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van Diepen S, Norris CM, Zheng Y, Nagendran J, Graham MM, Gaete Ortega D, Townsend DR, Ezekowitz JA, Bagshaw SM. Comparison of Angiotensin-Converting Enzyme Inhibitor and Angiotensin Receptor Blocker Management Strategies Before Cardiac Surgery: A Pilot Randomized Controlled Registry Trial. J Am Heart Assoc 2019; 7:e009917. [PMID: 30371293 PMCID: PMC6474971 DOI: 10.1161/jaha.118.009917] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background Postoperative clinical outcomes associated with the preoperative continuation or discontinuation of angiotensin‐converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) before cardiac surgery remain unclear. Methods and Results In a single‐center, open‐label, randomized, registry‐based clinical trial, patients undergoing nonemergent cardiac surgery were assigned to ACEI/ARB continuation or discontinuation 2 days before surgery. Among the 584 patients screened, 261 met study criteria and 126 (48.3%) patients were enrolled. In total,121 patients (96% adherence; 60 to continuation and 61 to ACEI/ARB discontinuation) underwent surgery and completed the study protocol, and follow‐up was 100% complete. Postoperative intravenous vasopressor use (78.3% versus 75.4%, P=0.703), vasodilator use (71.7% versus 80.3%, P=0.265), vasoplegic shock (31.7% versus 27.9%, P=0.648), median duration of vasopressor (10 versus 5 hours, P=0.494), and vasodilator requirements (10 versus 9 hours, P=0.469) were not significantly different between the continuation and discontinuation arms. No differences were observed in the incidence of acute kidney injury (1.7% versus 1.6%, P=0.991), stroke (no events, mortality (1.7% versus 1.6%, P=0.991), median duration of mechanical ventilation (6 versus 6 hours, P=0.680), and median intensive care unit length of stay (43 versus 27 hours, P=0.420) between the treatment arms. Conclusions A randomized study evaluating the routine continuation or discontinuation of ACEIs or ARBs before cardiac surgery was feasible, and treatment assignment was not associated with differences in postoperative physiological or clinical outcomes. These preliminary findings suggest that preoperative ACEI/ARB management strategies did not affect the postoperative course of patients undergoing cardiac surgery. Clinical Trial Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT02096406.
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Affiliation(s)
- Sean van Diepen
- 1 Department of Critical Care Medicine Faculty of Medicine and Dentistry University of Alberta Edmonton Alberta Canada.,2 Division of Cardiology Department of Medicine University of Alberta Edmonton Alberta Canada.,3 Canadian VIGOUR Center University of Alberta Edmonton Alberta Canada
| | - Colleen M Norris
- 1 Department of Critical Care Medicine Faculty of Medicine and Dentistry University of Alberta Edmonton Alberta Canada.,4 Division of Cardiac Surgery University of Alberta Hospital Edmonton Alberta Canada.,5 Faculty of Nursing University of Alberta Edmonton Alberta Canada
| | - Yinggan Zheng
- 3 Canadian VIGOUR Center University of Alberta Edmonton Alberta Canada
| | - Jayan Nagendran
- 4 Division of Cardiac Surgery University of Alberta Hospital Edmonton Alberta Canada
| | - Michelle M Graham
- 2 Division of Cardiology Department of Medicine University of Alberta Edmonton Alberta Canada
| | - Damaris Gaete Ortega
- 1 Department of Critical Care Medicine Faculty of Medicine and Dentistry University of Alberta Edmonton Alberta Canada
| | - Derek R Townsend
- 1 Department of Critical Care Medicine Faculty of Medicine and Dentistry University of Alberta Edmonton Alberta Canada
| | - Justin A Ezekowitz
- 2 Division of Cardiology Department of Medicine University of Alberta Edmonton Alberta Canada.,3 Canadian VIGOUR Center University of Alberta Edmonton Alberta Canada
| | - Sean M Bagshaw
- 1 Department of Critical Care Medicine Faculty of Medicine and Dentistry University of Alberta Edmonton Alberta Canada
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Ling Q, Gu Y, Chen J, Chen Y, Shi Y, Zhao G, Zhu Q. Consequences of continuing renin angiotensin aldosterone system antagonists in the preoperative period: a systematic review and meta-analysis. BMC Anesthesiol 2018; 18:26. [PMID: 29482507 PMCID: PMC5827977 DOI: 10.1186/s12871-018-0487-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 02/06/2018] [Indexed: 01/13/2023] Open
Abstract
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 patients remains debatable. The present systematic review and meta-analysis was conducted to clarify the consequences of continuing or withholding these drugs, especially with regards to the incidence of intraoperative hypotension, in patients who continue to use ACEIs/ARBs on the day of their scheduled surgery. Methods Studies with data pertinent to the incidence of intraoperative hypotension during anesthesia use in patients who continued the use of ACEIs/ARBs on the day of their scheduled surgery were considered for inclusion. Results Thirteen studies reporting on the incidences of intraoperative hypotension between patients who continued receiving ACEIs/ARBs and those who did not on the day of their surgical procedure were included. The pooled effects showed that hypotension during anesthesia was more likely to develop in patients who continued to take ACEIs/ARBs when compared to those who did not (RR = 1.41, 95% CI: 1.21–1.64). However, there were no significant differences between these groups of patients with regards to postoperative complications including ST-T abnormalities, myocardial injury, myocardial infarction, stroke, major adverse cardiac events, acute kidney injury, or death (RR = 1.25, 95% CI: 0.76–2.04). The differences remained similar in subgroup analyses and sensitivity analyses. Conclusions No sufficient available evidence to recommend discontinuing ACEIs/ARBs on the day of surgery was found in this literature review and meta-analysis. However, anesthetists should be cautious about the risk for intraoperative hypotension in patients chronically receiving ACEIs/ARBs, and should know how to treat it effectively.
