progress in vascular anesthesiology donald m. voltz, m.d. assistant professor of anesthesiology case...

Progress in Vascular Progress in Vascular AnesthesiologyAnesthesiology

Donald M. Voltz, M.D.Donald M. Voltz, M.D.Assistant Professor of AnesthesiologyAssistant Professor of Anesthesiology

Case Western Reserve University/University Case Western Reserve University/University Hospitals of ClevelandHospitals of Cleveland

OverviewOverview

Beta-blockers Beta-blockers

Fluid TherapyFluid Therapy

Regional AnesthesiaRegional Anesthesia

Beta-blockers in Beta-blockers in Vascular Patients Vascular Patients

Are We Using Too Few?Are We Using Too Few?

ВВeta-Blockerseta-Blockers

CardioprotectionCardioprotection

Hemodynamic ControlHemodynamic Control

Anesthetic ModificationAnesthetic Modification

B-blockers and CardioprotectionB-blockers and Cardioprotection

Well studied in vascular patient populationWell studied in vascular patient population

Evolving evidence supports there use as a Evolving evidence supports there use as a standard of care in at risk patientsstandard of care in at risk patients

Likely to find increasing role in the futureLikely to find increasing role in the future

B-blockers Evidence for B-blockers Evidence for UseUse

Effect of Atenolol on Mortality and Cardiovascular Morbidity after Noncardiac Surgery

Dennis T. Mangano, Ph.D., M.D., Elizabeth L. Layug, M.D., Arthur Wallace, Ph.D., M.D., Ida Tateo, M.S., for The Multicenter Study of Perioperative Ischemia Research Group

Next

Volume 335:1713-1721 December 5, 1996 Number 23

Mangano, et al. 1996Mangano, et al. 1996

Randomized trial of esmolol vs. saline Randomized trial of esmolol vs. saline (n=99, n=101) (n=99, n=101)

Patient followed for 2 yearsPatient followed for 2 years

Mortality decreased in esmolol groupMortality decreased in esmolol group 0% vs 8% at 6 months0% vs 8% at 6 months 3% vs 14% at 1 year3% vs 14% at 1 year 10% vs 21% at 2 years10% vs 21% at 2 years

Wallace, et al. 1998Wallace, et al. 1998

200 pts randomized to atenolol or saline200 pts randomized to atenolol or saline

EKG, Holter monitor, and CPK w/ MB EKG, Holter monitor, and CPK w/ MB were followed 24 hr prior and 7 days after were followed 24 hr prior and 7 days after surgerysurgery

Atenolol 0,5, or 10 mg or placebo prior to Atenolol 0,5, or 10 mg or placebo prior to induction and every 12 hours until po than induction and every 12 hours until po than qd for 1 weekqd for 1 week

Wallace, et al. 1998Wallace, et al. 1998

Decreased perioperative myocardial Decreased perioperative myocardial ischemiaischemia 17/99 esmolol vs 34/101 placebo (days 0-2)17/99 esmolol vs 34/101 placebo (days 0-2) 24/99 esmolol vs 39/101 placebo (days 0-7)24/99 esmolol vs 39/101 placebo (days 0-7)

Polderman, et al. 1999Polderman, et al. 1999

846 pts with one or more cardiac risk factors; 846 pts with one or more cardiac risk factors; 173 positive dobutamine stress tests173 positive dobutamine stress tests

Bisoprolol in 59; Placebo in 53Bisoprolol in 59; Placebo in 53

Nonfatal MINonfatal MI 0% bisoprolol0% bisoprolol 17% placebo group17% placebo group

Cardiac Death Cardiac Death 3.4% bisoprolol group3.4% bisoprolol group 17% placebo group17% placebo group

What Patients are at What Patients are at RiskRisk

B-blockers & At Risk PatientsB-blockers & At Risk Patients

Presence of CADPresence of CAD History of Myocardial InfarctionHistory of Myocardial Infarction Typical Angina or Atypical Angina with + Stress TestTypical Angina or Atypical Angina with + Stress Test

At Risk for CAD (2 or more of the following)At Risk for CAD (2 or more of the following) Age >65 yearsAge >65 years HypertensionHypertension Active SmokerActive Smoker Serum Cholesterol > 240 mg/dlSerum Cholesterol > 240 mg/dl Diabetes MellitusDiabetes Mellitus

B-blockers and CardioprotectionB-blockers and Cardioprotection

How well are we doing with at risk How well are we doing with at risk patients?patients? Not Very Well!Not Very Well!

