative betablockers in patients with 2 or more RCRI factors.

We should continue being careful in identifying this subset of patients. However, patients with stable systolic heart failure and coronary artery disease by themselves, benefit from the use of betablockers, regardless of the presence of other risk factors, although most likely they will in fact, have them given the common pathophysiologic ground - atherosclerosis -. The recent results of DECREASE group showed the benefits of adding fluvastatin perioperatively to patients undergoing vascular surgery (http://content.nejm.org/cgi/content/short/361/10/980).

I liked very much Dr. Wallace webpage (link above) and I think this large VA study will bring a significant backup to the use of betablockers in the perioperative setting. The use of clonidine was very refreshing. The idea is to control the heart rate - I wonder what result will a trial using calcium channel blockers or digoxin could bring . Comparing diltiazem or verapamil versus placebo versus betablockers versus clonidine and have subgroups with and without statins - I think the results will be very interesting. At the very end of the road, we want to decrease heart rate and perioperative oxygen consumption after induction of anesthesia.

I would love to see a discussion between Dr. Wallace, Dr. Devereaux and Dr. Poldermans. It would be very fascinating!

Reference can be accessed here. I look forward for a published article in a strong impact factor journal (JACC, Circulation or Anesthesia and Analgesia).

Sunday, October 18, 2009

Perioperative Evaluation, Assessment and Treatment in Pediatrics

The Cleveland Clinic Children's Hospital offers 4 hours CME courses (AMA category 1) every month. Yesterday, October 17, 2009, I presented at 9AM a lecture on Perioperative Assessment, Evaluation and Treatment in Pediatrics. (http://bit.ly/35RuPj)

What is unique about my presentation is that perioperative medicine as a separate field is way underdeveloped in Pediatrics. In adult medicine, especifically, in Hospital Medicine, the role of the hospitalist as an expert in Perioperative Medicine has been blossoming and growing up year by year, and is now a well established subspecialty field.

Perioperative Medicine is a discipline that provides a well rounded evaluation to the patient undergoing surgery, and has the objective of identifying and stabilizing in a timely fashion all the potential comorbidities, risk factors as well as potential complications that a patient can have during surgery.

In the perioperative evaluation for non-cardiac surgery, there are well developed guidelines for assessment and prevention of postoperative cardiovascular and pulmonary complications. For example, the 2007 AHA guidelines (http://bit.ly/4pzzK3) and the 2009 ESC guidelines (http://bit.ly/HAVZ2) or the ACP perioperative pulmonary guidelines (http://bit.ly/1nwVKL) or AHA guidelines for perioperative assessment of the morbid obese patient (http://bit.ly/26wUUU). Other well established guidelines are about perioperative management of antithrombotic therapy (http://bit.ly/K1Iaz) and prevention of venous thromboembolism (http://bit.ly/1Dfsv7).

However, there are no real guidelines or well delineated consensus or statements for perioerative management in children. There are well written articles that focuses on specific aspects or specific diseases (congenital heart surgery, diabetes, sickle cell anemia, etc.) but there is a lack of a guideline that delineates general rules in perioperative management of the Pediatric Patient.

In the lecture, I provide an outline that focus on the general approach to the perioperative management of the pediatric patient, and then on specific issues focused mostly on the children with complex medical problems.

I hope this effort offers a broad perspective of the important aspects to take into consideration in the perioperative evaluation and management of the pediatric patient.

As always, primum non nocere.

Thursday, October 1, 2009

Nephrology Resources

In a busy Nephrology service, the residents and fellows need to maximize their ability to study and be current with the latest literature available while performing their busy clinical duties and procedures, preparing and attending to Journal clubs, lectures, research, writing abstracts and articles, studying for the boards, and of course....attempting to live a normal life.

Multiple resources exist; however it becomes almost impossible to have awareness of every single item out there. What I personally do as a hospitalist (but with an incredibly intense interest for Nephrology -as well as I have for Cardiology and Endocrinology -) is to get in my e-mail the TOC of most of the important journals.

If you see, here in my blog I get the updated RSS feed for the most important Internal Medicine and Pediatrics journals. This facilitates my search for information as I have in my fingertips the latest table of contents for most journals and giving a quick look to them permits me to be aware of new articles that I can recall later on, if not, read them immediately.

Below is a list of articles and links to the different journals as well as resources for Nephrology:

1. Nature Reviews Nephrology - http://www.nature.com/nrneph/index.html - on the left side there is a box that has a little envelope that states "Sign-up for e-alerts" (you need to register, is free, and you can get emails with the Table of contents of only this journal, or all Nature Clinical Journals, including Nature Reviews Urology, which is very good).

2. Nephrology Dialysis Transplantation - http://ndt.oxfordjournals.org/ - on the left lower side there is a section called Alerting Services. Click on "Email table of contents" as well as "email advance access" - you need to register (is free).

3. Kidney International - http://www.nature.com/ki/index.html - this is a Nature publication - you can register to this one by the link from Nature Reviews Nephrology.

4. Current Opinion in Nephrology and Transplantation - http://journals.lww.com/co-nephrolhypertens/pages/default.aspx - they have excellent reviews and concise articles that suggests you further literature. Register at Subscribe to eTocs.

5. Journal of the American Society of Nephrology - http://jasn.asnjournals.org/ - go to http://jasn.asnjournals.org/cgi/alerts - and just type your email.

6. American Journal of Kidney Diseases - http://www.ajkd.org/ - this is published by Elsevier; register for free at http://www.ajkd.org/user/alerts - here you can register as well to get the Table of Contents of: Advances in Chronic Kidney Diseases (http://www.ackdjournal.org/), and Journal of Renal Nutrition (http://www.jrnjournal.org/)

7. Complimentary registration to National Kidney Foundation - http://www.kidney.org/professionals/physicians/ajkd.cfm
- they publish the KDOQI and the KDIGO guidelines.

8. Medscape Nephrology - http://www.medscape.com/nephrology - Excellent source for updated medical information and CME.

9. Medpage Nephrology - http://www.medpagetoday.com/Nephrology/ - Excellent source for updated medical information and CME. Has nice divisions in DM, ESRD, hypertension, Transplant, etc.

10. Ukidney - http://ukidney.com/ - excellent resource for education in Nephrology.

11. Nephrology Now - a blog dedicated to education in Nephrology - http://www.nephrologynow.com/

12. HDCN - Hypertension, Dialysis and Clinical Nephrology - http://www.hdcn.com/ - excellent resource for education in Nephrology.
Here you can access:
- Atlas of diseases of the kidney (http://cnserver0.nkf.med.ualberta.ca/cn/Schrier/Default6.htm) - nice PDF's and Powerpoint - you can use to prepare your lectures.
- Atlas of renal pathology (http://www2.us.elsevierhealth.com/ajkd/atlas/) - useful for preparing lectures.

13. Societies other than ASN - Renal Physician Association - http://www.renalmd.org/

14. British Medical Journal collections - http://www.bmj.com/collections/ - You select the arrow on "Renal Medicine" and it opens you the access to articles on ARF, CRF, Dialysis, Fluid, electrolyte and Acid-Base, Nephrotic Syndrome, Proteinuria, Renal Transplant. You select the arrow on "Cardiovascular Medicine" and you can access the Hypertension articles.

15. Medical Pearls - a nice webpage with links to useful sites - http://www.medicalpearls.com/neph/nephlinks

Feel free to share this information, copy and paste in your own blog and email to other Internal Medicine or Nephrology doctor. Hopefully Dr. Bertalan Mesko will publish this links along with others in his fantastic Webicina 2.0 webpage.

Enjoy!

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