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Affiliation(s)
- Qiong Ling
- Department of Anesthesiology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou City, 510120, People's Republic of China
| | - Yu Gu
- Department of Anesthesiology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou City, Guangdong Province, 510630, People's Republic of China
| | - Jiaxin Chen
- Department of Anesthesiology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou City, Guangdong Province, 510630, People's Republic of China
| | - Yansheng Chen
- Department of Anesthesiology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou City, 510120, People's Republic of China
| | - Yongyong Shi
- Department of Anesthesiology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou City, 510120, People's Republic of China
| | - Gaofeng Zhao
- Department of Anesthesiology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou City, 510120, People's Republic of China.
| | - Qianqian Zhu
- Department of Anesthesiology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou City, Guangdong Province, 510630, People's Republic of China.
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Risk assessment and outcomes of vasoplegia after cardiac surgery. Gen Thorac Cardiovasc Surg 2017; 65:557-565. [DOI: 10.1007/s11748-017-0789-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 06/04/2017] [Indexed: 10/19/2022]
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Coleman AE, Shepard MK, Schmiedt CW, Hofmeister EH, Brown SA. Effects of orally administered enalapril on blood pressure and hemodynamic response to vasopressors during isoflurane anesthesia in healthy dogs. Vet Anaesth Analg 2016; 43:482-94. [DOI: 10.1111/vaa.12338] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2015] [Accepted: 11/19/2015] [Indexed: 11/26/2022]
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Arain SR, Freed JK, Novalija J, Pagel PS, Ebert TJ. Short-Term Angiotensin Subtype 1 Receptor Blockade Does Not Alter the Circulatory Responses to Sympathetic Nervous System Modulation in Healthy Volunteers Before and During Sevoflurane Anesthesia: Results of a Pilot Study. J Cardiothorac Vasc Anesth 2016; 30:1479-1484. [PMID: 27751762 DOI: 10.1053/j.jvca.2016.08.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The mechanism of perioperative hypotension in patients taking an angiotensin-receptor blocker up to the time of surgery remains unclear. This study tested the hypothesis that short-term angiotensin-receptor blocker treatment attenuated the sympathetic and vascular responses to autonomic stimuli in volunteers undergoing anesthesia. DESIGN Randomized, crossover, blinded, pilot design. SETTING Zablocki Veterans Affairs Medical Center, Milwaukee, WI. PARTICIPANTS The study comprised 8 male and 6 female healthy, young volunteers (age 23±1.2 years [mean±standard error of the mean]). INTERVENTIONS Volunteers were studied after receiving oral placebo or 50 mg of losartan (angiotensin-receptor blocker) for 3 days before each test day. The effectiveness of angiotensin-receptor blocker treatment was confirmed using the mean arterial blood pressure response to intravenous angiotensin II (1-µg bolus). Eight volunteers underwent direct mean arterial pressure and forearm bloodflow measurements during conscious baseline, a cold pressor test, induction of anesthesia, tracheal intubation, maintenance of anesthesia with 1 minimum alveolar concentration of sevoflurane, and airway irritation with 12% desflurane. Six volunteers experienced mean arterial pressure responses to 0.1 mg of phenylephrine at baseline and during 1 minimum alveolar concentration of sevoflurane. MEASUREMENTS AND MAIN RESULTS Comparisons were made over time and across groups. Angiotensin-receptor blocker treatment significantly reduced-mean arterial pressure and forearm vascular resistance (forearm blood flow/mean arterial pressure) over time and blocked the mean arterial pressure response to angiotensin-II challenge. The changes in mean arterial pressure and forearm vascular resistance in response to all stressors did not differ between treatments. Mean arterial pressure increases from phenylephrine were preserved. CONCLUSIONS In healthy, young volunteers, sympathetically-mediated responses from the short-term use of an angiotensin-receptor blocker were not altered and most likely did not contribute to perioperative hypotension during the intraoperative period.
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Affiliation(s)
- Shahbaz R Arain
- Anesthesia Department, Clement J. Zablocki Veterans Affairs Medical Center and the Medical College of Wisconsin, Milwaukee, WI
| | - Julie K Freed
- Anesthesia Department, Clement J. Zablocki Veterans Affairs Medical Center and the Medical College of Wisconsin, Milwaukee, WI
| | - Jutta Novalija
- Anesthesia Department, Clement J. Zablocki Veterans Affairs Medical Center and the Medical College of Wisconsin, Milwaukee, WI
| | - Paul S Pagel
- Anesthesia Department, Clement J. Zablocki Veterans Affairs Medical Center and the Medical College of Wisconsin, Milwaukee, WI
| | - Thomas J Ebert
- Anesthesia Department, Clement J. Zablocki Veterans Affairs Medical Center and the Medical College of Wisconsin, Milwaukee, WI.
