Effect of perioperative beta blockade in patients with diabetes undergoing major non-cardiac surgery: randomised placebo controlled, blinded multicentre trial.

OBJECTIVES: To evaluate the long term effects of perioperative beta blockade on mortality and cardiac morbidity in patients with diabetes undergoing major non-cardiac surgery. DESIGN: Randomised placebo controlled and blinded multicentre trial. Analyses were by intention to treat. SETTING: University anaesthesia and surgical centres and one coordinating centre. PARTICIPANTS: 921 patients aged > 39 scheduled for major non-cardiac surgery. INTERVENTIONS: 100 mg metoprolol controlled and extended release or placebo administered from the day before surgery to a maximum of eight perioperative days. MAIN OUTCOME MEASURES: The composite primary outcome measure was time to all cause mortality, acute myocardial infarction, unstable angina, or congestive heart failure. Secondary outcome measures were time to all cause mortality, cardiac mortality, and non-fatal cardiac morbidity. RESULTS: Mean duration of intervention was 4.6 days in the metoprolol group and 4.9 days in the placebo group. Metoprolol significantly reduced the mean heart rate by 11% (95% confidence interval 9% to 13%) and mean blood pressure by 3% (1% to 5%). The primary outcome occurred in 99 of 462 patients in the metoprolol group (21%) and 93 of 459 patients in the placebo group (20%) (hazard ratio 1.06, 0.80 to 1.41) during a median follow-up of 18 months (range 6-30). All cause mortality was 16% (74/462) in the metoprolol group and 16% (72/459) in the placebo group (1.03, 0.74 to 1.42). The difference in risk for the proportion of patients with serious adverse events was 2.4% (- 0.8% to 5.6%). CONCLUSIONS: Perioperative metoprolol did not significantly affect mortality and cardiac morbidity in these patients with diabetes. Confidence intervals, however, were wide, and the issue needs reassessment. TRIAL REGISTRATION: Current Controlled Trials ISRCTN58485613.

[Acute normovolemic hemodilution combined with inhibition of fibrinolysis and use of cell saver in total hip arthroplasty]. / Akut normovolaemisk haemodilution kombineret med fibrinolyseinhibition og brug af "cellsaver" under indsaettelse af total hoftealloplastik.

INTRODUCTION: Transfusion with homologous blood is not without costs for the recipient: An increased risk of postoperative infections must be anticipated, and the risk of transfusion-transmitted viral infections is of growing concern. This has increased the interest for methods which can reduce the need for intraoperative blood transfusion. The goal of this study was to determine if acute normovolemic hemodilution combined with fibrinolytic inhibition and the use of cell saver can reduce the need for homologous blood transfusion in total hip arthroplasty compared to the cellsaver technique alone. MATERIAL AND METHODS: 145 patients undergoing total hip arthroplasty in spinal anesthesia were included in the study. They were all operated by the same surgeon. In group A (N = 64) only the cell saver was used, whereas in group B (N = 81) it was combined with acute normovolemic hemodilution and use of the fibrinolytic inhibitor tranexamic acid. RESULTS: The total blood loss and the need for homologous blood transfusion were significantly smaller in group B than in group A. DISCUSSION: Although the cell saving technique is effective in total hip arthroplasty, this study demonstrates that a further reduction of blood loss and homologous blood transfusion can be achieved by combining the method with acute normovolemic hemodilution and pharmacological inhibition of fibrinolysis.