The Hemodynamic Effects of Anesthetic Induction in Vascular Surgical Patients Chronically Treated with Angiotensin II Receptor Antagonists

Abstract

The use of angiotensin II receptor subtype-1 antagonists (ARA), recently introduced as antihypertensive drugs, is becoming more prevalent. We studied the prevalence and severity of hypotension after the induction of general anesthesia in 12 patients treated with ARA until the morning of surgery. The hemodynamic response to induction was compared with that of patients treated with ␤-adrenergic blockers (BB) and/or calcium channel blockers (CB) (BB/CB group, n ϭ 45) and angiotensin-converting enzyme inhibitors (ACEI) (ACEI group, n ϭ 27). A standardized anesthesia induction protocol was followed for all patients. Hypotension occurred significantly (p Յ 0.05) more often in ARA-treated patients (12 of 12) compared with BB/CBtreated patients (27 of 45) or with ACEI-treated patients (18 of 27). There was a significantly (P Յ 0.001) increased ephedrine requirement in the ARA group (21 Ϯ 3 mg) compared with the BB/CB group (10 Ϯ 6 mg) or the ACEI group (7 Ϯ 4 mg). Hypotension refractory to repeated ephedrine or phenylephrine administration occurred significantly (P Յ 0.05) more in the ARA group (4 of 12) compared with the BB/CB group (0 of 45) or the ACEI group (1 of 27), but it was treated successfully by using a vasopressin system agonist. Treatment with angiotensin II antagonism until the day of surgery is associated with severe hypotension after the induction of anesthesia, which, in some cases, can only be treated with an agonist of the vasopressin system. Implications: Hypotensive episodes occur more frequently after anesthetic induction in patients receiving Angiotensin II receptor subtype-1 antagonists under anesthesia than with other hypotensive drugs. They are less responsive to the vasopressors ephedrine and phenylephrine. The use of a vasopressin system agonist was effective in restoring blood pressure when hypotension was refractory to conventional therapy.

When the pressure drops: A case of vasoplegia during a structural heart intervention

“…increased more than any other anti-hypertensives prescribed within the United States. 8 Use of RASi is associated with a decrease in MAP after induction of anesthesia [9][10][11] and is identified as an independent risk factor for the development of catecholamine refractory VS. 10,12,13 In patients on chronic RASi therapy, arginine vasopressin (AVP) analogues such as vasopressin and terlipressin have been shown to be more effective than catecholamines in treating intraoperative hypotension. [14][15][16][17] Certain considerations should be made regarding use of AVP analogues for RASi associated vasoplegia.…”

Guidelines for the management of chronic medication in the perioperative period: systematic review and formal consensus

“…Rationale: This recommendation is supported by the formal consensus (median 9, IQR 0AE5), by evidence from two cohort studies (strength of evidence 2 + ) (12,14) and by evidence from two clinic cases (strength of evidence 3) (35,36).…”

“…Two randomized controlled trials (RCT) and one cohort study compared withdrawal with continuation of angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor antagonist (ARA) during the perioperative period (11)(12)(13). One cohort study compared the administration of ARA in the morning of surgery with administration of ACEI 24 h before surgery (14). Another study (15) compared ACEI ⁄ ARA users with no users.…”

“…These five studies found that intake of ACEI ⁄ ARA in the morning of surgery negatively affects haemodynamic control. Three of those studies (11,12,14) concluded that stopping ACEI ⁄ ARA on the day of surgery was associated with a minor number of hypotensive episodes in the post-induction period. Pigott et al (13) verified that patients who stopped ACEI, had higher levels of arterial blood pressure, consequently needing less vasoconstrictors administration during surgery, but often requiring vasodilator infusions to prevent hypertension in the early post-operative period.…”

“…No study comparing withdrawal with continuation of chronic diuretics in the perioperative period was Management of chronic medication in the perioperative period 451 (14) Clinic Case A 75 years old man submitted first an endaterectomy of the right and 2 months later of the left internal carotid artery. He takes nicardipine and enalapril to treat hypertension.…”