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Kwak HJ, Kwak YL, Oh YJ, Shim YH, Kim SH, Hong YW. Effect of Angiotensin-converting Enzyme Inhibitors on Phenylephrine Responsiveness in Patients with Valvular Heart Disease. J Int Med Res 2016; 33:150-9. [PMID: 15790126 DOI: 10.1177/147323000503300202] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
We studied patients with valvular heart disease to investigate whether chronic pre-operative treatment with angiotensin-converting enzyme (ACE) inhibitors modulates the effect of phenylephrine (PE) on anaesthesia-induced hypotension. Sixty-five patients were enrolled in the study and hypotension developed after anaesthesia in 36 (18 in the control group and 18 in the ACE inhibitor group). These patients received PE infusions, which were increased in a stepwise fashion at 10-min intervals. Increased mean arterial pressure due to PE infusion was significant only in the control group. There was no significant difference in pressor response or change in haemodynamic variables with PE infusion between the two groups. Treatment with ACE inhibitors did not increase the incidence of hypotensive episodes or significantly modify pressor response after anaesthesia in patients with valvular heart disease.
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Affiliation(s)
- H J Kwak
- Department of Anaesthesiology and Pain Medicine, Gachon Medical School, Gil Hospital, Incheon, Korea.
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Zou Z, Yuan HB, Yang B, Xu F, Chen XY, Liu GJ, Shi XY. Perioperative angiotensin-converting enzyme inhibitors or angiotensin II type 1 receptor blockers for preventing mortality and morbidity in adults. Cochrane Database Syst Rev 2016; 2016:CD009210. [PMID: 26816003 PMCID: PMC6478100 DOI: 10.1002/14651858.cd009210.pub2] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Perioperative hypertension requires careful management. Angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II type 1 receptor blockers (ARBs) have shown efficacy in treating hypertension associated with surgery. However, there is lack of consensus about whether they can prevent mortality and morbidity. OBJECTIVES To systematically assess the benefits and harms of administration of ACEIs or ARBs perioperatively for the prevention of mortality and morbidity in adults (aged 18 years and above) undergoing any type of surgery under general anaesthesia. SEARCH METHODS We searched the current issue of the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 12), Ovid MEDLINE (1966 to 8 December 2014), EMBASE (1980 to 8 December 2014), and references of the retrieved randomized trials, meta-analyses, and systematic reviews. SELECTION CRITERIA We included randomized controlled trials (RCTs) comparing perioperative administration of ACEIs or ARBs with placebo in adults (aged 18 years and above) undergoing any type of surgery under general anaesthesia. We excluded studies in which participants underwent procedures that required local anaesthesia only, or participants who had already been on ACEIs or ARBs. DATA COLLECTION AND ANALYSIS Two review authors independently performed study selection, assessed the risk of bias, and extracted data. We used standard methodological procedures expected by Cochrane. MAIN RESULTS We included seven RCTs with a total of 571 participants in the review. Two of the seven trials involved 36 participants undergoing non-cardiac vascular surgery (infrarenal aortic surgery), and five involved 535 participants undergoing cardiac surgery, including valvular surgery, coronary artery bypass surgery, and cardiopulmonary bypass surgery. The intervention was started from 11 days to 25 minutes before surgery in six trials and during surgery in one trial. We considered all seven RCTs to carry a high risk of bias. The effects of ACEIs or ARBs on perioperative mortality and acute myocardial infarction were uncertain because the quality of the evidence was very low. The risk of death was 2.7% in the ACEIs or ARBs group and 1.6% in the placebo group (risk ratio (RR) 1.61; 95% confidence interval (CI) 0.44 to 5.85). The risk of acute myocardial infarction was 1.7% in the ACEIs or ARBs group and 3.0% in the placebo group (RR 0.55; 95% CI 0.14 to 2.26). ACEIs or ARBs may improve congestive heart failure (cardiac index) perioperatively (mean difference (MD) -0.60; 95% CI -0.70 to -0.50, very low-quality evidence). In terms of rate of complications, there was no difference in perioperative cerebrovascular complications (RR 0.48; 95% CI 0.18 to 1.28, very low-quality evidence) and hypotension (RR 1.95; 95% CI 0.86 to 4.41, very low-quality evidence). Cardiac surgery-related renal failure was not reported. ACEIs or ARBs were associated with shortened length of hospital stay (MD -0.54; 95% CI -0.93 to -0.16, P value = 0.005, very low-quality evidence). These findings should be interpreted cautiously due to likely confounding by the clinical backgrounds of the participants. ACEIs or ARBs may shorten the length of hospital stay, (MD -0.54; 95% CI -0.93 to -0.16, very low-quality evidence) Two studies reported adverse events, and there was no evidence of a difference between the ACEIs or ARBs and control groups. AUTHORS' CONCLUSIONS Overall, this review did not find evidence to support that perioperative ACEIs or ARBs can prevent mortality, morbidity, and complications (hypotension, perioperative cerebrovascular complications, and cardiac surgery-related renal failure). We found no evidence showing that the use of these drugs may reduce the rate of acute myocardial infarction. However, ACEIs or ARBs may increase cardiac output perioperatively. Due to the low and very low methodology quality, high risk of bias, and lack of power of the included studies, the true effect may be substantially different from the observed estimates. Perioperative (mainly elective cardiac surgery, according to included studies) initiation of ACEIs or ARBs therapy should be individualized.
