Neuraxial block, death and serious cardiovascular morbidity in the POISE trial. Effect of ropivacaine skull block on perioperative outcomes in patients with supratentorial brain tumors and comparison with remifentanil: a pilot study. Peri vascular axillary block VII: the effect of a supplementary dose of 20 ml mepivacaine 1 % with adrenaline to patients with incomplete sensory blockade Lessons learned from a randomised controlled study of perioperative beta blockade in high risk patients undergoing emergency surgery. Early Neuromuscular Blockade in the Acute Respiratory Distress Syndrome. The effects of perioperative beta-blockade: results of the Metoprolol after Vascular Surgery (MaVS) study, a randomized controlled trial. Mortality benefit of beta-blockade after successful elective percutaneous coronary intervention. The impact of peripheral nerve blocks on perioperative outcome in hip and knee arthroplasty—a population-based study The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery. Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group. The influence of residual neuromuscular block on the incidence of critical respiratory events. A randomised, prospective, placebo-controlled trial Contrast-induced nephropathy in patients undergoing primary percutaneous coronary intervention without acute left ventricular ejection fraction impairment. Effect of perineural dexmedetomidine on the quality of supraclavicular brachial plexus block with 0.5% ropivacaine and its interaction with general anaesthesia Impact of beta blockade therapy on long-term mortality after ST-segment elevation acute myocardial infarction in the percutaneous coronary intervention era. Perioperative beta blockade with propranolol: reduction in myocardial oxygen demands and incidence of atrial and ventricular arrhythmias. The Diabetic Postoperative Mortality and Morbidity (DIPOM) trial: rationale and design of a multicenter, randomized, placebo-controlled, clinical trial of metoprolol for patients with diabetes mellitus who are undergoing major noncardiac surgery. Early mineralocorticoid receptor blockade in primary percutaneous coronary intervention for ST-elevation myocardial infarction is associated with a reduction of life-threatening ventricular arrhythmia. Beta-blockade benefits patients following a subarachnoid haemorrhage.
BACKGROUND This post hoc analysis aim ed to determine whether neuraxial block was associated with a composite of cardiovascular death , non-fatal myocardial infa rct ion ( MI ) and non-fatal cardiac arrest within 30 days of r and omization in POISE trial patients . METHODS A total of 8351 non-cardiac surgical patients at high risk of cardiovascular complications were r and omized  to β-blocker or placebo . Neuraxial block was defined as spinal , lumbar or thoracic epidural anaesthesia . Logistic regression , with weighting using estimated propensity scores , was used to determine the association between neuraxial block and primary and secondary outcomes . RESULTS Neuraxial block was associated with an increased risk of the primary outcome [ 287 ( 7.3 % ) vs 229 ( 5.7 % ) ; odds ratio ( OR ) , 1.24 ; 95 % confidence interval ( CI ) , 1.02 - 1.49 ; P=0.03 ] and MI [ 230 ( 5.9 % ) vs 177 ( 4.4 % ) ; OR , 1.32 ; 95 % CI , 1.07 - 1.64 ; P=0.009 ] but not stroke [ 23 ( 0.6 % ) vs 32 ( 0.8 % ) ; OR , 0.76 ; 95 % CI , 0.44 - 1.33 ; P=0.34 ] , death [ 96 ( 2.5 % ) vs 111 ( 2.8 % ) ; OR , 0.87 ; 95 % CI , 0.65 - 1.17 ; P=0.37 ] or clinical ly significant hypotension [ 522 ( 13.4 % ) vs 484 ( 12.1 % ) ; OR , 1.13 ; 95 % CI , 0.99 - 1.30 ; P=0.08 ] . Thoracic epidural with general anaesthesia was associated with a worse primary outcome than general anaesthesia alone [ 86 ( 12.1 % ) vs 119 ( 5.4 % ) ; OR , 2.95 ; 95 % CI , 2.00 - 4.35 ; P<0.001 ] . CONCLUSIONS In patients at high risk of cardiovascular morbidity , neuraxial block was associated with an increased risk of adverse cardiovascular outcomes , which could be causal or because of residual confounding OBJECT Skull blockade for craniotomy may result in the reduction of sympathetic stimulation associated with the application of head pins ( " pinning " ) , improvement in intraoperative hemodynamic stability , and a decrease in intraoperative anesthetic requirements . Postoperative benefits may include a decrease in pain , in analgesic requirements , and in the incidence of nausea and vomiting . The authors examined the potential benefits of a skull block