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The Beta Blocker and Clonidine Protocol

Lesson 8
Implementing a BBAC Protocol

2. General Guidelines: The 7 Rules

Rules 4 - 5:

4. Beta blockade should be continued until at least 30 days postoperatively.

5. The optimal time to start beta blockade is at the time of identification of the risk. This process should be multi-tiered to avoid missing patients. The culture must change for the maximal number of patients to be treated. We use the following approach.

a. The surgeon starts the patient on a beta blocker if they have CAD, PVD, or two risk factors. Atenolol 25 mg PO QD is an appropriate starting dose.

b. If a medical or cardiology consult is requested by surgery, the most common advice is start a beta blocker.

c. The anesthesia preop clinic checks to see if the patients at risk are on a beta blocker. If the patient is not adequately blocked the dose is increased.

d. On the day of surgery the anesthesia providers may increase the dose or treat with intravenous beta blockers. Intravenous metoprolol in 5 mg boluses is used. Standard dose is 10 mg IV (hold for heart rate less than 50 or systolic blood pressure less than 100 mmHg). Intraoperative doses are used as needed. The patient is also re-dosed in the PACU post op as needed.

e. The patient remains on the drug post-operatively for 30 days. If the patient is NPO, the patient receives intravenous metoprolol (10 mg IV Q12). Hold for systolic blood pressure less than 100 mmHg and/or heart rate less than 50 beats per minute. If the patient is taking PO medications, the patient receives atenolol 100 mg PO QD if the heart rate is greater than 65 and the systolic blood pressure is greater than 100 mmHg. If the heart rate is between 55 and 65 the dose is 50 mg. There is a hold order for heart rate less than 50 or systolic blood pressure less than 100 mmHg.

f. The patient remains on the drug for at least 30 days postoperatively.

g. Many patients should remain on the drug for life (known CAD, known PVD, hypertension).


Content by Art Wallace MD PhD
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