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The importance of interrupting angiotensin converting enzyme inhibitor treatment before spinal anaesthesia--a
1Department of Anaesthesiology and Intensive Care Medicine, Helsinki University Central Hospital, Finland.
Insights
Angiotensin-converting enzyme inhibitors (ACEIs) may cause severe hypotension during spinal anesthesia. Discontinuing ACEIs 48 hours before surgery significantly improved cardiovascular stability in a hypertensive patient.
Area of Science:
- Anesthesiology
- Cardiology
- Pharmacology
Background:
- Beta-blockers and calcium channel blockers are generally considered safe to continue during surgery.
- The safety of continuing angiotensin-converting enzyme inhibitors (ACEIs) during surgical procedures, particularly with spinal anesthesia, is not well-established.
- Hypertension management in surgical patients requires careful consideration of medication timing.
Observation:
- A hypertensive patient on enalapril underwent two hip replacement surgeries under spinal anesthesia.
- In the first surgery, enalapril was taken on the day of the procedure, leading to significant hypotension.
- In the second surgery, enalapril was stopped 48 hours prior, resulting in better blood pressure control.
Findings:
- Continuing enalapril on the day of spinal anesthesia can lead to severe, difficult-to-manage hypotension.
- Withdrawing enalapril 48 hours before spinal anesthesia significantly reduced the incidence and severity of hypotension.
Implications:
- Angiotensin-converting enzyme inhibitors (ACEIs) should be discontinued well before elective surgery involving spinal anesthesia.
- This contrasts with the practice for beta-blockers and calcium channel blockers.
- Further studies are warranted to establish definitive guidelines for ACEI management around surgery.
Abstract:
It is generally believed that in hypertensive patients both beta adrenoreceptor antagonists and calcium channel blockers can be continued up to the day of surgery without provoking problems with cardiovascular stability intra- and postoperatively. The same, however, has not been definitively established for angiotension converting enzyme inhibitors (ACEIs). A patient who was taking the ACAI enalapril for hypertension underwent two similar operations--right total hip replacement and three years later left--both with spinal anaesthesia. In the initial case, she received her enalapril on the morning of surgery, while for the second procedure, enalapril was stopped 48 hours earlier. Hypotension occurred which required more than 5 times the dose of etilefrin to maintain suitable blood pressure during the first instance as compared to that when enalapril had been discontinued 48 hours earlier. Spinal anaesthesia in conjunction with an ACEI may result in severe hypotension as seen in this patient. In view of this, it is suggested that in contrast to other antihypertenisve drugs, ACEIs should be withdrawn well in advance of spinal anaesthesia.
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