in patients in whom a maintenance anesthetic consisting of sevoflurane and a titratable remifentanil infusion  was used . In other studies examining the ability of a skull block to improve perioperative outcomes , investigators have not used remifentanil . METHODS Thirty patients presenting for resection of a supratentorial tumor were prospect ively enrolled . Patients were r and omized into 2 groups as follows : 14 patients ( skull block group ) received a skull block with 0.5 % ropivacaine at least 15 minutes prior to pinning , whereas the remaining 16 patients ( control group ) did not . RESULTS Patients in the skull block group did not have a significant increase in blood pressure or heart rate with placement of head pins , whereas patients in the control group did . Nevertheless , there was no difference in blood pressure variability between the groups . The mean intraoperative concentration of sevoflurane ( 1.0 % in both groups , p = 0.703 ) and remifentanil ( 0.163 microg/kg/min compared with 0.205 microg/kg/min , p = 0.186 ) used was similar in both groups . During the postoperative period , there was no difference in the 1- , 2- , or 4-hour visual analog scale scores ; in the need for postoperative narcotic analgesia ( 0.274 morphine equivalent mg/kg compared with 0.517 morphine equivalent mg/kg , p = 0.162 ) ; or in the incidence of nausea or vomiting . CONCLUSIONS Prospect i ve analysis of perioperative skull blockade failed to demonstrate significant benefit in patients treated with a remifentanil infusion Perivascular axillary blockade was performed on 233 patients with the aid of a catheter technique . All patients received a primary injection of 50 ml of mepivacaine 1 % with adrenaline .  Sensory blockade was evaluated 20 , 30 and 40 min after injection , and a complete sensory blockade was found in 90 ( 39 % ) , 131 ( 57 % ) and 146 ( 63 % ) , respectively . The blockade effect of a supplementary perivascular injection of 20 ml of the same agent was investigated on the remaining 87 blockades , which could be divided into three categories : 1 ) blockades which at 20 min showed lack of analgesia in several cutaneous segments of the h and ( 34 patients ) ; 2 ) blockades which at 30 min showed a total lack of sensory blockade within a limited area ( 29 patients ) ; and 3 ) blockades which at 40 min showed signs of blockade of all cutaneous segments , but one or several segments were not blocked with an intensity compatible with surgery ( 24 patients ) . Blockades of categories 1 and 2 were at 20 and 30 min , respectively , r and omly allocated to control or to perivascular supplementation groups , while blockades of category 3 all had supplementation at 40 min . Sensory blockade was reevaluated 10 and 20 min after group allocation , and it was found that perivascular supplementation had no significant effect on the sensory blockade in category 1 and 2 , while 68 % of the blockades in category 3 improved to a complete blockade . It was concluded that the effect of a supplementary perivascular dose of local anaesthetic could be judged as acceptable with regard to intensifying an insufficient sensory blockade , but that it was incapable of extending the blockade into areas which were totally unblocked after the primary injection . On the basis of a previous and the present investigation , we have suggested practical , simple guidelines which might help the anaesthetist in deciding on his course of action when faced with an inadequate axillary blockade BACKGROUND Perioperative beta blockade has been shown to reduce mortality after major elective surgery . The aim of this study was to determine whether it could reduce the rate of death and morbidity from cardiac complications in high risk patients undergoing emergency surgery . METHODS Over a one-year interval all patients undergoing major non-elective orthopaedic or general surgery were screened to identify those at high risk of cardiac complications . Consenting , high risk patients were r and omly allocated atenolol or placebo for seven days , commencing at anaesthetic induction . Deaths and cardiac complications within 30 days were recorded . RESULTS Some 2351 patients had an emergency operation ; 145 were at high risk and eligible for the study . Of 89 patients approached , 57 initially consented . Only 38 patients , however , completed the study protocol , 19 were withdrawn . Of those who completed the study , 5/20 patients in the