Refractory Hypotension in setting of ACE Inhibitor

[aneftp]

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LMA or ETT?
I ask because I think it makes a difference. Respiratory efforts are indicative of good or bad things happening in the Mellon.

ETT for shoulder.

 

[deleted162650]

Respiratory efforts are indicative of good or bad things happening in the Mellon.

That right there, word for word, needs to be in the next edition of big Miller.

 

[Noyac]

ETT for shoulder.

I haven't placed more than a few ETT's for any shoulder case in over 13 yrs

 

[Noyac]

That right there, word for word, needs to be in the next edition of big Miller.

I'll write my own anesthesia bible and call it Big Noyac.
It should be a quick read. Maybe 10-15 paragraphs.
And nothing very deep or intellectual.

 

[sevoflurane]

What was induction agent?

I didn't push the drugs but fairly simple anesthetic as far as I remember. Something like Fent, lido, prop, roc, ETT.

 

[hankbb02]

I haven't placed more than a few ETT's for any shoulder case in over 13 yrs

You place LMA's for beach chair? Lot's of people at my institution do this to and no one has convinced me I yet to get on board.

 

[nimbus]

You place LMA's for beach chair? Lot's of people at my institution do this to and no one has convinced me I yet to get on board.

I haven't intubated for beach chair in 15 years. Block first in preop. Then I sit them up, make sure the patient is nice and comfy, induce in the sitting position and slip an lma in. Hasn't failed yet. Then you don't have to sit up a dead weight patient and hope their neck is in a comfortable position.

 

[aneftp]

I haven't placed more than a few ETT's for any shoulder case in over 13 yrs

I do a few LMAs (maybe 15% of the time) for shoulders. But this dude was 360 poiunds and not the best looking airway.

 

[facted]

Mostly do LMA for shoulder scopes with rare issues. Have one surgeon who wants his total shoulders intubated for relaxation. But to be honest, what's so wrong about a tube for these cases?

 

[Noyac]

I do a few LMAs (maybe 15% of the time) for shoulders. But this dude was 360 poiunds and not the best looking airway.

That is tricky. I still do it for the morbid obese pts. I will induce them supine and make sure the seal I'd real good. Then if I'm happy we sit them up. Usually works fine. I don't recall having to pull the LMA and place a tube.
Your guy was 360 lbs but his BMI wasn't horrendous so I'm thinking he was just a real big guy. They do fine. Plus in the BC position you have removed that abdominal weight off the diaphragm and they breath even better.

 

[Noyac]

Mostly do LMA for shoulder scopes with rare issues. Have one surgeon who wants his total shoulders intubated for relaxation. But to be honest, what's so wrong about a tube for these cases?

We are not saying that anything is wrong with a tube in these cases. I was mentioning that I like LMA's for these cases because I fine that the respiratory pattern can alert you to poor cerebral perfusion if it is occurring.

 

[sevoflurane]

I didn't push the drugs but fairly simple anesthetic as far as I remember. Something like Fent, lido, prop, roc, ETT.

and 500 mg of Etomidate.

 

[propadope]

Other than holding the ACEI, fluids pre induction and pressors does anyone alter their anesthetic technique to prevent or minimize hypotension?

 

[facted]

We are not saying that anything is wrong with a tube in these cases. I was mentioning that I like LMA's for these cases because I fine that the respiratory pattern can alert you to poor cerebral perfusion if it is occurring.

Ok, sure, I could see that. On the other hand, could also get them spontaneous with ETT with a little PS if available. Lots of ways to skin a cat, clearly.

I know people who do plenty of scopes under block and mac. Personally not interested.

 

[Noyac]

and 500 mg of Etomidate.

😉

 

[nimbus]

I do a few LMAs (maybe 15% of the time) for shoulders. But this dude was 360 poiunds and not the best looking airway.

I've found the LMA works very well in the sitting position even in obese patients.

Mostly do LMA for shoulder scopes with rare issues. Have one surgeon who wants his total shoulders intubated for relaxation. But to be honest, what's so wrong about a tube for these cases?

I rarely get a request for relaxation. In those cases I just give some roc and turn on the vent.

That said I think you can't argue against an ETT. It's just that in my experience the LMA is easy and convenient and works very well for beach chair shoulders.

 

[pgg]

and 500 mg of Etomidate.

Why didn't you tell us the setting was "conscious sedation in the ER"?

 

[anes121508]

bumping this thread for the original topic of ace inhibitors on DOS. Two questions...

1. Elective cardiac case and patient took ace inhibitor night before. What's your/surgeon's practice?
- Our surgeons will cancel. I haven't seen this before. I can see the logic.

