oRIGINAl PAPERS - Advances in Clinical and Experimental Medicine

oRIGINAl PAPERS - Advances in Clinical and Experimental Medicine

original papers
Adv Clin Exp Med 2010, 19, 3, 329–336
ISSN 1230-025X
© Copyright by Wroclaw Medical University
Małgorzata Malinowska-Zaprzałka1, Marzena Wojewódzka-Żelezniakowicz2,
Jerzy R. Ładny2, Ewa Chabielska3
The Influence of Chronic and Short-Term Treatment
with Angiotensin-Converting Enzyme Inhibitor
on Hemodynamics During Induction
of General Anesthesia in Patients Undergoing
Maxillofacial Surgery*
Wpływ inhibitora – konwertazy angiotensyny stosowanego
w przewlekłej i krótkotrwałej terapii na wybrane wskaźniki
hemodynamiczne podczas wprowadzenia do znieczulenia ogólnego
pacjentów poddanych zabiegom naprawczym po urazach twarzoczaszki
Department of Anaesthesiology and Intensive Care, Medical University of Bialystok, Poland
Department of Emergency and Disaster Medicine, Medical University of Bialystok, Poland
3
Biopharmacy Department, Medical University of Bialystok, Poland
1
2
Abstract
Background. There is still no agreement whether antihypertensive treatment with ACE-I should be continued
until the day of surgery because of risk of perioperative hypotension. Moreover, non-treated hypertension is also
a major risk of complications during anesthesia, especially ischaemic episodes.
Objectives. The aim of the study was to compare short-term versus chronic treatment effects of ACE-I enalapril on
some hemodynamic (blood pressure and heart rate) parameters during the induction of general anesthesia.
Material and Methods. The authors compared systolic and diastolic blood pressure as well as heart rate during
induction in three groups of patients (n = 152) scheduled for maxillofacial trauma surgery. Group A (n = 48) was
chronically treated with ACE-I enalapril, group B (n = 54) received short term treatment. Group C (50) consisted
of normotensive patients.
Results. The authors have determined that short-term (3–4 doses) treatment of patients with moderate hypertension not previously treated with enalapril allows the successful reduction of high systolic and diastolic blood
pressures (SBP) – from 174 ± 18 to 148 ± 13 mm Hg and DBP from 112 ± 11 to 83 ± 14 mm Hg – until the day of
surgery and induces lower values of systolic blood pressure (SBP) during the induction period of general anesthesia
than does chronic treatment. The authors also confirmed the mild hypotensive effect of induction of anesthesia in
patients chronically (for at least 6 months) treated with enalapril.
Conclusions. These findings suggest that interruption of treatment before anesthesia is not necessary in hypertensive chronic ACE-I treated patients. Short-term treatment with ACE-I in hypertensive patients allows the successful reduction of high blood pressure and improves the level of safety during induction of anesthesia for maxillofacial trauma surgery (Adv Clin Exp Med 2010, 19, 3, 329–336).
Key words: general anesthesia, ACE-I, hemodynamic response.
Streszczenie
Wprowadzenie. Wiele kontrowersji budzi kontynuowanie leczenia nadciśnienia tętniczego inhibitorami konwertazy angiotensyny (ACE-I) do dnia zabiegu chirurgicznego z uwagi na niebezpieczeństwo okołooperacyjnego spad* This work was supported by a grant from the Polish Committee for Science Research 2PO5F 029 30.
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M. Malinowska-Zaprzałka et al.
ku ciśnienia tętniczego. Nieleczone nadciśnienie tętnicze stanowi natomiast poważne ryzyko powikłań podczas
znieczulenia ogólnego, co może prowadzić do epizodów niedokrwienia mięśnia sercowego.
Cel pracy. Porównanie wpływu enalaprylu stosowanego w przewlekłej i krótkotrwałej terapii na niektóre wskaźniki
hemodynamiczne (ciśnienie tętnicze i czynność serca) podczas wprowadzenia do znieczulenia ogólnego.
Materiał i metody. Badaniami objęto 152 pacjentów poddanych zabiegom naprawczym po urazach twarzoczaszki.
Oceniano wartości skurczowego i rozkurczowego ciśnienia tętniczego oraz częstość akcji serca w trzech grupach
chorych podczas wprowadzenia do znieczulenia. Grupę A (n = 48) stanowili pacjenci z przewlekle leczonym nadciśnieniem, grupę B (n = 54) chorzy leczeni krótkotrwale (3–4 dawki), a grupę kontrolną (n = 50) stanowili pacjenci
z prawidłowym ciśnieniem tętniczym.
Wyniki. Wykazano, że krótkotrwałe leczenie enalaprylem umiarkowanego nadciśnienia tętniczego pozwala skutecznie obniżyć zarówno skurczowe (174 ± 18 vs 148 ± 13 mm Hg), jak i rozkurczowe (112 ± 11 vs 83 ± 14 mm Hg)
ciśnienie tętnicze oraz wywołuje niższe wartości ciśnienia podczas wprowadzenia do znieczulenia niż w grupie
chorych leczonych przewlekle. Potwierdzono także umiarkowane działanie hipotensyjne ACE-I podczas wprowadzenia do znieczulenia ogólnego w grupie pacjentów leczonych przewlekle.