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Affiliation(s)
- Zui Zou
- Changzheng Hospital, The Second Military Medical UniversityDepartment of AnaesthesiologyNo 415, Feng Yang RoadShanghaiChina200003
| | - Hong B Yuan
- Changzheng Hospital, The Second Military Medical UniversityDepartment of AnaesthesiologyNo 415, Feng Yang RoadShanghaiChina200003
| | - Bo Yang
- Changzheng Hospital, Second Military Medical UniversityKidney Institute of CPLA, Division of Nephrology415 Fengyang RoadShanghaiChina200003
| | - Fengying Xu
- Changzheng Hospital, The Second Military Medical UniversityDepartment of AnaesthesiologyNo 415, Feng Yang RoadShanghaiChina200003
| | - Xiao Y Chen
- The General Hospital of the People's Liberation Army (PLAGH) (also Hospital 301)Department of NeurologyNo. 28, Fuxing RoadBeijingChina100853
| | - Guan J Liu
- West China Hospital, Sichuan UniversityCochrane ChinaNo. 37, Guo Xue XiangChengduChina610041
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Twersky RS, Goel V, Narayan P, Weedon J. The Risk of Hypertension after Preoperative Discontinuation of Angiotensin-Converting Enzyme Inhibitors or Angiotensin Receptor Antagonists in Ambulatory and Same-Day Admission Patients. Anesth Analg 2014; 118:938-44. [DOI: 10.1213/ane.0000000000000076] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Kose EA, Kabul HK, Yildirim V, Tulmac M. Preoperative exercise heart rate recovery predicts intraoperative hypotension in patients undergoing noncardiac surgery. J Clin Anesth 2013; 24:471-6. [PMID: 22986319 DOI: 10.1016/j.jclinane.2012.02.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2011] [Revised: 01/31/2012] [Accepted: 02/25/2012] [Indexed: 12/19/2022]
Abstract
STUDY OBJECTIVE To assess the predictive role of heart rate (HR) recovery in the detection of intraoperative hypotension in patients undergoing noncardiac surgery. DESIGN Prospective, observational study. SETTING Department of cardiology and operating rooms of university hospitals. PATIENTS 160 ASA physical status 1 and 2 patients scheduled for elective noncardiac surgery. MEASUREMENTS All patients underwent exercise stress testing. Maximum HRs and metabolic equivalent levels were recorded. Heart rate recovery at the first, second, and third minutes were calculated by subtracting HRs one, two, and three minutes into the recovery period from the maximal HR at peak exercise. A decrease in mean arterial pressure (MAP) of greater than 30% was defined as intraoperative hypotension and recorded. Patients were classified to two groups according to whether they had intraoperative hypotension. MAIN RESULTS Hypotensive episode was observed in 31 patients (19.7%) during the operation. The presence of diabetes mellitus was higher in patients with intraoperative hypotension (22.6% vs 7.1%, P = 0.019). Mean HR recovery at the first, second, and third minutes was significantly lower in the intraoperative hypotension group (P = 0.001, P = 0.004, and P = 0.031, respectively). Heart rate recovery at the first, second, and third minutes was a good predictor of intraoperative hypotension, but only HR recovery at the first minute (OR 0.82, 95% CI 0.73 to 0.92, P = 0.001) and HR recovery at the second minute (OR, 0.90; 95% CI, 0.82 to 0.98; P = 0.019) were independent predictors of intraoperative hypotension. A higher negative correlation was noted between the degree of MAP reduction and HR recovery at the first minute (r = -0.797, P = 0.001). CONCLUSIONS Abnormal preoperative exercise HR recovery predicts intraoperative hypotension in patients undergoing noncardiac surgery. Given the importance of intraoperative hypotension, preoperative use of exercise testing might be considered.
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Affiliation(s)
- Emine Arzu Kose
- Department of Anesthesiology and Reanimation, Kirikkale University, School of Medicine, 71100 Kirikkale, Turkey.
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Mets B. Management of Hypotension Associated With Angiotensin-Axis Blockade and General Anesthesia Administration. J Cardiothorac Vasc Anesth 2013; 27:156-67. [DOI: 10.1053/j.jvca.2012.06.014] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2012] [Indexed: 11/11/2022]
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Transfusion Increases the Risk for Vasoplegia After Cardiac Operations. Ann Thorac Surg 2011; 92:812-9. [DOI: 10.1016/j.athoracsur.2011.04.020] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2011] [Revised: 03/31/2011] [Accepted: 04/04/2011] [Indexed: 11/18/2022]
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Zou Z, Yuan HB, Chen XY, Liu GJ, Shi XY. Perioperative angiotensin-converting enzyme inhibitors or angiotensin II type 1 receptor blockers for preventing surgery-related mortality and morbidity. Cochrane Database Syst Rev 2011. [DOI: 10.1002/14651858.cd009210] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Beta-blockers, calcium channel blockers, angiotensin converting enzyme inhibitors and angiotensin receptor blockers: should they be stopped or not before ambulatory anaesthesia? Curr Opin Anaesthesiol 2011; 23:687-90. [PMID: 20805745 DOI: 10.1097/aco.0b013e32833eeb19] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW As day surgery continues to expand, more patients will be encountered who are chronically taking a range of cardiovascular medications for the management of hypertension and ischaemic heart disease. This review will consider the available evidence relating to whether or not these medications should be continued throughout the perioperative period in ambulatory surgical patients. RECENT FINDINGS There has been relatively little research in this area which is specific to ambulatory surgery and much of the available evidence from major surgery has been assembled over the many years that these medications have been in use. In order to provide a comprehensive and balanced review, we have considered relevant evidence outside of the usual review period. SUMMARY Patients should continue to take beta-blockers and calcium channel blockers on the day of surgery. Continuing angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers increases the likelihood of intraoperative hypotension. This can be reduced by withholding these drugs, but will also respond to simple treatments without any apparent adverse outcomes. It may therefore simplify instructions to patients if they are told to take all cardiac medications as normal.
