Any new updates about "ACE inhibitors and ARBs, and perioperative / postoperative hypotension"

[DrAmir0078]

Dear SDN Anesthesiologists,
I hope you are doing well. I had to search and go to old topics and threads in this forum and couple of them back in 2011 about this topic "ACE inhibitors and hypotension
".

I am also concerning about it, as I am personality consider withholding ACE inhibitors and ARBs (it was only ACE inhibitors, but they added it later) 24h before surgery and recommencing them 2d after surgery as written in some books and researches.
You know I have no access to fancy vasopressin, phenylephrine and most of the time no access to norepinephrine (not available). I can get ephedrine and epinephrine

So, from 2011 to 2023 what you all have learnt so far?
Withhold or continue? How will you individualize each case and if there is any score or brain map of thoughts about it?

I am sure you have wonderful PACU team that can manage postoperative hypotension with ease, unlike us or those in limited resources where PACU does not exist.

Love and Peace

Amir

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[BobLoblaw78]

I would hold both in your situation. Vasopressin is the drug of choice for the main issue you are concerned about- refractory hypotension. The downside is poorly controlled hypertension. You didn't mention access to vasodilators but modest hypertension would be more easily managed under anesthesia and afterwards than intraop/postop refractory hypotension. If you were going to selectively continue then I would reserve that for patients with treated hypertension that was still higher than 160/90. I have never personally used methylene blue, but it can be used in place of vasopressin if you have it available.

 

[DrAmir0078]

I would hold both in your situation. Vasopressin is the drug of choice for the main issue you are concerned about- refractory hypotension. The downside is poorly controlled hypertension. You didn't mention access to vasodilators but modest hypertension would be more easily managed under anesthesia and afterwards than intraop/postop refractory hypotension. If you were going to selectively continue then I would reserve that for patients with treated hypertension that was still higher than 160/90. I have never personally used methylene blue, but it can be used in place of vasopressin if you have it available.

Thank you, my bad I didn't mention what is available from Vasodilatators, we currently may have GTN, hydralazine. (I have to buy it sometimes).

I personally prefer labetalol in treating some hypertension bouts perioperatively.

I have personally seen a case with resistant hypotension following PNL op for a young patients who was on linsopril I believe and had taken his med in the morning of surgery. He developed it at the end of operation and continued afterward, it was very difficult to treat. That was 4 years ago in my PGY1.

 

[Onefellswoop87]

With your access to drugs, I agree that I’d have them without the dose prior to surgery
I’m not impressed by any new literature swaying the conversation. Anesthesia literature says continuing ACE-I/ARB increases episodes of hypotension. Internal medicine literature says no difference withholding or not, but they are looking generally farther out than the day or surgery.

 

[DrAmir0078]

If you were going to selectively continue then I would reserve that for patients with treated hypertension that was still higher than 160/90. I have never personally used methylene blue, but it can be used in place of vasopressin if you have it available.

Many thanks again @BobLoblaw78
I had to read it again and again; wow!

I postpone a case 57 years old female, with a long history of hypertension on a double antihypertensive Atacand plus, her Bp was 120 / 70 mmhg - I saw her honestly walking up 2 flights of stairs (Elevator was broken), then a quick history and Bp measurements which was as I said above; so I feared to give her anesthesia for the reasons given of lacking access to medication and what I witnessed before!

So, what you have said - it might augment my decision of withholding.

 

[jwk]

I still see many patients in whom their ACEI/ARB was held more than 24 hours and still have significant hypotension. Vasopressin is my go-to drug - the only reason I might have used ephedrine or phenylephrine first is because I have them readily available in pre-filled syringes. Since you don't have those, I think holding ACEI/ARB for 48 hours is more than reasonable.

 

[DrAmir0078]

With your access to drugs, I agree that I’d have them without the dose prior to surgery
I’m not impressed by any new literature swaying the conversation. Anesthesia literature says continuing ACE-I/ARB increases episodes of hypotension. Internal medicine literature says no difference withholding or not, but they are looking generally farther out than the day or surgery.

Apparently, internal medicine are happy with continuing as long as nobody will page them about resistant hypotension case postoperatively; they will say "wrong page, wrong call" !
Thank you !

