Refractory Hypotension During General Anesthesia Despite Withholding Telmisartan

Area of Science:

• Anesthesiology
• Pharmacology
• Cardiology

Background:

• Angiotensin receptor blockers (ARBs) are widely prescribed for hypertension.
• ARBs, like ACE inhibitors, can cause refractory hypotension during general anesthesia.
• Current guidelines recommend withholding ARBs for 24 hours before anesthesia.

Observation:

• A case of refractory hypotension occurred despite a 24-hour telmisartan washout before general anesthesia.
• The patient experienced less severe hypotension after a 5-day telmisartan washout in a subsequent anesthetic.
• Telmisartan has the longest half-life (24 hours) among currently used ARBs.

Findings:

• A 24-hour washout period may be insufficient to prevent severe intraoperative hypotension in patients taking telmisartan.
• Refractory hypotension necessitates potent vasopressors, increasing anesthetic risk.
• A washout period exceeding 24 hours is likely required for telmisartan.

Implications:

• Anesthesiologists should consider extended washout periods for telmisartan.
• Patient management may require tailored pre-anesthetic medication withdrawal protocols.
• This highlights the importance of understanding drug pharmacokinetics in perioperative care.