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Weisenberg M, Sessler DI, Tavdi M, Gleb M, Ezri T, Dalton JE, Protianov M, Zimlichmann R. Dose-dependent hemodynamic effects of propofol induction following brotizolam premedication in hypertensive patients taking angiotensin-converting enzyme inhibitors. J Clin Anesth 2010; 22:190-5. [DOI: 10.1016/j.jclinane.2009.07.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2009] [Revised: 06/23/2009] [Accepted: 07/04/2009] [Indexed: 11/17/2022]
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Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof EL, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF. 2009 ACCF/AHA focused update on perioperative beta blockade incorporated into the ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery. J Am Coll Cardiol 2009; 54:e13-e118. [PMID: 19926002 DOI: 10.1016/j.jacc.2009.07.010] [Citation(s) in RCA: 232] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof EL, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF. 2009 ACCF/AHA Focused Update on Perioperative Beta Blockade Incorporated Into the ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery. Circulation 2009; 120:e169-276. [PMID: 19884473 DOI: 10.1161/circulationaha.109.192690] [Citation(s) in RCA: 209] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Sierra P, Galcerán JM, Sabaté S, Martínez-Amenós A, Castaño J, Gil A. [Hypertension and anesthesia: consensus statement of the Catalan Associations of Anesthesiology and Hypertension]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2009; 56:493-502. [PMID: 19994618 DOI: 10.1016/s0034-9356(09)70440-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
The prevalence of hypertension is high in the surgical population. Differing practices and the absence of consensus among physicians involved in caring for hypertensive patients has made it one of the most frequent reasons for cancelling scheduled surgery. The aim of this consensus statement is to outline a practical approach to managing the hypertensive surgical patient. Hypertension is associated with increased risk of perioperative complications, particularly those related to systemic effects and notable fluctuations in blood pressure during surgery. Preoperative assessment should center on a search for signs and symptoms of target organ damage. The anesthesiologist should seek to reduce perioperative fluctuations in arterial pressure, particularly guarding against sustained hypotension. After surgery, antihypertensive medication should be resumed as soon as possible.
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Affiliation(s)
- P Sierra
- Servicio de Anestesiología y Reanimación, Fundación Puigvert, Barcelona.
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Documento de consenso sobre hipertensión arterial y anestesia de las Sociedades Catalanas de Anestesiología e Hipertensión Arterial. HIPERTENSION Y RIESGO VASCULAR 2009. [DOI: 10.1016/j.hipert.2009.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Piriou V. Prise en charge des patients à risque coronaire avant une anesthésie. Presse Med 2009; 38:1110-9. [DOI: 10.1016/j.lpm.2008.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2008] [Revised: 07/24/2008] [Accepted: 08/27/2008] [Indexed: 10/20/2022] Open
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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; 22:180-6. [DOI: 10.1053/j.jvca.2007.12.020] [Citation(s) in RCA: 105] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2007] [Indexed: 11/11/2022]
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Mittnacht AJC, Fanshawe M, Konstadt S. Anesthetic Considerations in the Patient With Valvular Heart Disease Undergoing Noncardiac Surgery. Semin Cardiothorac Vasc Anesth 2008; 12:33-59. [DOI: 10.1177/1089253208316442] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Valvular heart disease can be an important finding in patients presenting for noncardiac surgery. Valvular heart disease and resulting comorbidity, such as heart failure or atrial fibrillation, significantly increase the risk for perioperative adverse events. Appropriate preoperative assessment, adequate perioperative monitoring, and early intervention, should hemodynamic disturbances occur, may help prevent adverse events and improve patient outcome. This review article aims to guide the practitioner in the various aspects of anesthetic management in the perioperative care of patients with valvular heart disease. The pharmacological approach to optimization of patient outcome with drugs, such as βblockers and lipid-lowering medications (statins), is an evolving field, and recent developments are discussed in this article.
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Affiliation(s)
| | | | - Steven Konstadt
- Department of Anesthesiology, Maimonides Medical Center, Brooklyn New York
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Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof EL, Chaikof E, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Buller CE, Creager MA, Ettinger SM, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Nishimura R, Ornato JP, Page RL, Riegel B, Tarkington LG, Yancy CW. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) Developed in Collaboration With the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. J Am Coll Cardiol 2007; 50:e159-241. [PMID: 17950159 DOI: 10.1016/j.jacc.2007.09.003] [Citation(s) in RCA: 257] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Buller CE, Creager MA, Ettinger SM, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Nishimura R, Ornato JP, Page RL, Tarkington LG, Yancy CW. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery. Circulation 2007; 116:e418-99. [PMID: 17901357 DOI: 10.1161/circulationaha.107.185699] [Citation(s) in RCA: 377] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Abstract
INTRODUCTION The discussion about perioperative withdrawal or continuation of angiotensin-converting enzyme inhibitors (ACEI) remains controversial. Should it be continued to avoid peaks in blood pressure and heart rate during anesthesia? Or should it be discontinued the day before to avoid clinically relevant hypotonia? What is the greater risk? Since there are only a few studies dealing with this question, we compared the cardio-circulatory reaction during anesthesia after withdrawal and with continuation of ACEI therapy. METHODS A total of 100 hypertonic patients chronically treated with ACEIs were included in this prospective, randomized, double blind study. The last ACEI medication was given with the premedication in the morning (premed) or on the day before (withdrawal). Blood pressure and heart rate during induction and termination of anesthesia were compared between both groups. A threshold value for vasopressor therapy was determined to be a mean arterial pressure of 60 mmHg. RESULTS In the premed group Akrinor was necessary significantly more often and in higher dosages. Nevertheless, following induction the blood pressure and heart rates were significantly lower compared to the withdrawal group. The highest blood pressure and heart rate during induction and termination of anesthesia did not differ between the groups. CONCLUSIONS The continuation of ACEI therapy in the morning is not associated with a better control of blood pressure and heart rate but causes a more pronounced hypotension which forced a therapy more often. Patients chronically treated with ACEI should receive the ACEI the last time on the day before the operation and not with the premedication in the morning.