 

[Mehd School]

I feel strongly that ARBs and especially ACE-i should be held, although other professional organizations (Cardiologists...) disagree with this. Unfortunately the heart doctors don't see the life/organ threatening hypotension in the OR that we do. At the same time, extremely often when I am taking care of a patient that DID hold their ace/arb I am encountering significant hypertension in the PACU. That is usually easily treatable and I am also comfortable discharging them from pacu with somewhat elevated pressures but we would be foolish to assume this is 100% benign as well. I think it's a good trade off for not having to slam vaso and epi during a routine knee scope though.

 

[DrAmir0078]

I still see many patients in whom their ACEI/ARB was held more than 24 hours and still have significant hypotension. Vasopressin is my go-to drug - the only reason I might have used ephedrine or phenylephrine first is because I have them readily available in pre-filled syringes. Since you don't have those, I think holding ACEI/ARB for 48 hours is more than reasonable.

Wow ! Two questions arose - just in case; if I withhold, what medication should the patient switched to or bridge to ? or just keep the patient without ACE / ARBs for 24 hours and if the patient on diuretics like, will let it to continue and even if on BB too in case of triple or multiple Antihypertensive regimen !
The second question; how would you give Vasopressin ? I can recall it is in units only, since I don't use, I don't know how to prepare it or give it !

Many thanks from the bottom of my heart!

 

[DrAmir0078]

At the same time, extremely often when I am taking care of a patient that DID hold their ace/arb I am encountering significant hypertension in the PACU. That is usually easily treatable and I am also comfortable discharging them from pacu with somewhat elevated pressures but we would be foolish to assume this is 100% benign as well.

Thank you, this is very helpful. so, they can get their operation with managing their hypertension - if any - perioperatively, but afterward we will need to control further. Indeed, it is not 100% benign too, at least from my understanding it takes time to control refractory hypotension than treating hypertension. Can I say "the benefits outweigh the risks" !

 

[BobLoblaw78]

Wow ! Two questions arose - just in case; if I withhold, what medication should the patient switched to or bridge to ? or just keep the patient without ACE / ARBs for 24 hours and if the patient on diuretics like, will let it to continue and even if on BB too in case of triple or multiple Antihypertensive regimen !
The second question; how would you give Vasopressin ? I can recall it is in units only, since I don't use, I don't know how to prepare it or give it !

Many thanks from the bottom of my heart!

No need to bridge. I would start the following day. If they have problems with hypertension intraoperatively or postoperatively then I would start postoperatively. I would continue all other antihypertensive medications including betablockers.

Small boluses of vasopressin 2 units IV. Reassess and bolus again if needed. It comes in a vial that I dilute to 1 unit per mL in a 20 mL syringe.

 

[DrAmir0078]

No need to bridge. I would start the following day. If they have problems with hypertension intraoperatively or postoperatively then I would start postoperatively. I would continue all other antihypertensive medications including betablockers.

Small boluses of vasopressin 2 units IV. Reassess and bolus again if needed. It comes in a vial that I dilute to 1 unit per mL in a 20 mL syringe.

Thank you again Dr. BobLoblaw78. That is truly helpful.

 

[BLADEMDA]

Vasopressin is expensive. You may want to check the cost of that drug. I have seen more than a few cases where the ARB/ACE was given the night before or the day of surgery result in severe intraop hypotension. A few times the hypotension was so severe the cases had to be cancelled. The patients arrived in PACU on Epi and/or Vasopressin drips.

The majority of patients won't have severe intraop hypotension and because we have access to Vasopressin and Epi we don't cancel cases even though the patient took their ARB/ACE within the previous 24 hours (typically within the past 12 hours). However, if I was practicing in a third world country I would certainly understand the need to cancel these patients rather than risk dealing with the hypotension.

Refractory Hypotension During General Anesthesia Despite Withholding Telmisartan

Angiotensin receptor blockers (ARBs) are commonly used to treat hypertension. However, similar to angiotensin-converting enzyme inhibitors, ARBs can also cause refractory hypotension during general anesthesia. Therefore, it has been recommended that ARBs ...

www.ncbi.nlm.nih.gov

Withholding versus Continuing Angiotensin-converting Enzyme Inhibitors or Angiotensin II Receptor Blockers before Noncardiac Surgery: An Analysis of the Vascular events In noncardiac Surgery patIents cOhort evaluatioN Prospective Cohort

In a secondary analysis of 4,802 patients on these drugs in the Vascular events In noncardiac Surgery patIents cOhort evaluatioN prospective cohort study, those in whom the drugs were withheld in the 24 h before surgery were less likely to suffer a composite outcome of 30-day all-cause death...

pubs.asahq.org

 

[BLADEMDA]

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

Background Patients 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...

bmcanesthesiol.biomedcentral.com

 

[DrAmir0078]

Vasopressin is expensive. You may want to check the cost of that drug. I have seen more than a few cases where the ARB/ACE was given the night before or the day of surgery result in severe intraop hypotension. A few times the hypotension was so severe the cases had to be cancelled. The patients arrived in PACU on Epi and/or Vasopressin drips.