Prophylactic beta-blockade to prevent myocardial Prophylactic beta-blockade to prevent myocardial infarction perioperatively in high-risk patients who infarction perioperatively in high-risk patients who

undergoing general surgical procedures.undergoing general surgical procedures.

Taylor RC, Pagliarello G.Taylor RC, Pagliarello G.

Can J Surg. 2003 Jun;46(3):216-22Can J Surg. 2003 Jun;46(3):216-22

236 pts for laparotomy236 pts for laparotomy

143 pts at risk for CAD143 pts at risk for CAD

60.8% did not receive B-blockers pre-op60.8% did not receive B-blockers pre-op

33% pts had B-blockers discontinued33% pts had B-blockers discontinued

The Effect of Heart Rate Control on Myocardial Ischemia Among High-Risk Patients After Vascular

Surgery

Khether E. Raby, MD, FACC*, Sorin J. Brull, MD , Farris Timimi, MD, Shamsuddin Akhtar, MD, Stanley Rosenbaum, MD, Cameron Naimi, BS, and Anthony D. Whittemore, MD

Anesth Analg. 1999 Mar;88(3):477-82

The Effect of Heart Rate Control on Myocardial Ischemia Among High-Risk Patients After Vascular Surgery

Vascular Pts at High Risk for CAD Vascular Pts at High Risk for CAD underwent 24 hrs Holter Monitoringunderwent 24 hrs Holter Monitoring

26 of 150 pts had significant ischemia as 26 of 150 pts had significant ischemia as measured by ST-depression – PreOpmeasured by ST-depression – PreOp

Randomized to Esmolol gtt (n=15) or Randomized to Esmolol gtt (n=15) or Placebo (n=11)Placebo (n=11) Titrated to HR 20% below ischemic thresholdTitrated to HR 20% below ischemic threshold

Holter Monitoring for 48 hrs PostOpHolter Monitoring for 48 hrs PostOp

The Effect of Heart Rate Control on Myocardial Ischemia Among High-Risk Patients After Vascular Surgery

Ischemia Present PostOpIschemia Present PostOp 73% in Placebo Group (8 of 11)73% in Placebo Group (8 of 11) 33% in Esmolol Group (5 of 15)33% in Esmolol Group (5 of 15)

Number of Hours HR < Ischemic Number of Hours HR < Ischemic ThresholdThreshold 9 of 15 pts in Esmolol group <20% and all 9 of 15 pts in Esmolol group <20% and all

without ischemiawithout ischemia 4 of 11 pts in Placebo group <20%. 3 of 4 4 of 11 pts in Placebo group <20%. 3 of 4

without ischemiawithout ischemia

B-blockers - TypesB-blockers - Types

EsmololEsmolol

MetoprololMetoprolol

LabetelolLabetelol

AtenololAtenolol

EsmololEsmolol

Ultra-short actingUltra-short acting

Quick onset (peak effect by 5 min)Quick onset (peak effect by 5 min)

Loading dose 0.5 mg/kgLoading dose 0.5 mg/kg

BetaBeta11 selective selective

IV route onlyIV route only

ExpensiveExpensive

MetoprololMetoprolol

Can be given IV or POCan be given IV or PO

Long acting (q6h dosing)Long acting (q6h dosing)


Large doses may decrease the selectivityLarge doses may decrease the selectivity

LabetelolLabetelol

Can be given PO and IVCan be given PO and IV

Selective alphaSelective alpha11 and nonselective beta and nonselective beta1,21,2

Alpha:Beta blocking properties 3:1 oral Alpha:Beta blocking properties 3:1 oral and 7:1 IV. (not clinically seen)and 7:1 IV. (not clinically seen)

AtenololAtenolol


Can be given IV or POCan be given IV or PO

B-blocker Adverse ReactionsB-blocker Adverse Reactions

Bradycardia – is it symptomatic???Bradycardia – is it symptomatic???

