Ace Inhibitors prior to GA

[pencan]

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Do you have patients hold their ace inhibitors the day of surgery for patients receiving general anestheisa for non-cardiac procedures? Do you allow them to take it the night or day before surgery?


Thanks

 

[RussianJoo]

why would you hold it?

 

[GasEmDee]

why would you hold it?

We are considering this issue. Currently our policy is to continue it. But ACE Inhibitors decrease SVR. Anesthetics can worsen the low-SVR state to the point of hypotension that is very difficult to manage.

 

[kmurp]

We have seen one case of angioedema post difficult intubation blamed on ace inhibitors. It was, I understand, rather scary.

 

[pd4emergence]

We are considering this issue. Currently our policy is to continue it. But ACE Inhibitors decrease SVR. Anesthetics can worsen the low-SVR state to the point of hypotension that is very difficult to manage.

.5-1 unit of vasopressin works well in this situation. I see this from time to time but it hasn't been a huge issue.

 

[lord_jeebus]

Many of us at my program, myself included, do ask patients to hold ACEIs on the day of surgery, but if they forget it's no big deal.

 

[RussianJoo]

We are considering this issue. Currently our policy is to continue it. But ACE Inhibitors decrease SVR. Anesthetics can worsen the low-SVR state to the point of hypotension that is very difficult to manage.

do you really think holding one dose of a medication that the pt has been taking for years will really affect that? the half life of lisinopril is 12h.

It's like doctors explaining high BP's in the ER by saying the pt just didn't take his morning BP meds, a bunch of bull.

 

[lord_jeebus]

do you really think holding one dose of a medication that the pt has been taking for years will really affect that? the half life of lisinopril is 12h.

It's like doctors explaining high BP's in the ER by saying the pt just didn't take his morning BP meds, a bunch of bull.

2 papers for you. I don't think it's a big deal, but I do think there is an effect.

http://www.ncbi.nlm.nih.gov/pubmed/8053578

http://www.anesthesia-analgesia.org/content/100/3/636.abstract

 

[RussianJoo]

hm ok thanks for the articles. I wonder why that is..

 

[CambieMD]

.5-1 unit of vasopressin works well in this situation. I see this from time to time but it hasn't been a huge issue.

I gave 1 unit of vasopressin to treat hypotension in a patient on an ACE-I today. I gave .5 units X 2 10 minutes apart.

Cambie

 

[CrazyJake]

I have them hold ACEI's the morning of..hate dealing with the hypotension and trying to get Grandmas MAP up.

CJ

 

[gaspasser2004]

We tell patients to hold their ACEI's the day of surgery. In three years of residency and 2 1/2 years of practice, I have only had a handful of truly hypotensive episodes following induction of GA after taking an ACEI. Luckily, I haven't had to use vasopressin, but it took a bunch of phenylephrine and fluids. I do think there is an effect. I'm not sure I would go so far as to cancel a case on a patient who took their ACEI the morning of surgery. Hopefully, more information through case reports/retrospective studies will point to a definitive strategy.

 

[Idiopathic]

great topic. we used to have them hold it, but not any more. I think our view is that, similar to beta-blockade, the need for medicinal continuity and the possibility of rebound phenomena should be considered. we are also getting away from bolus dose VP, although its still used. Limb ischemia is a very real possibility, especially with small IVs and multiple boluses.

one study showed increased mortality in patients in RAAS blockers after AAA repair, interestingly enough.

 

[Impromptu]

We have them hold it, but won't cancel a case because of it. I used bolus vasopressin intra-op last week for the first time. It seemed that phenylephrine would work well for a while, then it would lose efficacy, so I would switch to vasopressin, which worked well for a couple doses, but then I would have to switch back to phenylephrine. Nice to gain experience with it.