Beta Blocker Use

To reduce perioperative cardiovascular events, a preadmission evaluation program is essential, because it can provide a central location to apply a standardized process to screen and recommend beta-blocker therapy in eligible patients through contact with the patient’s primary care provider.

An evidence-based clinical practice guideline will help decide whether to initiate or continue beta-blocker therapy in the weeks before surgery. Clinicaleffectiveness nurses can screen patients and use prompts both preoperatively and postoperatively to verify that eligible high-risk patients are in fact receiving beta blockers. Secondary-reminder systems will promote beta-blocker use in high-risk patients. The most successful interventions and process changes are based on reliability principles, including those here:

• Standardization of process.
• Make the desired action the default.
• Opt out is the desired action.
• Redesign built into flow of work.
• Create redundancies and time lapses.
• Build design aids into the system.
• “Hardwire” system thinking; identify critical failures and then redesign.
• Forcing functions.

Cardiovascular Events

To date, the use of beta blockers has been the sole intervention used to reduce perioperative cardiovascular events in high-risk populations or those undergoing vascular surgery. Current research is investigating other pharmacologic interventions, such as lipid-lowering agents and calcium channel blockers, but the evidence is as yet inconclusive.

For the present, beta blockers should be used in appropriate high-risk patients. A screening process through a central location facilitates a broad application of this intervention. Continuing patients on chronic beta-blocker therapy is critical, and populationbased case managers can help drive high compliance.

Glycemic Control

Tight glycemic control should be based on serum blood glucose levels, which is difficult to maintain for many facilities. In the operating room, the anesthesiologist can achieve blood glucose control through intravenous insulin infusion with frequent point of care serum glucose monitoring. In the critical care unit, intravenous insulin can be administered for the first 48 hours. Once the patient is out of the critical care unit and in a surgical unit, however, this tends to become more difficult. Many facilities cannot support the frequent blood glucose monitoring needed when using intravenous insulin administration outside of the critical care unit.

The use of “sliding scale insulin” administration with bedside glucose monitoring historically has not resulted in tight glycemic control. New trends in using basal, prandial and adjustment or correction dosing have yielded tighter glycemic control and overall better control management for patients on general medical surgical units.