placebo group and 3/18 in the treatment group died before hospital discharge ( p=0.520 ) . Four others in the placebo group and two in the atenolol group had post-operative non-fatal cardiac events ( positive troponin T ) , p=0.311 . CONCLUSIONS This study of emergency surgery proved more difficult than similar trials in elective surgery . The final study groups were small and there were no significant differences in outcomes . A much larger study is required for a definitive answer BACKGROUND The benefits of early continuous neuromuscular blockade in patients with acute respiratory distress syndrome ( ARDS ) who are receiving mechanical ventilation remain unclear . METHODS We r and omly assigned patients with moderate-to-severe ARDS ( defined by a ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen of < 150 mm Hg with a positive end-expiratory pressure [ PEEP ] of ≥8 cm of water ) to a 48-hour continuous infusion of cisatracurium with concomitant deep sedation ( intervention group ) or to a usual-care approach without routine neuromuscular blockade and with lighter sedation targets ( control group ) . The same mechanical-ventilation strategies were used in both groups , including a strategy involving a high PEEP . The primary end point was in-hospital death from any cause at 90 days . RESULTS The trial was stopped at the second interim analysis for futility . We enrolled 1006 patients early after the onset of moderate-to-severe ARDS ( median , 7.6 hours after onset ) . During the first 48 hours after r and omization , 488 of the 501 patients ( 97.4 % ) in the intervention group started a continuous infusion of cisatracurium ( median duration of infusion , 47.8 hours ; median dose , 1807 mg ) , and 86 of the 505 patients ( 17.0 % ) in the control group received a neuromuscular blocking agent ( median dose , 38 mg ) . At 90 days , 213 patients ( 42.5 % ) in the intervention group and 216 ( 42.8 % ) in the control group had died before hospital discharge ( between-group difference , -0.3 percentage points ; 95 % confidence interval , -6.4 to 5.9 ; P = 0.93 ) . While in the hospital , patients in the intervention group were less physically active and had more adverse cardiovascular events than patients in the control group . There were no consistent between-group differences in end points assessed at 3 , 6 , and 12 months . CONCLUSIONS Among patients with moderate-to-severe ARDS who were treated with a strategy involving a high PEEP , there was no significant difference in mortality at 90 days between patients who received an early and continuous cisatracurium infusion and those who were treated with a usual-care approach with lighter sedation targets . ( Funded by the National Heart , Lung , and Blood Institute ; ROSE Clinical Trials.gov number , NCT02509078 . ) BACKGROUND Patients undergoing vascular surgery comprise the highest risk group for perioperative cardiac mortality and morbidity after noncardiac procedures . Many current guidelines recommend the use of beta-blockers in all patients undergoing vascular surgery . We report a trial of the perioperative administration of metoprolol and its effects on the incidence of cardiac complications at 30 days and 6 months after vascular surgery . METHODS Patients undergoing abdominal aortic surgery and infrainguinal or axillofemoral revascularizations were recruited to a double-blind r and omized controlled trial of perioperative metoprolol versus placebo . Patients were r and omized to receive study medication , starting 2 hours preoperatively until hospital discharge or maximum of 5 days postoperatively . Primary outcome were postoperative 30-day composite incidence of nonfatal myocardial infa rct ion , unstable angina , new congestive heart failure , new atrial or ventricular dysrhythmia requiring treatment , or cardiac death . RESULTS Patients were r and omized to receive either metoprolol ( n = 246 ) or placebo ( n = 250 ) . Primary outcome events at 30 days postoperative occurred in 25 ( 10.2 % ) versus 30 ( 12.0 % ) ( P = .57 ) in metoprolol and placebo groups , respectively ( relative risk reduction 15.3 % , 95 % CI -38.3 % to 48.2 % ) . Observed effects at 6 months were not significantly different ( P = .81 ) ( relative risk reduction 6.2 % , 95 % CI% -58.4 % to 43.8 % ) . Intraoperative bradycardia requiring treatment was more frequent in the metoprolol group ( 53/246 vs 19/250 , P = .00001 ) , as was intraoperative hypotension requiring