Perioperative beta blockade for major vascular surgery: a descriptive study of current intended practice across South African specialist training facilities

A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in partial fulfillment of the requirements for the degree of Master of Medicine in the branch of Anaesthesia Johannesburg, April 2013BACKGROUND: Once lauded as one of the most valuable interventions across all fields of contemporary medicine, perioperative beta blockade (PBB) is a practice that has come under intense scrutiny. Publication of the PeriOperative ISchemic Evaluation (POISE) study forced a modification of recommendations for PBB in consensus guidelines. Practice in South Africa has not been previously reported. OBJECTIVES: The primary objective of this study was to describe current intended practice, with respect to PBB, in patients undergoing major vascular surgery at South African specialist training facilities. Secondary objectives were describing participant satisfaction with current strategy, reporting suggested modifications to clinician responsibilities in the future, and identifying potential barriers to the intervention. METHOD: One anaesthesiologist and one vascular surgeon from each of the seven recognised training facilities for vascular surgery in South Africa were included in a partially selective observational survey. Data was generated by the use of a semi-structured questionnaire specifically developed to address the objectives of the study. RESULTS: The POISE study results and updated international consensus guidelines had not prompted a change in approach at most facilities. There was inconsistency in methods of risk stratification, treatment implementation, titration practices, and the timing of withdrawal of medication. Anaesthesiologist and vascular surgeon opinion on current intended practice correlated poorly. Opinions correlated least well at facilities where both clinicians claimed responsibility for PBB, implying that communication may be a problem. Similarities, where they did occur, were in keeping with recommendations that are widely supported in the literature. Less than half of the participants were satisfied with current practice. The involvement of the anaesthesiologists in the perioperative management of vascular surgery patients was less than reported in other countries. The participants supported a major role for anaesthesiologists in the future, and a move towards multidisciplinary involvement in policy development and patient management. The need for appropriate monitoring was identified as one of many important barriers. CONCLUSIONS: This study describes current intended practice at South African training facilities for vascular surgery. The variable practice across the country; the poor correlation of participant responses; widespread dissatisfaction with current strategy; suggested changes to clinician responsibilities; and the identification of multiple barriers to the implementation of strategy, highlight the need for review at all facilities. Further research is needed, since the optimal strategy for reducing risk in patients undergoing vascular surgery remains elusive