ace arb renal failure

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A hospital that I practice at has now instituted withholding ace inhibitors and arb's night before and day of surgery for all patients. They can not provide me with any peer reviewed data to justify the withholding. While I feel it has minimal risk to the patient, is withholding arb/acei common practice?

Jeff

 

[Laryngophed]

A hospital that I practice at has now instituted withholding ace inhibitors and arb's night before and day of surgery for all patients. They can not provide me with any peer reviewed data to justify the withholding. While I feel it has minimal risk to the patient, is withholding arb/acei common practice?

Jeff

Being that I am but a lowly M1, take what I type with a grain of salt. Actually, that may be insulting to the grain of salt, so just nearly disregard all that I type.

A quick PubMed search landed this paper on my desk top. It appears that long term treatment with ACEi/ARBs increases the likelihood of hypotensive events in non-cardiothoracic procedures. I'm not sure about their methods as this is not research I've done before, but JCVA appears to be a peer-reviewed publication, but that may not mean as much as one would think. There doesn't appear to be much in the way of research on this, though my brief (and probably ineffective) search may be the problem.

Kheterpal S, Khodaparast O, Shanks A, O'Reilly M, Tremper KK. Chronic angiotensin-converting enzyme inhibitor or angiotensin receptor blocker therapy combined with diuretic therapy is associated with increased episodes of hypotension in noncardiac surgery. J Cardiothorac Vasc Anesth. 2008 Apr;22(2):180-6.

PMID: 18375317

OBJECTIVE: Chronic angiotensin-converting enzyme inhibitor (ACE-I) or angiotensin receptor blocker (ARB) therapy has been reported to result in intraoperative hypotension in patients undergoing general anesthesia. This study evaluated the association between ACE-I/ARB therapy and the hemodynamics of patients undergoing noncardiac surgery using a large patient dataset.

DESIGN AND SETTING: A prospective, observational study performed at a single tertiary care hospital.

PARTICIPANTS: All adult patients undergoing noncardiac surgery.

INTERVENTIONS: None.

MEASUREMENTS AND MAIN RESULTS: Propensity score matching for the likelihood of chronic ACE-I/ARB therapy was used to create 2 patient cohorts with similar cardiovascular and pulmonary comorbidities. The number of periods of absolute and relative hypotension, vasopressor requirements, and postoperative myocardial infarction and renal failure rates were compared among patients with and without ACE-I/ARB therapy. A total of 65,043 noncardiac cases between 2003 and 2006 were included. Two-digit propensity score matching resulted in a study population of 12,381 operative cases with very similar cardiovascular comorbidities between the ACE-I/ARB and control cohort. Patients with chronic ACE-I/ARB and diuretic therapy showed more periods with a mean arterial pressure <70 mmHg, periods with a 40% decrease in systolic blood pressure, periods with a 50% decrease in systolic blood pressure, and vasopressor boluses when compared with patients with diuretic therapy alone. There were no statistically significant differences in the rates of postoperative myocardial infarction or renal failure between patients with and without ACE-I/ARB therapy.

CONCLUSIONS: Chronic diuretic therapy is associated with more frequent hypotension in ACE-I/ARB-treated patients undergoing noncardiac surgery.

 

[hoyden]

They are not withheld in my current place but were in the hospital I was doing residency. If I had my choice in this - I would withhold ace/arb here as well - we have only propofol and etomidate for induction and even with careful slow induction, small doses of propofol, there are many cases of hypotension not easily corrected with phenylephrine. Not that it has ever been a big problem( I mean correcting the BP), but it could be avoided.

 

[Idiopathic]

we debate this as well, although one thing is usually the case, if they take an ace/arb they will not be very responsive to phenylephrine or volume and will need exogenous vasopressin through an IV

 

[BLADEMDA]

we debate this as well, although one thing is usually the case, if they take an ace/arb they will not be very responsive to phenylephrine or volume and will need exogenous vasopressin through an IV

Based on tens of thousands of cases my experience is very different. The vast majority of patients on either an ACE/ARB or a Calcium Channel Blocker tolerate their anesthetic well with little problems. However, when you combine the Ca Channel Blocker and the ACE/ARB the incidence of severe hypotension increases (2-5 %). Then, you may need Vasopressin or low dose epi on half this group (the other half will respond tp Phenylephrine and Ephedrine).

We do not discontinue our ACE, ARB or Calcium Channel Blockers. Our incidence of severe hypotension refractory to treatment is low. But, I have seen it and dealt with it.

 

[BLADEMDA]

There were no differences between groups in the incidence of severe hypotension, nor was there a difference in the use of vasopressors. During the 31&#8211;60 min after induction, the incidence of either moderate (P = 0.43) or severe (P = 0.97) hypotension was similar in the two groups. No differences in postoperative complications were found between groups. In conclusion, discontinuation of ACEI/ARA therapy at least 10 h before anesthesia was associated with a reduced risk of immediate postinduction hypotension.

http://www.ncbi.nlm.nih.gov/pubmed/15728043?dopt=Abstract

 

[BLADEMDA]

Conclusions: In patients who received long-term treatment with renin-angiotensin system inhibitors, intraoperative refractory arterial hypotension was corrected with both terlipressin and norepinephrine. However, terlipressin was more rapidly effective for maintaining normal systolic arterial blood pressure during general anesthesia

 

[BLADEMDA]

Terlipressin has been proposed as an appropriate
drug to treat hypotensive episodes refractory to
ephedrine in anesthetized patients chronically treated
with ACEI. However, we suggest that terlipressin
should be use cautiously in patients with coronary
artery disease especially if they are not chronically​

treated with renin-angiotensin system inhibitors.