treatment ( 114/246 vs 84/250 , P = .0045 ) . CONCLUSION Our results showed metoprolol was not effective in reducing the 30-day and 6-month postoperative cardiac event rates . Prophylactic use of perioperative beta-blockers in all vascular patients is not indicated OBJECTIVES The goal of this study was to evaluate the mortality benefit of beta-blockers  after successful percutaneous coronary intervention ( PCI ) . BACKGROUND Beta-blockers reduce mortality after myocardial infa rct ion ( MI ) , though limited data are available regarding their role after successful PCI . METHODS Each year from 1993 through 1999 , the first 1,000 consecutive patients undergoing PCI  were systematic ally followed up . Patients presenting with acute or recent MI , shock , or unsuccessful revascularization procedures were excluded from the analysis . Clinical , procedural , and follow-up data of beta-blocker-treated and non-beta-blocker-treated patients were compared . A multivariate survival analysis model using propensity analysis was used to adjust for heterogeneity between the two groups . RESULTS Of the 4,553 patients , 2,056 ( 45 % ) were treated with beta-blockers at the time of the procedure . Beta-blocker therapy was associated with a mortality reduction from 1.3 % to 0.8 % at 30 days ( p = 0.13 ) and a reduction from 6.0 % to 3.9 % at one year ( p = 0.0014 ) . This survival benefit of beta-blockers was independent of left ventricular function , diabetic status , history of hypertension , or history of MI . Using propensity analysis , beta-blocker therapy remained an independent predictor for one-year survival after PCI ( hazard ratio , 0.63 ; 95 % confidence interval , 0.46 to 0.87 ; p = 0.0054 ) . CONCLUSIONS Within this large prospect i ve registry , beta-blocker use was associated with a marked long-term survival benefit among patients undergoing successful elective percutaneous coronary revascularization Abstract The role of anesthesia techniques on perioperative outcomes on a population level has recently gained widespread interest . Although mainly neuraxial vs general anesthesia has been addressed , population -level data on the impact of peripheral nerve blocks ( PNBs ) are still lacking . Therefore , we investigated the association between PNB use and outcomes using retrospective data on 1,062,152 recipients of hip and knee arthroplasties ( total hip arthroplasty [THA]/total knee arthroplasty [ TKA ] ) from the national Premier Perspective data base ( 2006 - 2013 ) . Multilevel multivariable logistic regression models measured associations between PNB use and outcomes . Complications included cardiac , pulmonary , gastrointestinal and renal complications , cerebrovascular events , infections , wound complications , thromboembolic complications , inpatient falls , and mortality . Re source utilization variables included blood transfusions , intensive care unit admissions , opioid consumption , cost , and length of stay . Overall , 12.5 % of patients received a PNB , with an increase over time particularly among TKAs . Peripheral nerve block use was associated with lower odds for most adverse outcomes mainly among patients with THA . Notable beneficial effects were seen for wound complications ( odds ratio 0.60 [ 95 % confidence interval , 0.49 - 0.74 ] ) among THA recipients and pulmonary complications ( odds ratio 0.83 [ 95 % confidence interval , 0.72 - 0.94 ] ) in patients with TKA . Peripheral nerve block use was significantly ( P < 0.0001 ) associated with a −16.2 % and −12.7 % reduction in opioid consumption for patients with THA and TKA , respectively . In conclusion , our results indicate that PNBs might be associated with superior perioperative population -level outcomes . In light of the inability to establish a causal relationship and the presence of residual confounding , we strongly advocate for further prospect i ve investigation , ideally in multicenter , r and omized trials , to establish the potential impact of PNBs on outcomes on a population level BACKGROUND Cardiovascular complications are the most important causes of perioperative morbidity and mortality among patients undergoing major vascular surgery . METHODS We performed a r and omized , multicenter trial to assess the effect of perioperative blockade of beta-adrenergic receptors on the incidence of death from cardiac causes and nonfatal myocardial infa rct ion within 30 days after major vascular surgery in patients at high risk for these events . High-risk patients were identified by the presence of both clinical risk factors and positive results on dobutamine echocardiography . Eligible patients were r and omly assigned to receive st and ard perioperative care or st and ard care plus perioperative beta-blockade with bisoprolol . RESULTS A total of 1351 patients were screened , and 846 were found to have one or more cardiac risk factors . Of these 846 patients , 173 had positive results on dobutamine echocardiography . Fifty-nine patients were r and omly assigned to receive bisoprolol , and 53 to receive st and ard care .  