Prolonged Washout Period for Avoiding Azilsartan-Induced Refractory Hypotension During General Anesthesia for a Patient With Renal Impairment

2021 ◽  
Vol 68 (4) ◽  
pp. 220-223
Author(s):  
Takayuki Hojo ◽  
Yukifumi Kimura ◽  
Keiji Hashimoto ◽  
Takahito Teshirogi ◽  
Toshiaki Fujisawa

Angiotensin receptor blockers (ARBs) are widely used to treat hypertension, but severe refractory hypotension during general anesthesia is a well-known complication associated with the continuation of ARBs during the perioperative period. It has therefore been recommended that ARBs be withheld for 24 hours before induction of general anesthesia. However, impaired renal function affects the pharmacokinetics of each ARB differently. The half-life of azilsartan is prolonged in accordance with the degree of renal impairment. Herein, we describe a patient with chronic kidney disease grade 3B who experienced severe refractory hypotension after induction of general anesthesia requiring administration of dopamine following inadequate responses to ephedrine and phenylephrine despite a 24-hour azilsartan washout period. When the same patient underwent general anesthesia for a subsequent surgery, azilsartan was withheld for 48 hours before induction, resulting in mild intraoperative hypotension that responded adequately to phenylephrine. Severe refractory hypotension during general anesthesia cannot always be avoided by holding azilsartan for 24 hours in patients with significant renal impairment. Therefore, a longer washout period may be preferable for patients regularly taking azilsartan who also have concurrent substantial renal impairment.

F1000Research ◽  
2013 ◽  
Vol 2 ◽  
pp. 12 ◽  
Author(s):  
Raha Nabbi ◽  
Harvey J Woehlck ◽  
Matthias L Riess

Due to their beneficial reduction in morbidity and mortality angiotensin receptor blockers (ARBs) have become increasingly popular to treat hypertension. However, similar to angiotensin converting enzyme inhibitors, they can lead to severe hypotension in conjunction with general anesthesia and thus have been recommended to be withheld in the morning of surgery. Here, we present a 51 year old female who developed severe refractory hypotension after induction of general anesthesia, although she had discontinued her medication 24 hours preoperatively as instructed. Therefore, halting ARBs for more than 24 hours before surgery may be necessary. Heightened awareness of this potential interaction and recognizing the need to treat with vasopressin is required when ARB-induced hypotension occurs.


2020 ◽  
Vol 67 (2) ◽  
pp. 86-89
Author(s):  
Takayuki Hojo ◽  
Makiko Shibuya ◽  
Yukifumi Kimura ◽  
Yuki Otsuka ◽  
Toshiaki Fujisawa

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 be withheld for 24 hours prior to the induction of anesthesia. This is a case report of refractory hypotension requiring the administration of potent vasopressors after the induction of general anesthesia despite withholding telmisartan for 24 hours. In the same patient undergoing a subsequent general anesthetic, telmisartan was withheld for 5 days before induction, leading to mild intraoperative hypotension that responded adequately to phenylephrine. The primary cause of refractory hypotension during the first general anesthetic was suspected to be an insufficient telmisartan washout period. Telmisartan's half-life of 24 hours is notably the longest of all ARBs in current use. This case report demonstrates that refractory hypotension during general anesthesia cannot always be avoided by withholding telmisartan for 24 hours before the induction of anesthesia. Therefore, a washout period greater than 24 hours is preferable for patients taking telmisartan.


PeerJ ◽  
2018 ◽  
Vol 6 ◽  
pp. e5061 ◽  
Author(s):  
Sophie L.M. Walker ◽  
Tom E.F. Abbott ◽  
Katherine Brown ◽  
Rupert M. Pearse ◽  
Gareth L. Ackland

Background Angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARB) are the most commonly prescribed antihypertensive medications in higher-risk surgical patients. However, there is no clinical consensus on their use in the perioperative period, in part, due to an inconsistent evidence-base. To help inform the design of a large multi-centre randomized controlled trial (ISRCTN17251494), we undertook a questionnaire-based survey exploring variability in ACEi/ARB prescribing in perioperative practice. Methods The online survey included perioperative scenarios to examine how consistent respondents were with their stated routine preoperative practice. Clinicians with an academic interest in perioperative medicine were primarily targeted between July and September 2017. STROBE guidelines for observational research and ANZCA Trials Group Survey Reporting recommendations were adhered to. Results 194 responses were received, primarily from clinicians practicing in the UK. A similar minority of respondents continue ACEi (n = 57; 30%) and ARBs (n = 62; 32%) throughout the perioperative period. However, timing of preoperative cessation was highly variable, and rarely influenced by the pharmacokinetics of individual ACE-i/ARBs. Respondents’ stated routine practice was frequently misaligned with their management of common pre- and postoperative scenarios involving continuation or restarting ACE-i/ARBs. Discussion This survey highlights many inconsistencies amongst clinicians’ practice in perioperative ACE-i/ARB management. Studies designed to reveal an enhanced understanding of perioperative mechanisms at play, coupled with randomised controlled trials, are required to rationally inform the clinical management of ACE-i/ARBs in patients most at risk of postoperative morbidity.


2016 ◽  
Vol 17 (7) ◽  
pp. 681-691 ◽  
Author(s):  
Ruirui Yang ◽  
Zhiqiang Luo ◽  
Yang Liu ◽  
Mohan Sun ◽  
Ling Zheng ◽  
...  

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