Case Report: Refractory hypotension during general anesthesia despite preoperative discontinuation of an angiotensin receptor blocker

Nabbi, Raha; Woehlck, Harvey J.; Riess, Matthias L.

doi:10.12688/f1000research.2-12.v1

Cited by 15 publications

(7 citation statements)

References 12 publications

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“…[1,[3][4][5] However, several reports have shown refractory hypotension occurring during general anesthesia even after a 24-hour discontinuation of ARBs. [6][7][8][9] Some reports suggest that prolonging the medication discontinuation period to 2 to 5 days can secure hemodynamic stability during anesthesia. [7][8][9] This indicates the need for new criteria for the duration of ARBs discontinuation.…”

Section: Discussionmentioning

confidence: 99%

Severe refractory hypotension during induction of general anesthesia in patient after 48 hours of azilsartan discontinuation: A case report

Lee,

Kim,

Heo

et al. 2023

Medicine

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Rationale: Angiotensin II receptor blockers (ARBs) are currently considered first-line antihypertensive drugs, effectively inhibiting the renin-angiotensin-aldosterone system. However, ARBs have been associated with intraoperative hypotension during general anesthesia. Although it is recommended to discontinue ARBs for 24 hours before surgery, the optimal duration of discontinuation remains unclear. We present a severe refractory hypotension encountered during general anesthesia despite discontinuing ARBs for 48 hours before anesthesia. Patient concerns: A severe refractory hypotension occurred during the induction of general anesthesia for cranioplasty in a 66-year-old male patient (170 cm/75 kg). The patient was taking azilsartan, angiotensin receptor blocker, for hypertension, which was discontinued 48 hours before anesthesia induction. Despite repeated administration of ephedrine and continuous infusion of norepinephrine, hemodynamic instability did not improve. Therefore, the surgery was postponed. Diagnosis: The patient was diagnosed with angiotensin receptor blocker-induced refractory hypotension. Interventions: Before the second surgery, the angiotensin receptor blocker was discontinued 96 hours prior to the surgery. Invasive blood pressure monitoring was performed before anesthesia induction, and vasopressin was prepared. General anesthesia was induced using remimazolam and maintained with desflurane. Outcomes: The surgery was completed successfully without occurrence of refractory hypotension. Lessons: Refractory hypotension induced by Angiotensin receptor blockers can still occur even after discontinuing the medication for 48 hours before induction of general anesthesia. Despite withholding the medication, caution should be practiced regarding hypotension during general anesthesia in patient taking ARBs.

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Section: Discussionmentioning

confidence: 99%

Severe refractory hypotension during induction of general anesthesia in patient after 48 hours of azilsartan discontinuation: A case report

Lee,

Kim,

Heo

et al. 2023

Medicine

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“…Additionally, some researchers have suggested that ACEIs/ARBs reduce the adrenergic vasoconstrictive response [ 19 ]. This might partly explain why ACEI/ARB-associated hypotension was refractory and resistant to phenylephrine, ephedrine, and norepinephrine [ 6 , 28 ]. However, severe or refractory hypotension during anesthesia administration in patients chronically receiving ACEIs/ARBs has only been reported in several cases [ 24 , 25 ].…”

Section: Discussionmentioning

confidence: 99%

“…However, patients using ACEIs/ARBs have been reported to be prone to side effects like hypotension and even refractory hypotension during the administration of anesthesia [ 5 , 6 ]. Therefore, some anesthetists have suggested the possibility of discontinuing these drugs in order to maintain the patient’s hemodynamic stability during surgery [ 7 , 8 ].…”

Section: Introductionmentioning

confidence: 99%

Consequences of continuing renin angiotensin aldosterone system antagonists in the preoperative period: a systematic review and meta-analysis