The majority of patients won't have severe intraop hypotension and because we have access to Vasopressin and Epi we don't cancel cases even though the patient took their ARB/ACE within the previous 24 hours (typically within the past 12 hours). However, if I was practicing in a third world country I would certainly understand the need to cancel these patients rather than risk dealing with the hypotension.

Refractory Hypotension During General Anesthesia Despite Withholding Telmisartan

Angiotensin receptor blockers (ARBs) are commonly used to treat hypertension. However, similar to angiotensin-converting enzyme inhibitors, ARBs can also cause refractory hypotension during general anesthesia. Therefore, it has been recommended that ARBs ...

www.ncbi.nlm.nih.gov

Withholding versus Continuing Angiotensin-converting Enzyme Inhibitors or Angiotensin II Receptor Blockers before Noncardiac Surgery: An Analysis of the Vascular events In noncardiac Surgery patIents cOhort evaluatioN Prospective Cohort

In a secondary analysis of 4,802 patients on these drugs in the Vascular events In noncardiac Surgery patIents cOhort evaluatioN prospective cohort study, those in whom the drugs were withheld in the 24 h before surgery were less likely to suffer a composite outcome of 30-day all-cause death...

pubs.asahq.org

Thank you so much Dr @BLADEMDA for your insight and valuable links provided.
I won't touch a patient on ACE/ARBs unless emergency!

 

[dabears505]

How do you guys handle the situation where the patient has held these drugs, but in the morning of surgery has a pressure of 220? I've had this happen a few times. What is the game plan for these patients to get surgery?

 

[2Fast2Des]

How do you guys handle the situation where the patient has held these drugs, but in the morning of surgery has a pressure of 220? I've had this happen a few times. What is the game plan for these patients to get surgery?

Hard call, especially when you know the reason, and add the anxiety factor as well. On the private side, people give some labetalol, some reassurance and make sure no other causes or symptoms. In academic I've seen the case cancelled.

 

[FiO2@21]

How do you guys handle the situation where the patient has held these drugs, but in the morning of surgery has a pressure of 220? I've had this happen a few times. What is the game plan for these patients to get surgery?

If I was confident it was from ACEi/ARB being held and that they have documented normal pressures typically, I would feel comfortable inducing and using short acting antihypertensives during the case with the plan to give their home medication in PACU. The concern with poorly controlled BP is their perfusion auto regulation being chronically right shifted, which wouldn't be an issue here. I think it'd be difficult to argue that this case would need to be delayed without a clear rationale for harm.

 

[nimbus]

Hard call, especially when you know the reason, and add the anxiety factor as well. On the private side, people give some labetalol, some reassurance and make sure no other causes or symptoms. In academic I've seen the case cancelled.

Also depends on the case. If it’s an elective craniotomy or carotid, I’m more likely to wait until BP is well-controlled. If it’s a knee replacement or or gallbladder where tight intraop and postop BP control is less critical, I’m more likely to proceed.

 

[repititionition]

Hard call, especially when you know the reason, and add the anxiety factor as well. On the private side, people give some labetalol, some reassurance and make sure no other causes or symptoms. In academic I've seen the case cancelled.

I run in to this fairly commonly and generally find a way, barring something else to give me pause, to do the case.

My only concern is that we know starting beta-blockade in the preoperative period worsens outcomes. In the off chance that something does go sideways, I am confident that my use of labetalol is going to make it very hard for me to prevail in a malpractice suit.

But, like I said... see above. I generally find a way to make the case work.

 

[periopdoc]

How do you guys handle the situation where the patient has held these drugs, but in the morning of surgery has a pressure of 220? I've had this happen a few times. What is the game plan for these patients to get surgery?

Judicious beta blockers in preop. Just looking to get a small drop in the pressure. I don't want it to go down much, I just want to have a lid on it. Over treat, and they are certain to dump their pressures post-induction.

Post-op, hydralazine.