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Susan M Goodman1, Daniel Krauser, C Ronald Mackenzie
1Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA ; Weill Cornell Medical College, New York, NY USA.
Insights
Angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor antagonists (ARA) can cause severe hypotension during anesthesia. Discontinuation of these hypertension medications may mitigate perioperative risks.
Area of Science:
- Cardiology
- Anesthesiology
- Pharmacology
Background:
- Angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor antagonists (ARA) are common first-line antihypertensive medications.
- These drugs interfere with the renin-angiotensin system, crucial for hemodynamic compensation during volume depletion.
- Their use is frequent in the perioperative setting, particularly for orthopedic patients.
Observation:
- The renin-angiotensin system normally compensates for perioperative volume depletion.
- ACEI/ARA block this compensatory mechanism.
- This patient experienced severe hypotension during anesthesia induction, potentially linked to ACEI/ARA use.
Findings:
- ACEI/ARA may contribute to severe hypotension during anesthesia induction.
- Combined factors like increased intra-abdominal pressure, respiratory obstruction, diuretic use, and fasting can exacerbate hypotension.
- Medication use represents a potentially modifiable risk factor for perioperative adverse events.
Implications:
- Careful consideration of ACEI/ARA use is warranted in the perioperative period.
- Anesthesiologists should be aware of the potential for severe hypotension in patients taking these medications.
- Further research into managing patients on ACEI/ARA undergoing surgery is recommended.
Abstract:
Angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor antagonists (ARA) are effective and well-tolerated first-line drugs in the therapy of hypertension and, therefore, are frequently encountered in the perioperative setting. Hemodynamic compensation for volume depletion seen in the perioperative period is normally mediated by the renin-angiotensin system, which is blocked by ACEI/ARA. These drugs may contribute to severe hypotension during anesthesia induction and may have contributed to the cardiac arrest seen in this patient. Additional factors such as increased intra-abdominal pressures and respiratory obstructive episodes leading to diminished venous return, as well diuretic use and the fasting state, common in the perioperative orthopedic patient, are likely to have contributed as well. Medication use may be an easily modifiable risk factor for severe hypotension and possible cardiac arrest in the perioperative setting.
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