Bronchospasm in COPD/Asthma patients Bronchospasm in COPD/Asthma patients – no evidence to suggest problem in these – no evidence to suggest problem in these patients with selective agentspatients with selective agents

Heart Failure – use carefully in patients Heart Failure – use carefully in patients with low EF, however, has been shown to with low EF, however, has been shown to improve function with ACEI in end-stage improve function with ACEI in end-stage CHFCHF

Summary for At Risk PatientsSummary for At Risk Patients

Preemptive BradycardiaPreemptive Bradycardia

Think about heart rate as separate from Think about heart rate as separate from blood pressureblood pressure

Be aggressive with heart rate controlBe aggressive with heart rate control

Incorporate into preoperative and Incorporate into preoperative and postoperative care.postoperative care. Involve Primary Care PhysicianInvolve Primary Care Physician Involve Vascular Surgeon and NursingInvolve Vascular Surgeon and Nursing

Balanced Anesthesia andBalanced Anesthesia andBeta-blockersBeta-blockers

AmnesiaAnalgesia

Unconsciousness Paralysis

Hemodynamic Control

Components of Balanced Anesthesia3/15/2003 - v2

B-blockers and B-blockers and Anesthetic ReductionAnesthetic Reduction

Esmolol Promotes Esmolol Promotes Electroencephalographic Electroencephalographic Burst Suppression During Burst Suppression During

Propofol/Alfentanil Propofol/Alfentanil AnesthesiaAnesthesia

Jay W. JohansenJay W. Johansen

Anesth Analg 2001; 93:1526-31Anesth Analg 2001; 93:1526-31

Esmolol Promotes Electroencephalographic Burst Suppression During Esmolol Promotes Electroencephalographic Burst Suppression During Propofol/Alfentanil AnesthesiaPropofol/Alfentanil Anesthesia

N=20 patientsN=20 patients

Alfentanil Groups (50 or 150 ng/ml)Alfentanil Groups (50 or 150 ng/ml)

Saline vs Esmolol infusionSaline vs Esmolol infusion

Monitored BIS output and Suppression Monitored BIS output and Suppression RatioRatio

Esmolol Promotes Electroencephalographic Burst Esmolol Promotes Electroencephalographic Burst Suppression During Propofol/Alfentanil AnesthesiaSuppression During Propofol/Alfentanil Anesthesia

BIS OutputBIS Output Esmolol – 40% reduction (37Esmolol – 40% reduction (37→→22)22) Saline – no changeSaline – no change

Suppression RatioSuppression Ratio Esmolol – 13.4 fold increase (5 Esmolol – 13.4 fold increase (5 →→ 67) 67) Saline – no changeSaline – no change

Efficacy of esmolol versus Efficacy of esmolol versus alfentanil as a supplement alfentanil as a supplement to propofol-nitrous oxide to propofol-nitrous oxide

anesthesiaanesthesiaSmith, J. Van Hemelrijck, and P. WhiteSmith, J. Van Hemelrijck, and P. White

Anesth Analg 2003;97:1633-1638Anesth Analg 2003;97:1633-1638

Efficacy of esmolol versus alfentanil as a supplement to propofol-Efficacy of esmolol versus alfentanil as a supplement to propofol-nitrous oxide anesthesianitrous oxide anesthesia

N=97 patients for arthroscopyN=97 patients for arthroscopy

Compared esmolol to alfentanilCompared esmolol to alfentanil

Efficacy of esmolol versus alfentanil as a supplement to Efficacy of esmolol versus alfentanil as a supplement to propofol-nitrous oxide anesthesiapropofol-nitrous oxide anesthesia

Esmolol decreased time to eye opening Esmolol decreased time to eye opening (7.2 vs 9.8 min)(7.2 vs 9.8 min)

Esmolol reported more pain in PACUEsmolol reported more pain in PACU

Esmolol required more opiods in PACUEsmolol required more opiods in PACU

Esmolol Potentiates Esmolol Potentiates Reduction in Minimal Reduction in Minimal Alveolar Isoflurane Alveolar Isoflurane

ConcentrationConcentrationJay W. Johansen, et al.Jay W. Johansen, et al.