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Affiliation(s)
- U Schirmer
- Abteilung Kardioanästhesiologie, Universitätsklinikum Ulm, Steinhövelstr. 9, 89075, Ulm.
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Huang CJ, Kuok CH, Kuo TBJ, Hsu YW, Tsai PS. Pre-operative measurement of heart rate variability predicts hypotension during general anesthesia. Acta Anaesthesiol Scand 2006; 50:542-8. [PMID: 16643221 DOI: 10.1111/j.1399-6576.2006.001016.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Peri-operative hymodynamic instability is one of the major concerns for anesthesiologists when performing general anesthesia for individuals with autonomic dysfunction. The purpose of this study was to examine the potential usage of pre-operative measurement of heart rate variability (HRV) in identifying which individuals, with or without diabetes, may be at risk of blood pressure (BP) instability during general anesthesia. METHODS We studied 46 patients with diabetes and 87 patients without diabetes ASA class II or III undergoing elective surgery. Participants' cardiovascular autonomic function and HRV were assessed pre-operatively, and hymodynamic parameters were monitored continuously intra-operatively by an independent observer. RESULTS Only 6% of the participants were classified as having cardiovascular autonomic neuropathy (CAN) based on traditional autonomic function tests whereas 15% experienced hypotension. Total power (TP, P = 0.006), low frequency (LF, P = 0.012) and high frequency (HF, P = 0.028) were significantly lower in individuals who experienced hypotension compared with those who did not. Multivariate logistic regression analysis revealed that TP [odds ratio (OR) = 0.15, 95% confidence interval (CI) = 0.05-0.47, P = 0.001] independently predicted the incidence of hypotension, indicating that each log ms2 increase in total HRV lowers the incidence of hypotension during general anesthesia by 0.15 times. After stepwise multiple linear regression analysis (R2= 11.5%), HF (beta = -11.1, SE = 2.79, P < 0.001) was the only independent determinant of the magnitude of systolic blood pressure (SBP) reduction at the 15th min after tracheal intubation. CONCLUSIONS Spectral analysis of HRV is a sensitive method for detecting individuals who may be at risk of BP instability during general anesthesia but may not have apparent CAN according to traditional tests of autonomic function.
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Affiliation(s)
- C-J Huang
- Department of Anesthesiology, Mackay Memorial Hospital, Taipei, Taiwan
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Knüttgen D, Trojan S, Weber M, Wolf M, Wappler F. Präoperative Bestimmung der Herzfrequenzvariabilität bei Diabetikern zur Einschätzung des Blutdruckverhaltens während der Anästhesieeinleitung. Anaesthesist 2005; 54:442-9. [PMID: 15778806 DOI: 10.1007/s00101-005-0837-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND In diabetics severe hyopotension can occur during anaesthesia as a consequence of cardiovascular autonomic neuropathy (CAN). A simple approach to recognize CAN is heart rate variability (HRV) measured at rest. The aim of this study was to determine the relationship between pre-operatively measured HRV and blood pressure stability during induction phase of anaesthesia. PATIENTS AND METHODS A total of 35 diabetics undergoing an ophthalmosurgical procedure under general anaesthesia were investigated. HRV was examined one day before surgery by the following parameters: coefficient of variation (CV), root mean squared successive difference (RMSSD), and power spectrum. Anaesthesia was induced with thiopental and fentanyl and maintained with enflurane/N(2)O; tracheal intubation was performed after relaxation with vecuronium. Patients who developed a drop in systolic blood pressure below 90 mmHg during anaesthesia induction were assigned to group H (hypotensive), the other patients to group N (normotensive). The groups were compared regarding HRV and other variables. RESULTS Of all patients 13 developed hypotension during anaesthesia induction (group H). The groups were comparable regarding the demographic data. Parameters of HRV, with the exception of spectral power in low frequency (LF) band of power spectrum, were significantly lower in group H. The groups differed mainly in relation to spectral power in the mid-frequency (MF) band of the power spectrum, and especially regarding CV. In patients with normal CV incidence of hypotension after anaesthesia induction was 11%, but in patients with abnormally reduced CV, 65% (p=0.002). CONCLUSION The results confirm a significant relationship between HRV pre-operatively measured at rest and blood pressure stability during anaesthesia induction in diabetics. Particularly examination of CV, a simple test feasible within few minutes, may be useful in pre-operative risk stratification of these patients. Application of the time consuming traditional test combination to identify CAN seems to be unnecessary.
