PPMC
Physician’s Orders for Peri-Operative Beta Blockers
#238649 (Page 1 of 2) 10/2005 –Pilot
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 betablocker 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:
- AMI within 12 months
- Current Angina
- Positive Stress Test
- Diagnostic Q waves on ECG
- Abnormal ECG:
- LVH, new ST-T changes
Significant Aortic Stenosis
Hypertension
History of Congestive Heart Failure
Significant Ventricular Arrhythmia
Contraindications to Beta Blocker Therapy
Decompensated Congestive Heart Failure
Second or Third Degree Heart Block
Phenochromocytoma
Documented Allergy to Beta Blocker
Other Significant Risk Factors:
Diabetes Mellitus
History of CVA
Renal failure (serum Creatinine > 2.0)
Current Smoker
Cholesterol > 240 mg/dL
Poor Functional Status
(<4 Metabolic Equivalents Table:
unable to carry groceries up one flight
of stairs.)
Uncontrolled Asthma
Uncontrolled Chronic Pulmonary Disease
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 or
frail or baseline SBP < 100 mmHG or HR<65
bpm
Metoprolol 25 mg po bid
or
Atenolol 25 mg po daily
If baseline SBP > 100 mmHG or HR> 65 bpm
Metoprolol 50 mg po bid
or
Atenolol 50 mg po qd