Anesth Analg 1998; 87:671-6Anesth Analg 1998; 87:671-6

Esmolol Potentiates Reduction in Minimal Alveolar Esmolol Potentiates Reduction in Minimal Alveolar Isoflurane ConcentrationIsoflurane Concentration

N=100; divided into 5 groupsN=100; divided into 5 groups Isoflurane aloneIsoflurane alone Isoflurane with large dose esmolol (250 Isoflurane with large dose esmolol (250

mcg/kg/min)mcg/kg/min) Isoflurane with AlfentanilIsoflurane with Alfentanil Isoflurane, Alfentanil, small dose esmolol (50 Isoflurane, Alfentanil, small dose esmolol (50

mcg/kg/min)mcg/kg/min) Isoflurane, Alfentanil, large dose esmolol (250 Isoflurane, Alfentanil, large dose esmolol (250

mcg/kg/min)mcg/kg/min)

Esmolol Potentiates Reduction in Minimal Alveolar Esmolol Potentiates Reduction in Minimal Alveolar Isoflurane ConcentrationIsoflurane Concentration

MAC levels after steady stateMAC levels after steady state Isoflurane – 1.28%Isoflurane – 1.28% Iso + large dose Esmolol – 1.23%Iso + large dose Esmolol – 1.23% Iso + Alfentanil – 0.96%*Iso + Alfentanil – 0.96%* Iso + Alfentanil + small dose Esmolol – 0.96%Iso + Alfentanil + small dose Esmolol – 0.96% Iso + Alfentanil _ large dose Esmolol – Iso + Alfentanil _ large dose Esmolol –

0.74%**0.74%**

Michael Zaugg, M.D.; Thomas Tagliente, M.D., Ph.D.; Eliana Lucchinetti, M.S.; Ellis Jacobs, Ph.D.; Marina Krol, Ph.D.; Carol Bodian, Dr.P.H.; David L. Reich, M.D.; Jeffrey

H. Silverstein, M.D.ANESTHESIOLOGY 1999;91:1674-1686

Beneficial Effects from B-Adrenergic Blockade in Elderly Patients Undergoing Noncardiac Surgery


N=63 patients for noncardiac surgeryN=63 patients for noncardiac surgery

Monitored – Neuropeptide Y, epinephrine, Monitored – Neuropeptide Y, epinephrine, norepinephrine, cortisol, and ACTHnorepinephrine, cortisol, and ACTH

Randomly assignedRandomly assigned Group 1: no atenololGroup 1: no atenolol Group 2: Pre- and Post-operative atenololGroup 2: Pre- and Post-operative atenolol Group 3: Intraoperative AtenololGroup 3: Intraoperative Atenolol


Beta-blockade did not change Beta-blockade did not change neuroendocrine stress responseneuroendocrine stress responseLower Narcotic RequirementLower Narcotic Requirement Groups II and III – 27.7% less fentanylGroups II and III – 27.7% less fentanyl

Lower Anesthetic RequirementsLower Anesthetic Requirements Group III – 37.5% less isoflurane (BIS same in Group III – 37.5% less isoflurane (BIS same in

all groups)all groups)

Lower PACU Morphine requirementsLower PACU Morphine requirementsShorter PACU timesShorter PACU times

Beta-blockers and Bariatric SurgeryBeta-blockers and Bariatric Surgery

Randomized Study of Morbidly Obese Randomized Study of Morbidly Obese Patients Undergoing Gastric BypassPatients Undergoing Gastric Bypass

Metoprolol vs. PlaceboMetoprolol vs. Placebo

EvaluateEvaluate Intraoperative Volatile RequirementsIntraoperative Volatile Requirements PACU Pain RequirementPACU Pain Requirement PCA UsagePCA Usage

Fluid Therapy for Fluid Therapy for Vascular PatientsVascular Patients

Are We Using Way Too Much?Are We Using Way Too Much?

AAA Change in Anesthetic CareAAA Change in Anesthetic Care

Retrospective study of AAA and Retrospective study of AAA and anesthesiaanesthesia

Patients for elective infra-renal AAA in Patients for elective infra-renal AAA in 1991 and 20011991 and 2001

End-PointsEnd-Points Time to extubationTime to extubation Intraoperative Fluid AdministrationIntraoperative Fluid Administration Time to return of Bowel FunctionTime to return of Bowel Function

AAA and Crystaloid UseAAA and Crystaloid Use

Crystalloid (cc)

0

2000

4000

6000

8000

1991 2001

1991

2001

AAA Length of StayAAA Length of Stay

02468

1012

ICU LOS (days) Hospital LOS(days)

1991

2001

AAA and Bowel FunctionAAA and Bowel Function

020406080

100120140160180

NG TubeRemoval

ClearLiquidIntake

RegularDiet

Intake

1991

2001

Fluid Therapy in Vascular PatientsFluid Therapy in Vascular Patients

Ensure adequate end-organ perfusionEnsure adequate end-organ perfusion

Treat hypotension of reperfusion with a Treat hypotension of reperfusion with a combination of fluid and vasopressorscombination of fluid and vasopressors

Replace blood loss with blood, not Replace blood loss with blood, not crystaloidcrystaloid

Question replacing insensible losses and Question replacing insensible losses and NPO deficits by formulas. NPO deficits by formulas.