Fifty-three patients were excluded from r and omization because they were already taking a beta-blocker , and eight were excluded because they had extensive wall-motion abnormalities either at rest or during stress testing . Two patients in the bisoprolol group died of cardiac causes ( 3.4 percent ) , as compared with nine patients in the st and ard-care group ( 17 percent , P=0.02 ) . Nonfatal myocardial infa rct ion occurred in nine patients given st and ard care only ( 17 percent ) and in none of those given st and ard care plus bisoprolol ( P<0.001 ) . Thus , the primary study end point of death from cardiac causes or nonfatal myocardial infa rct ion occurred in 2 patients in the bisoprolol group ( 3.4 percent ) and 18 patients in the st and ard-care group ( 34 percent , P<0.001 ) . CONCLUSIONS Bisoprolol reduces the perioperative incidence of death from cardiac causes and nonfatal myocardial infa rct ion in high-risk patients who are undergoing major vascular surgery Context Residual paralysis is associated with post-operative pulmonary complications , including critical respiratory events . Objective We determined the incidence of critical respiratory events , such as hypoxaemia , in patients with minimal residual neuromuscular blockade and compared these data with those from patients with full recovery of blockade . Design R and omised , prospect i ve , placebo-controlled trial . Setting Single centre ; Rostock , Germany , from January 2007 to February 2008 . Patients One hundred and thirty-two adult patients , aged 18–80 years , with the American Society of Anesthesiology I – III physical status , undergoing orthopaedic surgery under general anaesthesia , including rocuronium to produce neuromuscular blockade ; 114 patients were r and omised to one of two groups : neostigmine group ( neostigmine 20 & mgr;g kg−1 ) or placebo group ( saline ) . Interventions In the patients in the neostigmine group , the tracheal tube was removed at a train-of-four ( TOF ) ratio of 1.0 ; in the patients in the placebo group , the trachea was extubated at a TOF ratio less than 1.0 , but without fade in TOF and double-burst stimulation ( DBS ) . Neuromuscular monitoring was assessed simultaneously with qualitative TOF/DBS monitoring , and with quantitative calibrated acceleromyography . Critical respiratory events , such as hypoxaemia , were assessed in the post-anaesthesia care unit . Main outcome measures Forty-five patients ( 39.5 % ) became hypoxaemic ( SaO2 < 93 % ) ; there was a significant difference between the groups ( 29 patients in the placebo group versus 16 in the neostigmine group ; P = 0.021 ) . Results In the neostigmine group , all patients were extubated at a TOF ratio of 1.0 . In the placebo group , the median TOF ratio was 0.7 ( range : 0.46–0.9 ; P < 0.001 ) . The median time for spontaneous recovery in the placebo group was 16 min ( range 3–49 min ) . Neostigmine 20 & mgr;g kg−1 was effective in antagonising rocuronium-induced blockade without fade in TOF and DBS . Conclusion In this r and omised , prospect i ve , placebo-controlled trial , minimal residual block was associated with hypoxaemia in the post-anaesthesia care unit . Neostigmine 20 & mgr;g kg−1 was effective in antagonising rocuronium-induced ( minimal ) blockade The prognostic relevance of direct contrast toxicity in patients treated with primary percutaneous coronary intervention  remains unclear , owing to the confounding hemodynamic effect of acute left ventricular ejection fraction ( LVEF ) impairment on kidney function estimation . In the present study , 644 consecutive patients with ST-segment elevation myocardial infa rct ion undergoing primary percutaneous coronary intervention were prospect ively enrolled .  