2. Elective non cardiac case, our pre-admission people are having people hold ACE-I, but not ARB's.
- This is new to me as well. Can't find that ARB has minimal or significantly less vasoplegia than ACE

Thoughts?

 

[Hoya11]

bumping this thread for the original topic of ace inhibitors on DOS. Two questions...

1. Elective cardiac case and patient took ace inhibitor night before. What's your/surgeon's practice?
- Our surgeons will cancel. I haven't seen this before. I can see the logic.

2. Elective non cardiac case, our pre-admission people are having people hold ACE-I, but not ARB's.
- This is new to me as well. Can't find that ARB has minimal or significantly less vasoplegia than ACE

Thoughts?

People are going to show up in imperfect condition. My practice can barely get them to show up on time and NPO. Some of them will take their ACE-I or ARB, some will not. Cancelling for either is silly. Just do the case and normalize the BP. I have seen many patients who take ACE-I who have hypotension and need NEO, sure. I have seen many who took it and still needed additional beta blockers or nitrates to further reduce BP. Hard to tell who is who, but just do the case and do whats necessary to normalize BP. Seems like a little bit of an academic discussion. Where I practice, cancelling a case because they took a ACE-I would be laughed at..

 

[anes121508]

People are going to show up in imperfect condition. My practice can barely get them to show up on time and NPO. Some of them will take their ACE-I or ARB, some will not. Cancelling for either is silly. Just do the case and normalize the BP. I have seen many patients who take ACE-I who have hypotension and need NEO, sure. I have seen many who took it and still needed additional beta blockers or nitrates to further reduce BP. Hard to tell who is who, but just do the case and do whats necessary to normalize BP. Seems like a little bit of an academic discussion. Where I practice, cancelling a case because they took a ACE-I would be laughed at..

"Seems like a little bit of an academic discussion".......Completely disagree considering I'm in my first year out of fellowship at a very academic place where a case would never be cancelled for ace/arb. Now in pp and surgeon is canceling. He was pissed at me that I knew about it and didn't tell him prior to the case. Said he would have cancelled the case. Two months later, he kept to his word when I told him his patient took lisinopril and he cancelled. So this is more of a real life clinical question and not an academic question. Your comment would be more fair if you meant that cancelling a case due to ace-i is an academic thing. However, my question is completely practical.

 

[anes121508]

with all due respect sir/mam, considering I know I've learned quite of a bit over the years from your posts

 

[anes121508]

in terms of my question (#2) in regards to elective non cardiac case and ARB's...

I've noticed that many of patients have taken their losartan. I asked them about it and they told me that the preop people are telling them to take it. So I mentioned it to the preop folks and they told me "yeah that's our policy, take the ARB and skip the ACE". I've never cancelled a case because of it (cuz I share a similar opinion as you, just treat it if it happens), but wondering if there is any reasoning behind their recommendation that I'm not aware of.

So, to clarify...question #2: Is there evidence to suggest that ARB's have less incidence of hypotension/vasoplegia than ACE-I?

 

[Hoya11]

with all due respect sir/mam, considering I know I've learned quite of a bit over the years from your posts

Didn’t mean to insult you buddy ... just giving my honest perspective.. never had a surgeon cancel for this reason nor would I , I don’t think the surgeons I work with even know the difference between blood pressure meds

 

[deleted162650]

I’m wondering if the cardiac surgeon has concerns regarding renal perfusion and gfr while on pump in the setting of an ACEi.

 

[anes121508]

Didn’t mean to insult you buddy ... just giving my honest perspective.. never had a surgeon cancel for this reason nor would I , I don’t think the surgeons I work with even know the difference between blood pressure meds

lol, yeah that was almost my exact same response to the surgeon when he was mad that I let his case go despite the pt taking the ace-i. I was kinda shocked

 

[anes121508]

I’m wondering if the cardiac surgeon has concerns regarding renal perfusion and gfr while on pump in the setting of an ACEi.

good point , not sure the data on that ....specifically for him it's vasoplegia

 

[coffeebythelake]

Actually the majority of vasopressin was given in the first 10 minutes post induction (6 units). The remaining 4 units were given over the next 90 minutes. Everyone's a critic on SDN but I have no plans on running any drips now or in the future when I can push some meds via a syringe. I only use drips when absolutely necessary because I keep it KISS.

i've had patients like this where i ended up giving large doses of vasopressin in short order due to likely ACEI induced refractory hypotension. i think there's certainly a concern that this may cause ATN/AKI

 

[Hamhock]

Who else gambled by buying stock in La Jolla PC?

HH