Renin–angiotensin system antagonists in the perioperative setting: clinical consequences and recommendations for practice

Abstract

There are no existing guidelines supporting the withdrawal or continuation of renineangiotensinealdosterone system (RAAS) antagonists in the preoperative setting. RAAS antagonists include ACE inhibitors, angiotensin II receptor subtype 1 blockers and direct renin inhibitors (eg, aliskiren), as well as the aldosterone antagonists. The use of these agents before surgery has been associated with a variable incidence of hypotension during the initial 30 min after induction of anaesthesia; however, these hypotensive episodes have not been conclusively linked to any significant postoperative complications, although recent data suggest an increase in postoperative morbidity and mortality in patients undergoing coronary artery bypass grafting. Further studies are required to be able to demonstrate if the organ-protective benefits of RAAS antagonists justify their continuation in the perioperative setting. Temporary withdrawal of RAAS antagonists in these patients may prevent or attenuate intraoperative hypotension and hypovolaemia. Alternatively, the increase in RAAS activity and blood pressure expected with cessation of RAAS antagonist therapy may impair regional circulation secondary to an increase in systemic vascular resistance. Full discussion of the potential implications of perioperative RAAS antagonist therapy with the surgical team is important, and strategies to ensure careful monitoring and maintenance of adequate intravenous volume before induction of anaesthesia are essential.

Association between angiotensin converting enzyme inhibitor or angiotensin receptor blocker use prior to major elective surgery and the risk of acute dialysis

“…By inhibiting angiotensin II, ACEi/ARB use may increase the risk of functional AKI (i.e., a drop in GFR) but may paradoxically reduce the risk of “true AKI” (true tubular injury) [36,40-42]. In this regard, ACEi and ARB may improve renal blood flow and oxygenation to the renal tubules by vasodilatation of efferent arterioles and may prevent tubular cell necrosis during ischemic insults around surgery [13]. To wit, a recent analysis from a large multi-center cohort of patients undergoing cardiac surgery (TRIBE-AKI cohort) showed that while AKI defined by changes in serum creatinine, was higher in those that had ACEi or ARB continued pre-operatively, there was not a concomitant increase in several biomarkers of kidney injury [43].…”

“…Despite their demonstrated benefits in outpatient settings, their continued use in the perioperative period remains controversial as preoperative ACEi/ARB use may lead to the development of perioperative hypotension and subsequent AKI [8,13-16]. However, previous observational studies on the association between preoperative ACEi/ARB use and AKI have had conflicting results, and have focused on milder forms of AKI rather than the most serious renal outcome of AKI-D. We conducted this large retrospective cohort study to test the hypothesis that preoperative ACEi/ARB use compared to non-use associates with a different risk of AKI-D following major elective surgery.…”

Perioperative Care of an Adolescent With 11-Beta-Hydroxylase Deficiency

“…While continuation of anti-hypertensive medications is generally recommended, the perioperative administration of angiotensinconverting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) may result in excessive intraoperative hypotension [21,22]. Anecdotal success has been reported with the use of vasopressin in cases refractory to direct acting adrenergic agonists (epinephrine, phenylephrine) [23].…”

Paciente Adulto Mayor Y Cirugía No Cardíaca: ¿qué Debemos Saber?

“…Estudios muestran aumento de la morbimortalidad postoperatoria relacionado a episodios de hipotensión moderada y severa luego de la inducción anestésica 22 , por lo que estaría recomendado la suspensión de estos fármacos al menos 24 h previas a la cirugía 23 . Sin embargo, una cuidadosa y adecuada inducción anestésica no debería producir episodios graves de hipotensión, aún en pacientes en los cuales se ha mantenido su terapia antihipertensiva, siendo más importante una acuciosa administración de fármacos anestésicos antes que suspender los fármacos mencionados.…”