Contrast-induced nephropathy ( CIN ) was defined as an increase in serum creatinine > 25 % or a decrease in the estimated glomerular filtration rate ( eGFR ) < 25 % from baseline in the first 72 hours . The primary end point of the study was major adverse cardiovascular events at 1 year ( composite of death , myocardial infa rct ion , target lesion revascularization , and bleeding ) . Among the global population , the interaction between the LVEF and eGFR at admission to define CIN was statistically significant ( p < 0.001 ) . When only the 385 patients without acute LVEF impairment ( i.e. , those with LVEF ≥40 % ) were considered , 27 ( 7 % ) developed postprocedural CIN that was associated with increased major adverse cardiovascular events rate at 1 year of clinical follow-up ( 38 % vs 9 % ; p < 0.001 ) . On adjusted Cox multivariate analysis , CIN was an independent predictor of worse outcomes , both when defined according to creatinine ( hazard ratio 3.81 , 95 % confidence interval 1.71 to 8.48 , p = 0.001 ) or eGFR ( hazard ratio 3.77 , 95 % confidence interval 1.53 to 9.28 , p = 0.004 ) variations . In conclusion , in patients with ST-segment elevation myocardial infa rct ion undergoing primary percutaneous coronary intervention  , LVEF has a significant interaction with eGFR . When only patients without acute LVEF impairment were considered , CIN confirmed its negative prognostic effect on the 1-year clinical outcomes Background and Aims : The effect of perineural dexmedetomidine on the time to onset , quality and duration of motor block with ropivacaine has been equivocal and its interaction with general anaesthesia ( GA ) has not been reported . We assessed the influence of dexmedetomidine added to 0.5 % ropivacaine on the characteristics of supraclavicular brachial plexus block and its interaction with GA . Methods : In a r and omised , double blind study , 36 patients scheduled for orthopaedic surgery on the upper limb under supraclavicular block and GA were divided into either R group ( 35 ml of 0.5 % ropivacaine with 0.5 ml of normal saline [ n - 18 ] ) or RD group ( 35 mL of 0.5 % ropivacaine with 50 μg dexmedetomidine [ n - 18 ] ) . The onset time and duration of motor and sensory blockade were noted . The requirement of general anaesthetics was recorded . Results : Both the groups were comparable in demographic characteristics . The time of onset of sensory block was not significantly different . The proportion of patients who achieved complete motor blockade was more in the RD group . The onset of motor block was earlier in group RD than group R ( P < 0.05 ) . The duration s of analgesia , sensory and motor blockade were significantly prolonged in group RD ( P < 0.00 ) . The requirement of entropy guided anaesthetic agents was not different in both groups . Conclusions : The addition of dexmedetomidine to 0.5 % ropivacaine  improved the time of onset , quality and duration of supraclavicular brachial plexus block but did not decrease the requirement of anaesthetic agents during GA Although clinical guidelines recommend long-term β-blocker ( BB ) therapy to decrease mortality after acute myocardial infa rct ion , these recommendations are based predominantly on evidence from before the reperfusion and thrombolytic eras . To investigate the effects of BB therapy for patients with acute myocardial infa rct ions on mortality in the percutaneous coronary intervention era , a total of 5,628 consecutive patients who were admitted < 24 hours after the onset of ST-segment elevation myocardial infa rct ion , treated with emergent percutaneous coronary intervention , and discharged alive were studied . During a median follow-up period of 1,430 days , mortality rates did not differ between patients with and without BB therapy ( 5.2 % vs 6.2 % , p = 0.786 ) . Multivariate analysis revealed that BB treatment was not associated with a reduced risk for mortality ( hazard ratio 0.935 , 95 % confidence interval 0.711 to 1.230 , p = 0.534 ) . The results of propensity score matching also indicated that the mortality rates did not differ between the 2 groups . However , subgroup analyses among matched population s revealed that BB treatment was associated with a significantly lower mortality risk for high-risk patients , who were defined as those with Global Registry of Acute Coronary Events ( GRACE ) risk scores ≥121 ( hazard ratio 0.596 , 95 % confidence interval 0.416 to 0.854 , p = 0.005 ) or those administered diuretics ( hazard ratio 0.602 , 95 % confidence interval 0.398 to 0.910 , p = 0.016 ) , but