Vascular Surgery and Vascular Surgery and Regional AnesthesiaRegional Anesthesia

Benefits of Regional AnesthesiaBenefits of Regional Anesthesia

Cardiac ProtectionCardiac ProtectionPreservation of Pulmonary FunctionPreservation of Pulmonary FunctionLower graft thrombosisLower graft thrombosisDecrease postoperative hypercoagulable Decrease postoperative hypercoagulable statestateFaster return of bowel functionFaster return of bowel functionSuperior postoperative analgesiaSuperior postoperative analgesiaBetter immune functionBetter immune function

Regional Anesthesia and Cardiac Regional Anesthesia and Cardiac ProtectionProtection

Thoracic epidural a must, no benefit from Thoracic epidural a must, no benefit from lumbar catheterlumbar catheter

High level to block cardiac accelerator High level to block cardiac accelerator fibersfibers

Maintain an infusion or PCEA post-Maintain an infusion or PCEA post-operatively for maximal benefitsoperatively for maximal benefits

Low risk of bleeding if placed 1 hour prior Low risk of bleeding if placed 1 hour prior to systemic heparinizationto systemic heparinization


Still not clearStill not clear

Some studies show no differenceSome studies show no difference

The role of beta-blockers to control The role of beta-blockers to control sympathetic response confoundingsympathetic response confounding

No clear evidence regional is superiorNo clear evidence regional is superior


Problems with regional anesthesia studies Problems with regional anesthesia studies and cardiac protectionand cardiac protection Groups not normalized to heart rate?Groups not normalized to heart rate? Is the benefit only from cardiac accelerator Is the benefit only from cardiac accelerator

fibers being blocked?fibers being blocked? Are there other benefits of beta-blockers not Are there other benefits of beta-blockers not

being used because of a high epidural level?being used because of a high epidural level?

Is Reduced Cardiac Performance the Is Reduced Cardiac Performance the Only Mechanism for Myocardial Only Mechanism for Myocardial Infarction Size Reduction During Infarction Size Reduction During

beta-Adrenergic Blockade?beta-Adrenergic Blockade?

Stangeland, L. Grong, K. Vik-Mo, H. Stangeland, L. Grong, K. Vik-Mo, H. Anderson, K. Levken, J.Anderson, K. Levken, J.Cardiovasc Res 1986;20: 322-30Cardiovasc Res 1986;20: 322-30

Stangeland, et al.Stangeland, et al.

Anaesthetized cats to elucidate if Anaesthetized cats to elucidate if decreased heart rate was the mechanism decreased heart rate was the mechanism for cardiac protection.for cardiac protection.Treated groups with either timolol or Treated groups with either timolol or alinidine (clonidine derivative that alinidine (clonidine derivative that decreases HR independently of Beta-decreases HR independently of Beta-receptors)receptors)Induced regional ischemia (LAD occlusion Induced regional ischemia (LAD occlusion for 6 hours)for 6 hours)

Stangeland, et al.Stangeland, et al.

Alinidine Group:Alinidine Group: Decreased Necrotic Area to 77% of controlDecreased Necrotic Area to 77% of control

Timolol Group:Timolol Group: Decreased Necrotic Area to 65% of controlDecreased Necrotic Area to 65% of control

This data suggested another mechanism for This data suggested another mechanism for beta-blocker cardioprotection other than heart beta-blocker cardioprotection other than heart rate controlrate control

Regional Anesthesia and Regional Anesthesia and Pulmonary FunctionPulmonary Function

FRC is decreased due toFRC is decreased due to Diaphragmatic dysfunction of upper Diaphragmatic dysfunction of upper

abdominal or thoracic incisionsabdominal or thoracic incisions Decreased chest wall complianceDecreased chest wall compliance Incisional Pain LimitationsIncisional Pain Limitations


Advantages for thoracic and upper Advantages for thoracic and upper abdominal surgeryabdominal surgery

Unclear benefits in lower abdominal and Unclear benefits in lower abdominal and peripheral surgeryperipheral surgery

No Change in hospital LOSNo Change in hospital LOS

Time and Post-Op labor intensiveTime and Post-Op labor intensive Time to placeTime to place Requires pain service to followRequires pain service to follow


