Vasopressin and ACEi

[Gator05]

Hi all,

Here's the scenario: 60 y/o gentleman on ACEi for hypertension/renal protection (or substitute ARB), happily took it morning of surgery. Following induction, the BP just drops, and I mean drops. You give some volume, some neo, some more volume, some more neo, some ephedrine perhaps, and your SBP goes 70's-->80's. You turn your agent down, your pt moves, you turn your agent up, your BP still sucks.

How many of you would give some vasopressin?

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[apma77]

this is a classic indication that ace i should be d/c'd prior to surgery if possible
infact is intractable hypotension has been described in MILLER following induction with pts on acei.
if neo or ephedrine doesnt work then try some levophed, if that doesnt work consider epi (this is ofcourse if youve already turned off all anesthetic that is causing hypotension)

Hi all,

Here's the scenario: 60 y/o gentleman on ACEi for hypertension/renal protection (or substitute ARB), happily took it morning of surgery. Following induction, the BP just drops, and I mean drops. You give some volume, some neo, some more volume, some more neo, some ephedrine perhaps, and your SBP goes 70's-->80's. You turn your agent down, your pt moves, you turn your agent up, your BP still sucks.

How many of you would give some vasopressin?

 

[Noyac]

We have held all acei's for the day of surgery unless they are low dose for this reason exactly.

vasopressin is my drug of choice for these pts.

One of my partners will start it b/4 induction even on the pts that have taken their dose.

 

[Gator05]

We hold it for persons on it purely for htn. If on s/p MI for issues of ventricular remodelling, we continue.

I'd argue against escalating to norepi/epi. Principle is, the adrenergic system is short-circuited by the lack of AT2 available.

I'm amazed at how far 2 units of vasopressin will go.

 

[TIVA]

Vasopressin is a good drug, but ...


In the setting of anesthetic-induced hypotension that is refractory to neosynephrine or ephedrine, don't be so quick to discount levophed which is mighty potent. In fact, both neo and ephedrine are spits in the wind compared to levophed. Levophed is very good stuff in that type of situation.

Not only that, but one of the mechanisms for vasopressin's action is to upregulate the receptors that levophed binds, hence further potentiating it's action. Thus, start with levophed first, titrate in your vasopressin, once your stable, titrate off the vasopressin and then titrate down the levophed. At least that's what the CT anesthesiology review lecture in this past year's IARS conference indicated.

 

[Annette]

We hold it for persons on it purely for htn. If on s/p MI for issues of ventricular remodelling, we continue.

Why wouldn't you hold the ACEI s/p MI. It is for what, one day at most?

 

[Noyac]

Why wouldn't you hold the ACEI s/p MI. It is for what, one day at most?

Ditto.
When a s/p MI pts BP heads for the basement they need to be treated as well. They may have less ability to compensate and therefore have a greater drop in BP. I/we hold it for all unless theyare on a small dose.

 

[jetproppilot]

this is a classic indication that ace i should be d/c'd prior to surgery if possible
infact is intractable hypotension has been described in MILLER following induction with pts on acei.
if neo or ephedrine doesnt work then try some levophed, if that doesnt work consider epi (this is ofcourse if youve already turned off all anesthetic that is causing hypotension)

On the other side of the coin, I've got a buddy who works at a busy surgery center who routinely gives just about everyone clonidine PO in the pre-op area and swears by it. Says it makes railroad-track hemodynamics intraoperatively.

 

[jetproppilot]

this is a classic indication that ace i should be d/c'd prior to surgery if possible
infact is intractable hypotension has been described in MILLER following induction with pts on acei.
if neo or ephedrine doesnt work then try some levophed, if that doesnt work consider epi (this is ofcourse if youve already turned off all anesthetic that is causing hypotension)

I never withhold ACEs, especially clonidine.

 

[Laryngospasm]

I never withhold ACEs, especially clonidine.

Uhh Jet, clonidine is a central alpha 2 agonist, with sedative properties

 

[Disse]

I never withhold ACEs, especially clonidine.

Isn't clonidine an alpha-2 agonist?

(also pre-op clonidine = poor man's precedex--nice stuff)

 

[jetproppilot]

I never withhold ACEs, especially clonidine.

Man, talk about a brain fart.

Sorry.

I was thinking Captopril and somehow clonidine entered in.

Sorry folks.

Geez....and I'm only 42...anybody have an Aricept prescription for me?

ANYWAAAYYYYYY, we don't withhold Aces. Havent seen a big problem so far, but I'm never above modification.

Mil/UT, do you guys withhold these?

 

[Annette]

I/we hold it for all unless theyare on a small dose.

But for post-MI, the dosages are usually pretty big.

Thanks for the info on the clonidine! Didn't realize it had sedative properties. Because of the frequency, I've never rx'd long term, only PRN in house.

 

[Mapleson D]

We've weaned people off of dexmedetomidine in the SICU by crossing them onto clonidine . . .

Does it work? Eh, I dunno. <shrug>