not for lower risk patients . In conclusion , BB treatment was associated with reduced long-term mortality in patients after ST-segment elevation myocardial infa rct ion at higher risk , but not in those at lower risk . Although r and omized controlled studies are warranted to confirm these results , the implementation of BB therapy for discharged patients with ST-segment elevation myocardial infa rct ion may need to be assessed on the basis of individual mortality risk in the percutaneous coronary intervention era To determine the effect of beta blockade with propranolol on myocardial oxygen dem and s and postoperative arrhythmias in patients having coronary bypass operations , 50 patients with chronic stable angina undergoing operation were r and omized in a double-blind fashion to receive either propranolol ( 60 mg every 6 hours ) or a placebo . Drug administration began 24 to 48 hours prior to operation and continued through the operative period and for one month after operation . There were no deaths . Two perioperative myocardial infa rct ions occurred , both in patients receiving a placebo .  Myocardial oxygen dem and as measured by the rate-pressure product ( heart rate X mean arterial pressure ) was significantly reduced during induction of anesthesia ( 7,658 + /- 451 versus 5,786 + /- 340 ; p less than 0.002 ) and during sternotomy ( 8,400 + /- 550 versus 6,756 + /- 384 ; p less than 0.02 ) in propranolol-treated patients . In the first two postoperative days , nitroprusside was required for control of hypertension of 10 patients in the placebo group but in only 3 patients given propranolol ( p less than 0.05 ) . Postoperatively , 15 of the 26 patients who received a placebo had 45 episodes of arrhythmia . Seven of the 24 propranolol-treated patients had 17 episodes ( p less than 0.04 ) . We conclude that propranolol given perioperatively in doses large enough to induce beta blockade significantly reduces myocardial oxygen dem and s in the vulnerable period during induction of anesthesia and sternotomy , reduces the need for antihypertensive therapy in the immediate postoperative period , and causes a marked reduction in the incidence and frequency of both supraventricular and ventricular arrhythmias in the postoperative period BACKGROUND Recent trials suggest that perioperative beta-blockade reduces the risk of cardiac events in patients with a risk of myocardial ischemia who are undergoing noncardiac surgery . Patients with diabetes mellitus are at a high-risk for postoperative cardiac morbidity and mortality . They may , therefore , benefit from perioperative beta-blockade . METHODS The Diabetic Postoperative Mortality and Morbidity ( DIPOM ) trial is an investigator-initiated and -controlled , central ly r and omized , double-blind , placebo-controlled , multicenter trial . We compared the effect of metoprolol with placebo on mortality and cardiovascular morbidity rates in patients with diabetes mellitus who were beta-blocker naive , > or=40 years old , and undergoing noncardiac surgery . The study drug was given during hospitalization for a maximum of 7 days beginning the evening before surgery . The primary outcome measure is the composite of all-cause mortality , acute myocardial infa rct ion , unstable angina , or congestive heart failure leading to hospitalization or discovered or aggravated during hospitalization . Follow-up involves re-examination of patients at 6 months and collection of mortality and morbidity data via linkage to public data bases . The study was powered on the basis of an estimated 30 % 1-year event rate in the placebo arm and a 33 % relative risk reduction in the metoprolol arm . The median follow-up period was 18 months . RESULTS Enrollment started in July 2000 and ended in June 2002 . A total of 921 patients were r and omized , and 54 % of these patients had known cardiac disease , hypertension , or both . CONCLUSION The results of this study may have implication s for reduction of perioperative and postoperative risk in patients with diabetes mellitus who are undergoing major noncardiac surgery BACKGROUND Aldosterone levels are high early after admission for ST elevation myocardial infa rct ion ( STEMI ) concomitantly with high risk of sudden death and life-threatening ventricular arrhythmia . METHODS We assessed the hypothesis that early aldosterone blockade on admission for primary percutaneous coronary intervention ( PCI ) may be associated with a