 

[Idiopathic]

all i know is what i see and that is that patients on an ACE who did not hold it get hypotensive with MAPs in the 40s fairly consistently and I feel compelled to treat that.

vasopressin and its analogues are more effective than norepinephrine and i am more comfortable bolus dosing them, although I have seen one definite incidence of coronary vasospasm and suspect more.

 

[BLADEMDA]

all i know is what i see and that is that patients on an ACE who did not hold it get hypotensive with MAPs in the 40s fairly consistently and I feel compelled to treat that.

vasopressin and its analogues are more effective than norepinephrine and i am more comfortable bolus dosing them, although I have seen one definite incidence of coronary vasospasm and suspect more.

Bull crap. Tens of thousands of GAs with patients on ACE inhibitors or ARB. Only minor hypotension (easily treated) after induction.


http://books.google.com/books?id=BOqlw_H5gxoC&pg=PA309&lpg=PA309&dq=hypotension+after+induction+with+ace+inhibitors&source=bl&ots=Hv1_r9_G-k&sig=1eFmfO5jrdxKAZNIlgO5CmDgFzs&hl=en&ei=lQSVTLGVJYH6lwezgsmrCg&sa=X&oi=book_result&ct=result&resnum=7&ved=0CCwQ6AEwBg#v=onepage&q=hypotension%20after%20induction%20with%20ace%20inhibitors&f=false (read page 309)

 

[BLADEMDA]

http://www.scielo.br/scielo.php?pid=S0034-70942009000600006&script=sci_arttext&tlng=en



CONCLUSIONS: We did not observe an association between the use of ACE inhibitors and hypotension during anesthesia. The authors considered that the recommendation to discontinue ACE inhibitors on the day before the surgery should be reviewed. Other studies are necessary to confirm those results.

 

[BLADEMDA]

A hospital that I practice at has now instituted withholding ace inhibitors and arb's night before and day of surgery for all patients. They can not provide me with any peer reviewed data to justify the withholding. While I feel it has minimal risk to the patient, is withholding arb/acei common practice?

Jeff

This is institution dependent. While the risk to any particular patient is low (less than one percent experience refractory hypotension requiring vasopressin treatment) it is nonetheless real.

Some "experts" recommend discontinuing ACE/ARBs the day before in order to minimize hypotension and the rare, but far worse, refractory hypotension.

Our practice experience of several hundred thousand cases (at least 20,000 or more on ARBs or ACE inhibitors) shows post induction hypotension to be a real phenomenon with most patients responding to our usual pressor agents.
Still, those patients on ACE/ARBS and CCBs plus or minus a diuretic at are a far greater risk of developing refractory intraoperative hypotension.

 

[BLADEMDA]

Can J Anaesth. 2000 May;47(5):433-40.
Cardiovascular responses to anesthetic induction in patients chronically treated with angiotensin-converting enzyme inhibitors.

Licker M, Schweizer A, Höhn L, Farinelli C, Morel DR.
Division of Anesthesiology, Hôpital Cantonal Universitaire, Geneve, Switzerland. [email protected]
Abstract

PURPOSE: To investigate the effects of chronic ACE inhibition on cardiac neural function following induction of general anesthesia in patients with underlying coronary artery disease.
METHOD: In a prospective case-control study, heart rate variability (HRV) and baroreflex control were compared preoperatively and 30 min after anesthesia induction in patients receiving, or not, ACEI (n=16, control group and n=16, ACEI group). All patients had normal cardiac function and anesthesia consisted of a fixed dose regimen of fentanyl and midazolam. Anesthesia-related hypotension was defined by systolic blood pressure < 90 mmHg. Spectral density of HRV was calculated for low frequency and high frequency bands (LF, from 0.05 to 0.15 Hz and HF, from > 0.15 to 0.6 Hz). Baroreflex sensitivity was estimated after blood pressure changes induced by injections of phenylephrine (PHE) and nitroglycerin (NTG).
RESULTS: The HRV parameters and baroreflex sensitivity were not different between groups, during the awake and anesthesia periods. Anesthesia produced similar reduction in total HRV in the Control and ACEI groups (-93 +/- 28% vs -89 +/- 32%), and in baroreflex sensitivity during NTG (-64 +/- 21% vs -54 +/- 17%) or PHE tests (-74 +/- 25% vs -72 +/- 22%). Anesthesia-related hypotension occurred in nine patients in the ACEI group (vs two controls). Although the hypertensive response to phenylephrine was greater after anesthesia in both groups, the sensitivity to phenylephrine was attenuated in those patients experiencing hypotension in the ACEI group.
CONCLUSIONS: Chronic preoperative treatment with ACEIs does not influence cardiac autonomic regulation and anesthetic-induced hypotensive episodes are mainly attributed to decreased alpha-adrenergic vasoconstrictive response.

 

[BLADEMDA]

In conclusion, in patients receiving chronic ACEI/ARA therapy who receive general anesthesia, the administration of these drugs <10 hours before anesthesia is a significant independent risk factor for developing moderate hypotension within 30 minutes after induction. However, this hypotension responded to conventional therapy and thus seemed to be of little clinical consequence in the surgical population studied. These results do not provide a strong rationale for strict guidelines regarding preoperative management of these drugs. Nonetheless, preoperative withholding of ACEI/ARA should be considered for patients who may be especially prone to hypotension-induced complications (e.g., patients with severe aortic stenosis or critical cerebrovascular disease).

http://www.ncbi.nlm.nih.gov/pubmed/15728043?dopt=Abstract

 

[Idiopathic]

id kind of like to see a study that demonstrated differences between people whose ace was held for a day or more rather than a 10 hour cutoff. lisinopril has like a 12 hour half life and can accumulate...