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Affiliation(s)
- D Knüttgen
- Klinik für Anästhesiologie, Universität Witten/Herdecke, Lehrstuhl für Anästhesiologie II, Krankenhaus Köln-Merheim
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Comfere T, Sprung J, Kumar MM, Draper M, Wilson DP, Williams BA, Danielson DR, Liedl L, Warner DO. Angiotensin System Inhibitors in a General Surgical Population. Anesth Analg 2005; 100:636-644. [PMID: 15728043 DOI: 10.1213/01.ane.0000146521.68059.a1] [Citation(s) in RCA: 144] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We studied the relationship between the timing of discontinuing chronic angiotensin-converting enzyme inhibitors (ACEI) and angiotensin II receptor subtype 1 antagonists (ARA) and hypotension after the induction of general anesthesia in a general surgical population. We retrospectively studied 267 hypertensive patients receiving chronic ACEI/ARA therapy undergoing elective noncardiac surgery under general anesthesia. During preoperative visits, patients were asked to either take their last ACEI/ARA therapy on the morning of surgery or withhold it up to 24 h before surgery. The number of hours from the last ACEI/ARA dose to surgery was recorded during the preoperative interview. Electronic medical and anesthesia records were reviewed for comorbidities, type and dose of anesthetics used, intraoperative hemodynamics, IV fluids, perioperative vasopressor administration, and rate of severe postoperative complications. Arterial blood pressure (BP) and heart rate were recorded during the 60-min postinduction period, and hypotension was classified as moderate (systolic BP <or=85 mm Hg) and severe (systolic BP <or=65 mm Hg). We analyzed all variables separately for patients who took their last ACEI/ARA therapy <10 h and >or=10 h before surgery. During the first 30 min after anesthetic induction, moderate hypotension was more frequent in patients whose most recent ACEI/ARA therapy was taken <10 h (60%) compared with those who stopped it >or=10 h (46%) before induction (P = 0.02). The adjusted odds ratio for moderate hypotension was 1.74 (95% confidence interval, 1.03-2.93) for those who took their ACEI/ARA therapy <10 h before surgery (P = 0.04). There were no differences between groups in the incidence of severe hypotension, nor was there a difference in the use of vasopressors. During the 31-60 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.
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Affiliation(s)
- Thomas Comfere
- *Department of Anesthesiology and †Division of Biostatistics, Mayo Clinic College of Medicine, Rochester, Minnesota
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Uusitalo ALT, Laitinen T, Väisänen SB, Länsimies E, Rauramaa R. Physical training and heart rate and blood pressure variability: a 5-yr randomized trial. Am J Physiol Heart Circ Physiol 2004; 286:H1821-6. [PMID: 14726297 DOI: 10.1152/ajpheart.00600.2003] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
We studied the effect of regular physical activity on cardiac and vascular autonomic modulation during a 5-yr controlled randomized training intervention in a representative sample of older Finnish men. Heart rate variability (HRV) and blood pressure variability (BPV) are markers of cardiac and vascular health, reflecting cardiac and vascular autonomic modulation. One hundred and forty randomly selected 53- to 63-yr-old men were randomized into two identical groups: an intervention (EX) group and a reference (CO) group, of which 89 men remained until the final analysis (EX: n = 47; CO: n = 42). The EX group trained for 30–60 min three to five times a week with an intensity of 40–60% of maximal oxygen consumption. The mean weekly energy expenditure of the training program for the 5-yr training period was 3.80 MJ, and 71% of the EX group exceeded the mean. The EX group had a significantly ( P < 0.01) higher oxygen consumption at ventilatory aerobic threshold (V̇o2VT) than the CO group at the 5-yr time point. V̇o2VT had a tendency to increase in the EX group and decrease in the CO group (interaction P < 0.001) from the baseline to the 5-yr time point. Peak performance did not change. Low-frequency power of R-R interval variability decreased in the EX group ( P < 0.01, by 6%) from the baseline to the 5-yr time point. BPV did not change. In conclusion, low-intensity regular exercise training did not prevent HRV from decreasing or change BPV in 5 yr in older Finnish men.
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Affiliation(s)
- Arja L T Uusitalo
- Department of Clinical Physiology and Nuclear Medicine, Kuopio University Hospital, 70211 Kuopio, Finland.
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Licker M, Spiliopoulos A, Tschopp JM. Influence of thoracic epidural analgesia on cardiovascular autonomic control after thoracic surgery. Br J Anaesth 2003; 91:525-31. [PMID: 14504154 DOI: 10.1093/bja/aeg212] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Thoracic epidural analgesia (TEA) is effective in alleviating pain after major thoracoabdominal surgery and may also reduce postoperative mortality and morbidity. This study investigated cardiovascular autonomic control in patients undergoing elective thoracic surgery and its modulation by continuous TEA. METHODS Thirty-eight patients were randomly assigned to receive patient-controlled analgesia (PCA group) or thoracic epidural analgesia (TEA group) with doses of bupivacaine (0.25% during operation, 0.125% after operation) and fentanyl (2 microg ml(-1)). Heart rate variability (HRV), baroreflex function and pressure response to nitroglycerine and phenylephrine were assessed before operation, 4 h after the end of surgery (POD 0) and on the first and second postoperative days (POD 1 and POD 2). RESULTS Early after surgery, all HRV variables and baroreflex sensitivities were markedly decreased in both groups. In the TEA group, total HRV and its high-frequency components (HF) increased towards preoperative values at POD 1 and POD 2, whereas the ratio of low to high frequencies (LF/HF) was significantly reduced (mean (SD), -44 (15)% at POD 0, -38 (17)% at POD 1, -37 (18%) at POD 2) and associated with blunting of the postoperative increase in heart rate and blood pressure. In the PCA group, the ratio of LF/HF remained unchanged and the decrements in HRV variables persisted until POD 2. In the two groups, baroreflex sensitivities and pressure responses recovered preoperative values at POD 2. CONCLUSIONS In contrast with PCA management, TEA using low concentrations of bupivacaine and fentanyl blunted cardiac sympathetic neural drive, resulting in vagal predominance, while HRV variables were better restored after surgery.
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Affiliation(s)
- M Licker
- Division of Anaesthesia and Unit of Thoracic Surgery, University Hospital, rue Micheli du-Crest, CH-1211 Geneva 14, Switzerland.