reduction of life-threatening ventricular arrhythmia in a prospect i ve cohort-nested case ( n=159 ) versus historical control ( n=623 ) study . All cases were treated on admission by 200 mg IV bolus of potassium canrenoate , followed by 25 mg PO spironolactone daily during the coronary care unit stay . The primary endpoint -- in-hospital composite of death , resuscitated cardiac arrest and ventricular tachycardia -- was assessed by logistic regression models adjusted on major pre-specified variables and vali date d by a bootstrap procedure and propensity-score based analyses . RESULTS Aldosterone blockade was associated with lower risks of the primary endpoint ( adjusted ORs 0.26 , 95 % CI [ 0.13 - 0.57 ] ) , resuscitated cardiac arrest ( adjusted OR 0.39 , 95 % CI [ 0.16 - 0.94 ] ) , ventricular tachycardia or fibrillation ( adjusted ORs 0.23 , 95 % CI [ 0.12 - 0.45 ] ) , as well as ventricular arrhythmia requiring resuscitation or anti-arrhythmic therapy ( adjusted OR 0.41 , 95 % CI [ 0.19 - 0.88 ] ) . All findings were confirmed by the bootstrap procedure . The benefit on death or resuscitated cardiac arrest seemed sustained at 6month follow-up . CONCLUSIONS Early aldosterone blockade in patients presenting for primary PCI for STEMI is associated with significant reductions in rates of life-threatening arrhythmia and cardiac arrest independent of the initial risk profile , heart failure or hemodynamic status . These findings support the concept of aldosterone blockade early after STEMI , warranting further confirmation by ongoing r and omized trials Previous studies have shown that ECG changes following a subarachnoid haemorrhage are associated with increased catecholamine levels , necrotic myocardial lesions , and a poor prognosis . Furthermore , beta-blockade using propranolol reverses some of the ECG changes and prevents necrotic myocardial lesions . This study was established to assess the affects of adrenergic blockade on morbidity and mortality following subarachnoid haemorrhage . Patients were admitted to the r and omized double-blind between- patients study if they presented at the neurosurgical unit within 48 hours of a subarachnoid haemorrhage confirmed by lumbar puncture . Of 224 patients , the first 118 received an alpha-blocker , phentolamine 20 mg three-hourly , and either the beta-blocker propranolol 80 mg eight-hourly , or placebo . The last 106 patients received either propranolol or placebo . Treatment was continued for three weeks . Assessment at four weeks revealed significant improvements in the treated group for neurological deficit ( p = 0.003 ) and death ( p = 0.02 ) . More treated patients underwent operation and those that did had a better outcome ( p = 0.01 ) . Assessment at one year showed that although patients had improved in both groups , patients in the treated group had significantly fewer neurological deficits ( p = 0.003 ) . There were fewer deaths in the treated group but this difference was not significant ( p = 0.09 ) . Possible mechanisms for this protective effect of propranolol may include a reduction in plasma renin activity , a reduction in pulmonary oedema , prevention of myocardial infa rcts , and a reduction in cerebral oxygen requirements . It is concluded that early beta-blockade benefits patients with subarachnoid haemorrhage , in terms of fewer neurological deficits , for up to one year
Compared with general anaesthesia , a central neuraxial block may reduce the zero to 30-day mortality for patients undergoing surgery with intermediate to high cardiac risk ( level of evidence , moderate ) .
BACKGROUND Various beneficial effects derived from neuraxial blocks have been reported .
However , it is unclear whether these effects have an influence on perioperative mortality and major pulmonary/cardiovascular complications .
OBJECTIVES Our primary objective was to summarize Cochrane systematic review s that assess the effects of neuraxial blockade on perioperative rates of death , chest infection and myocardial infa rct ion by integrating the evidence from all such review s that have compared neuraxial blockade with or without general anaesthesia versus general anaesthesia alone for different types of surgery in various population s. Our secondary objective was to summarize the evidence on adverse effects ( an adverse event for which a causal relation between the intervention and the event is at least a reasonable possibility ) of neuraxial blockade .