PPMC #238649 (Page 1 of 2) 10/2005 –Pilot

Physician’s Orders for Peri-Operative Beta Blockers

Check appropriate box(es) where multiple order options occur & complete blank lines. All other orders are active unless crossed out.

The use of peri-operative beta-blocker therapy for patients at risk of peri-operative cardiac events has been shown to reduce the morbidity and mortality associated with ischemia and arrhythmias when administered to high-risk patients undergoing major, non-cardiac surgery. Risk factor assessment and recommendations are included on the back of this page.

Pre-operative Therapy

 For patients on home maintenance beta-blocker therapy:

Continue taking ______(drug, dose, route, frequency).

Take last dose within 2 hours prior to surgery on day of surgery.

 Oral therapy (recommended to start 5 days prior to surgery if possible)

 Atenolol 12.5 mg po daily Metoprolol 25 mg po bid

 Atenolol 25 mg po daily Metoprolol 50 mg po bid

Take last dose within 2 hours prior to surgery on day of surgery.

Hold for SBP < 100 or HR<55

 Intravenous therapy (for patients who are NPO only)

Metoprolol 5 mg IV every 10 minutes pm HR> 90 bpm. Do not exceed total dose of 15 mg. Hold if SBP < 100 or HR < 55 bpm. If patient has not previously been on oral beta-blockers, monitor HR and BP q 5 min x 3, q 15 min x 3, q 30 min x 2. Therapy should begin 2 hours prior to surgery.

Post – Operative Therapy

 Continuation of home maintenance beta-blocker therapy. Patient to take usual dose of beta-

blocker starting post-op day #1 and continue through discharge.

Continue taking ______(drug, dose, route, frequency).

 Oral therapy (recommend to continue 30 days post-operatively; then titrate to discontinue)

 Atenolol 12.5 mg po daily Metoprolol 25 mg po bid

 Atenolol 25 mg po daily Metoprolol 50 mg po bid

Hold for SBP < 100 or HR<55

 If patient is NPO post-operatively (recommend switch to oral therapy when able for 30

day post-operative period):

Metoprolol 5 mg IV Q 4 hours pm HR>90 bpm. Hold forSBP<100 or HR<55.

If patient has not previously been on oral beta-blockers, monitor HR and BP q 5 min x 3,

q 15 min x 3, q 30 min x 2.

 If patient is in the ICU and NPO:

Start esmolol drip at 100 mcg/kg/min and titrate upwards, in increments of 50 mcg, to 300 mcg/kg/min to maintain HR<90 bpm. Do not give starting bolus infusion. May be titrated in the OR, PACU, CICU or ICU. Continue for 48 hours or switch to oral medication when tolerating oral medications / diet.

Physician’s Signature: ______Date/Time: ______

*ALL VERBAL ORDERS MUST BE SIGNED/DATED/TIMED BY AUTHORIZED

PRACTITIONER,

NO LATER THAN THE DATE THE RECORD IS CLOSED.*

(Page 2 of 2)
Guidelines for the Prevention of Coronary

Events in High-Risk Surgical Patients

Assessment: Identified Risk Factors (Increased risk when Age > 65)

Known Coronary Disease as defined: Other Significant Risk Factors:

- AMI within 12 months Diabetes Mellitus

- Current Angina History of CVA

- Positive Stress Test Renal failure (serum Creatinine > 2.0)

- Diagnostic Q waves on ECG Current Smoker

- Abnormal ECG: Cholesterol > 240 mg/dL

- LVH, new ST-T changes Poor Functional Status

Significant Aortic Stenosis (<4 Metabolic Equivalents Table:

Hypertension unable to carry groceries up one flight

History of Congestive Heart Failure of stairs.)

Significant Ventricular Arrhythmia

Contraindications to Beta Blocker Therapy

Decompensated Congestive Heart Failure Uncontrolled Asthma

Second or Third Degree Heart Block Uncontrolled Chronic Pulmonary Disease

Phenochromocytoma

Documented Allergy to Beta Blocker

Recommendations for patients with the following risk factors:

No Risk Factors ------Proceed with surgery without further workup, but DO NOT stop

current beta blocker therapy.

1 to 3 risk factors ---- Use a beta blocker to control the heart rate 55 to 90, keep the systolic

blood pressure > 100.

4 or more ------Consider non-invasive testing prior to elective surgery.

Dosage guidelines:

Ideally, beta-blockers should be titrated to a dose that maintains the heart rate in the range of 55-90 bpm and systolic blood pressure > 100 mmHG.

For patients who are small (<50kg), elderly orMetoprolol 25 mg po bid

frail or baseline SBP < 100 mmHG or HR<65 or

bpmAtenolol 25 mg po daily

If baseline SBP > 100 mmHG or HR> 65 bpmMetoprolol 50 mg po bid

or

Atenolol 50 mg po qd