To Stop Or Not? Withholding Anti-hypertensive Therapy Before Surgery Is Not Safe

Abstract

The pulmonary artery catheter (PAC) is a hemodynamic monitor commonly used during cardiac surgery. Conventionally, the PAC is inserted intraoperatively using the pressure waveform transduction technique. The measurement of changes in pressure as the PAC traverses the superior vena cava to the main pulmonary artery helps guide PAC insertion. This approach to PAC insertion, however, can be challenging in patients with certain pathologic conditions such as: systolic heart failure, moderate-to-severe tricuspid regurgitation, right atrial enlargement, right ventricular enlargement, right ventricular outflow tract obstruction, and in those with intracardiac leads. 1,2 As a consequence, multiple attempts may be required during PAC insertion using the pressure waveform transduction technique, which may lead to complications such as arrhythmias, PAC kinking, tricuspid valve injury, and pulmonary artery injury. 1,2 Considering that the pressure transduction technique does not provide the operator the ability to visualize the location of the PAC during insertion, transesophageal echocardiography (TEE) may be of value during PAC placement.In a prior issue of the Journal, Cronin et al 2 reported on the successful use of TEE guidance for PAC catheter insertion in 20 patients with chronic thromboembolic pulmonary hypertension undergoing pulmonary thromboendarterectomy. During PAC placement, 11 of 20 patients required PAC manipulation based on TEE findings, resulting in expedited PAC insertion while avoiding complications. The median time of PAC insertion was 43 seconds, with the catheter insertion time ranging from 16 to 370 seconds. TEE facilitated PAC insertion in a safe and timely manner in these high-risk patients without any complications.This important, single-center study by Cronin et al 2 suggested that TEE placement before PAC insertion may be a useful technique during cardiac surgery. Despite the small, homogenous, and single-center nature of the study, the findings were remarkable. At the Ohio State University Wexner Medical Center, TEE is placed routinely before central venous access to facilitate safe and expedient PAC insertion in patients requiring PAC and TEE monitoring. The ability to visualize the PAC balloon during insertion is very useful and may reduce complications associated with PAC placement. 2 As such, in cardiac cases warranting TEE monitoring, PAC placement with TEE guidance in addition to the standard pressure transduction technique should be strongly considered. References 1 Gidwani UK, Mohanty B, Chatterjee K. The pulmonary artery catheter: A critical reappraisal. Cardiol Clin 2013;31:545-65. 2 Cronin B, Robbins R, Maus T. Pulmonary artery catheter placement using transesophageal echocardiography.We read, with interest, the article by Balzer et al. 1 As the authors eloquently remarked, postoperative hypertension (HTN) is more frequent in patients with a history of preoperative HTN and is associated with increased morbidity and mortality.The 20-year debate on preoperative management of antihyperte...

The effect of continuing versus withholding angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers on mortality and major adverse cardiovascular events in hypertensive patients undergoing elective non-cardiac surgery: study protocol for a multi-centric open-label randomised controlled trial

“…Other evidence points to the beneficial effects of a continuation of these drugs in the perioperative period with the demonstration of improved outcomes [ 5 ]. While perioperative hypotension is certainly a concern with the continuation of ACEIs/ARBs, discontinuation of these drugs before surgery makes patients susceptible to postoperative hypertension when the effects of anaesthetics wear off, and this may cause harm by increasing the risk of myocardial ischaemia [ 6 ]. In fact, postoperative hypertension is more frequently seen in those with preoperative hypertension and is known to increase the risk of occurrence of major adverse cardiovascular events [ 7 ].…”

Study on Perioperative Management of Blood Pressure and Effects of Anaesthesia in Hypertensive Patients Undergoing General & Orthopaedic Surgery

“…ACE inhibitors and ARB have been linked to an increased risk of intraoperative hypotension in studies [26,27]. In addition, a comprehensive study found no advantage to maintaining ARBs and ACE inhibitors in terms of avoiding morbidity, hemodynamic problems, and mortality [28]. ACE inhibitors should be avoided on the morning before surgery, according to various research [29,30].…”