Ling

Chen

et al. 2018

BMC Anesthesiol

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BackgroundPatients who use angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin II receptor blockers (ARBs) are prone to developing side effects like hypotension and even refractory hypotension during anesthesia use, and whether ACEIs/ARBs should be continued or discontinued in such patients remains debatable. The present systematic review and meta-analysis was conducted to clarify the consequences of continuing or withholding these drugs, especially with regards to the incidence of intraoperative hypotension, in patients who continue to use ACEIs/ARBs on the day of their scheduled surgery.MethodsStudies with data pertinent to the incidence of intraoperative hypotension during anesthesia use in patients who continued the use of ACEIs/ARBs on the day of their scheduled surgery were considered for inclusion.ResultsThirteen studies reporting on the incidences of intraoperative hypotension between patients who continued receiving ACEIs/ARBs and those who did not on the day of their surgical procedure were included. The pooled effects showed that hypotension during anesthesia was more likely to develop in patients who continued to take ACEIs/ARBs when compared to those who did not (RR = 1.41, 95% CI: 1.21–1.64). However, there were no significant differences between these groups of patients with regards to postoperative complications including ST-T abnormalities, myocardial injury, myocardial infarction, stroke, major adverse cardiac events, acute kidney injury, or death (RR = 1.25, 95% CI: 0.76–2.04). The differences remained similar in subgroup analyses and sensitivity analyses.ConclusionsNo sufficient available evidence to recommend discontinuing ACEIs/ARBs on the day of surgery was found in this literature review and meta-analysis. However, anesthetists should be cautious about the risk for intraoperative hypotension in patients chronically receiving ACEIs/ARBs, and should know how to treat it effectively.

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“…In addition, there are several studies that have warned of episodes of profound hypotension during surgical procedures in patients treated chronically with ACEI. [28] Such hypotensive episodes may have lead to coronary hypoperfusion and myocardial injury during PCI. This would further be in agreement with our finding that, in a multivariate logistic regression analysis, hypertension is inversely related to the development of PMI.…”

Section: Discussionmentioning

confidence: 99%

Association of chronic kidney disease with periprocedural myocardial injury after elective stent implantation

Jerkić

Letilović²,

Stipinović³

et al. 2016

Medicine

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Coronary artery disease (CAD) is the leading cause of mortality in patients with chronic kidney disease (CKD). Patients with CKD who undergo percutaneous coronary intervention (PCI) may have more ischemic events than patients without CKD. The aim of our study was to determine the incidence of periprocedural myocardial injury (PMI) after elective stent implantation in patients with CKD using the Third Joint ESC/ACCF/AHA/WHF PMI definition.In a single center prospective cohort study, we enrolled 344 consecutive patients who underwent elective PCI in a period of 39 months. Serum troponin I (cTnI) concentrations were measured at baseline and at 8 and 16 hours after PCI. Periprocedural increase of cTnI, according to the most recent PMI definition, was used to define both the presence and intensity of PMI. Patients were further stratified according to the estimated glomerular filtration rate (eGFR) using 4 variable Modification of Diet in Renal Disease (MDRD) equation: control group with eGFR >90 mL/min/1.73 m2 and the CKD group with eGFR < 90 mL/min/1.73 m2, with further subdivision according to the CKD stage.We found no significant difference in the incidence as well as intensity of the PMI in the control (>90 mL/min/1.73 m2) and the CKD group (<90 mL/min/1.73 m2) both 8 and 16 hours after PCI. When the CKD patients were further subdivided according to their CKD stage, there was again no difference in the intensity or incidence of PMI compared to the control group. Further analyses of our data showed angina pectoris CCS IV, bare metal stent (BMS) implantation, and treatment with angiotensin-converting enzyme inhibitors (ACEI) as independent predictors of PMI. Furthermore, the presence of hypertension was inversely related to the occurrence of PMI.Applying the new guidelines for PMI and using the eGFR equation most suitable for our patients, we found no association between PMI and CKD. Further analyses showed other factors that could potentially influence the occurrence of PMI.

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Case Report: Refractory hypotension during general anesthesia despite preoperative discontinuation of an angiotensin receptor blocker

Cited by 15 publications

References 12 publications

Severe refractory hypotension during induction of general anesthesia in patient after 48 hours of azilsartan discontinuation: A case report

Severe refractory hypotension during induction of general anesthesia in patient after 48 hours of azilsartan discontinuation: A case report

Consequences of continuing renin angiotensin aldosterone system antagonists in the preoperative period: a systematic review and meta-analysis

Association of chronic kidney disease with periprocedural myocardial injury after elective stent implantation

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