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Abstract
Typically, old patients scheduled to undergo a surgical procedure take many medications for various disorders. The anaesthetist must consider the benefits and/or risks of continuation or withdrawal of such chronic medications. This chapter reviews these issues in respect of cardiovascular drugs (calcium channel blockers, beta adrenoreceptor antagonists, angiotensin-converting enzyme inhibitors and angiotensin receptor antagonists) and of psychotropic and antiparkinson medications and insulin. Focus is put on the few scientific studies available and on the recommendations given by experts in the field.
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Affiliation(s)
- Thomas Bruessel
- Department of Anaesthesia and Pain Management, Canberra Clinical School, University of Sydney, The Canberra Hospital, Yamba Drive, Garran ACT 2605, Australia.
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Abstract
This article focuses on new findings leading to improved understanding of the pathophysiology and mechanisms of potential drug interactions between anesthetic drugs or techniques and cardiovascular medications in patients scheduled for surgery. Only the most frequently used drugs are reviewed. Elective surgery provides the luxury to consider these risks and alter therapy accordingly. Under urgent circumstances, however, the increased risks associated with these agents should be anticipated with the goal to minimize adverse effects while maintaining optimal cardiovascular function in the perioperative period.
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Affiliation(s)
- Sheldon Goldstein
- Division of Cardiac Anesthesia, Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
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Uusitalo ALT, Laitinen T, Väisänen SB, Länsimies E, Rauramaa R. Effects of endurance training on heart rate and blood pressure variability. Clin Physiol Funct Imaging 2002; 22:173-9. [PMID: 12076342 DOI: 10.1046/j.1475-097x.2002.00414.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To study the influences of a 1-year controlled, randomized endurance exercise training period on heart rate (HR) and blood pressure variability in a representative sample of Finnish men in their late middle age. METHODS AND RESULTS Subjects were 140 sedentary men aged 53-63 years. The men were randomized into two identical groups: an intervention (EX) and a reference (CO) group. One hundred and twelve of them remained in the final analysis (EX: n=59, CO: n=53). EX trained for 30-60 min three to five times a week with the intensity of 40-60% of maximal oxygen consumption. In EX, 1 year of regular exercise training increased oxygen consumption at respiratory compensation threshold by 11% (P < or = 0.001) in a maximal cardiorespiratory test. Total power and very low frequency power of R-R interval variability (ms2) tended to increase in the EX group by 26 and 42% and to decrease in the CO group by 13 and 10% (interaction P<0.05 and P<0.01), respectively. There were no significant changes in blood pressure variability. CONCLUSION Regular low- to moderate-intensity exercise training could retard the declining tendency in cardiac autonomic nervous function in older men during 1 year.
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Affiliation(s)
- Arja L T Uusitalo
- Department of Clinical Physiology and Nuclear Medicine, Kuopio University Hospital, Kuopio, Finland.
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Meersschaert K, Brun L, Gourdin M, Mouren S, Bertrand M, Riou B, Coriat P. Terlipressin-ephedrine versus ephedrine to treat hypotension at the induction of anesthesia in patients chronically treated with angiotensin converting-enzyme inhibitors: a prospective, randomized, double-blinded, crossover study. Anesth Analg 2002; 94:835-40, table of contents. [PMID: 11916781 DOI: 10.1097/00000539-200204000-00011] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
UNLABELLED In patients chronically treated with angiotensin converting-enzyme inhibitors (ACEI), typically selected doses of ephedrine do not always restore arterial blood pressure when anesthesia-induced hypotension occurs. We postulated that the administration of terlipressin, an agonist of the vasopressin system, with ephedrine more effectively restores pressure in this setting than the administration of ephedrine alone. This prospective, randomized, cross-over, double-blinded study compared terlipressin combined with ephedrine (n = 19) with ephedrine alone (n = 21) in treating hypotension at the induction of anesthesia in 40 ACEI-treated patients undergoing hypotension (mean arterial blood pressure [MAP] <65 mm Hg or <30% of baseline value) after standardized anesthetic protocol (target-controlled IV anesthesia with propofol). Data are mean +/- SD. Patient characteristics, MAP, and heart rate before and after the induction of anesthesia during hypotensive episodes were not significantly different between the two groups. After the first bolus, MAP was significantly greater in the Terlipressin-Ephedrine group (72 +/- 12 mm Hg versus 65 +/- 8 mm Hg, P < 0.05). The occurrence of a second hypotensive episode (5% versus 71%, P < 0.001), the duration (2 +/- 1 min versus 3 +/- 1 min, P < 0.01) of hypotensive episodes, and the median dose of ephedrine (3 versus 6 mg, P < 0.05) were significantly less in the Terlipressin-Ephedrine group. In conclusion, terlipressin combined with ephedrine is more effective than ephedrine alone for treating anesthesia-induced hypotension in ACEI-treated patients. We conclude that this patient population with a partially blocked endogenous response to hypotension may be good candidates for successful use of a vasopressin analog to counteract intraoperative refractory hypotension. IMPLICATIONS Vascular surgical patients chronically treated with drugs that inhibit the functioning of the renin-angiotensin system may experience hypotension unresponsive to conventional therapy. This double-blinded, cross-over study demonstrated that in these patients the use of a vasopressin analog, terlipressin given with ephedrine, was effective in reversing intraoperative systemic hypotension refractory to ephedrine.
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Affiliation(s)
- Karoline Meersschaert
- Department of Anesthesiology and Critical Care, Centre Hospitalier Universitaire Pitié-Salpétrière, Assistance-Publique-Hôpitaux de Paris, Pierre et Marie Curie University, Paris, France
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