Currently are not using thoracic epidurals Currently are not using thoracic epidurals for AAA surgeryfor AAA surgery

Pain control in ICU and on Floor is Pain control in ICU and on Floor is adequateadequate

Surgeon’s and Anesthesiologist’s are in Surgeon’s and Anesthesiologist’s are in agreement to post-operative pain controlagreement to post-operative pain control


No increased incidence in pneumoniaNo increased incidence in pneumonia

No delay in extubation for elective aortic or No delay in extubation for elective aortic or lower extremity surgerylower extremity surgery

Regional Anesthesia and Graft Regional Anesthesia and Graft ThrombosisThrombosis

Improvement in lower extremity blood flowImprovement in lower extremity blood flowDecrease sympathetic activation and stimulation Decrease sympathetic activation and stimulation of coagulation systemof coagulation systemSystemic absorption of local anesthetics block Systemic absorption of local anesthetics block thromboxane A2, platelet aggregation and thromboxane A2, platelet aggregation and reduce blood viscosityreduce blood viscosityLarge meta-analysis done in orthopedics looking Large meta-analysis done in orthopedics looking at DVT.at DVT.Abdominal surgery patients had a less Abdominal surgery patients had a less significant effectsignificant effectMinimization of blood loss.Minimization of blood loss.

Regional Anesthesia and LOSRegional Anesthesia and LOS

No increase in LOS at our institutionNo increase in LOS at our institution

Unclear in literature if LOS is improved Unclear in literature if LOS is improved with regional anesthesiawith regional anesthesia

Double-masked Randomized Trial Comparing Double-masked Randomized Trial Comparing Alternate Combinations of Intraoperative Alternate Combinations of Intraoperative

Anesthesia and Postoperative Analgesia in Anesthesia and Postoperative Analgesia in Abdominal Aortic SurgeryAbdominal Aortic Surgery

Norris, E.J. et al.Norris, E.J. et al.Anesthesiology 2001;95:1054-67Anesthesiology 2001;95:1054-67

Norris et al. Norris et al.

N=168 pts for elective aortic surgeryN=168 pts for elective aortic surgery

Randomized to either epidural with light Randomized to either epidural with light GA vs. GA aloneGA vs. GA alone

Pts either with PCA or PCEA for 72h Pts either with PCA or PCEA for 72h postoperativelypostoperatively

Norris et al.Norris et al.

Postoperative outcomes were similar in Postoperative outcomes were similar in groupsgroups MI, reoperation, renal failure, pneumoniaMI, reoperation, renal failure, pneumonia LOS and direct medical costsLOS and direct medical costs VAS Pain ScoresVAS Pain Scores

Epidural groups with shorterEpidural groups with shorter Time to extubation (19 vs. 13 hours)Time to extubation (19 vs. 13 hours) ICU discharge (46 vs. 43 hours)ICU discharge (46 vs. 43 hours) Return of Bowel Function (111 vs. 102 hours)Return of Bowel Function (111 vs. 102 hours)

Regional Anesthesia and Bowel Regional Anesthesia and Bowel FunctionFunction

Thought to relate to narcotic use as well Thought to relate to narcotic use as well as sympathetic reflex arcsas sympathetic reflex arcsThought is decreased sympathetic slowing Thought is decreased sympathetic slowing while maintaining parasympathetic while maintaining parasympathetic peristalisperistalisProblems with randomized studies are Problems with randomized studies are higher amounts of narcotics. higher amounts of narcotics. Lower narcotic usage has impacted post-Lower narcotic usage has impacted post-operative ileus in out institutionoperative ileus in out institution

Regional Anesthesia and Vascular Regional Anesthesia and Vascular Surgery - SummarySurgery - Summary

Not presently known if regional superior to Not presently known if regional superior to beta-blockade for cardioprotectionbeta-blockade for cardioprotection

Regional may be beneficial in severely Regional may be beneficial in severely reduced pulmonary function patientsreduced pulmonary function patients

Pain control is similar with IVPCA vs Pain control is similar with IVPCA vs PCEAPCEA

Unclear if additional factors are significant Unclear if additional factors are significant in vascular patientsin vascular patients

THE ENDTHE END

Vascular Anesthesia at University Hospitals of Cleveland

progress in vascular anesthesiology donald m. voltz, m.d. assistant professor of anesthesiology case...

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