Wnioski. Wyniki sugerują, że przerwanie leczenia ACE-I pacjentów z nadciśnieniem nie jest konieczne przed
zabiegiem chirurgicznym naprawczym po urazach twarzoczaszki. Już krótkotrwałe przygotowanie tymi lekami
pacjentów z umiarkowanym nadciśnieniem pozwala obniżyć jego wartości w dniu zabiegu chirurgicznego i podczas znieczulenia do zabiegów naprawczych po urazach twarzoczaszki, poprawiając bezpieczeństwo pacjenta (Adv
Clin Exp Med 2010, 19, 3, 329–336).
Słowa kluczowe: znieczulenie ogólne, ACE-I, odpowiedź hemodynamiczna.
Hypertension in patients undergoing anesthesia
and surgery is considered to be a major risk determinant of complications during anesthesia and the
post-anesthetic period. Among the complications,
myocardial ischemia and stroke are mentioned more
than others. Although the magnitude of the risk
remains controversial [1], it is always a warning for
the anesthesiologist. It has often been concluded that
hypertensive patients should rather undergo surgery
with well-controlled blood pressure [2]. Therefore,
to avoid undesired events during anesthesia in such
patients, efforts have been made to provide such control in as smooth a manner as possible.
General anesthesia interferes with many cardiovascular regulating systems [3]. First, most
inhaled and intravenous anesthetics are known to
dull sympathetic reflexes which, in patients with
limited cardiovascular reserve, may lead to myocardial depression [4]. Secondly there are data
that general anesthesia may increase the release of
arginin-vasopressin (AVP) and the formation of
angiotensin II [3]. Inhalation anesthesia and surgical stress themselves have widely been shown to the
activate renin-angiotensin system (RAS) [5–7].
Many authors have focused on the preanesthetic
status of patients. Routinely, antihypertensive treatment is continued until the day of surgery. It is suggested, that this treatment, influencing the anesthesia, minimizes the hypertensive response to intubation [7]. Nowadays, the opinion is rising suggesting
the discontinuation of such treatment as a method
for avoiding hypotensive episodes in hypertensive
patients [8–10]. This is of great importance especially when angiotensin – converting enzyme inhibitors
(ACE-I) are concerned. As this group of drugs is the
most widely used in the treatment of hypertension
[11], the authors can also expect an increasing num-
ber of ACE-I-treated patients in the operation room
[12]. However, some authors warn of profound
hypotension in patients treated with enalapril or
captopril occurring during induction of anesthesia
[4, 6, 13], and there are no data comparing the effect
of new ACE-I during induction.
There is very little data concerning the influence of ACE-I given as a short-term mode during
the induction period of anesthesia [3, 5, 13] and
the results are controversial. It has even stated that
short-term blockade of RAS might provide perioperative organ protection and improve circulatory conditions [15]. To our knowledge, there is
no data comparing the effect of short-term versus
chronic treatment with enalapril, one of the most
frequently used ACE-I, on hemodynamic changes
occurring during induction of anesthesia.
Therefore, the aim of the study was to compare short-term versus chronic treatment effects of
enalapril on some hemodynamic (blood pressure
and heart rate) parameters during the induction of
general anesthesia.
Material and Methods
Patients and Treatment
In own retrospective study we compared 152
patients scheduled for maxillofacial trauma surgery in the years 2005–2008. Group A (n = 48)
has been chronically treated for hypertension with
enalapril for at least 6 months. The median dose of
enalapril was 10 mg per day. These patients did not
take any other medicaments. Treatment was continued until the morning of surgery with the usual
dose. Patients of group B (n = 54) were patients
with untreated mild hypertension with mean val-
331
ACE-I and Hemodynamics During Induction of General Anesthesia
ues of systolic blood pressure (SBP) > 160 mm Hg
and diastolic blood pressure (DBP) < 110 mm Hg.
In this group 5 mg enalapril was introduced on the
day of admission (morning and evening) and continued until the morning of surgery. All hypertensive patients were classified as ASA 2 (risk assessment American Society of Anesthesiologists).
Group C consisted of 50 normotensive patients
with ASA 1. All patients were admitted to the hospital two days before surgery and did not present
any concomitant diseases.
On the morning of surgery, patients were premedicated with oral midazolam (7.5 mg) one hour
before. Anesthesia was induced with etomidate
(0.3 mg/kg) while the patient breathed 100% oxygen by mask. After loss of eyelid reflex chlorsuccinilocholin (1.5 mg/kg) was injected and after
1 minute the trachea was intubated. Before induction, each patient received 500 ml of Ringer solution.
Anesthesia was maintained throughout with a mixture of 66% nitrous oxide and 33% oxygen, supplemented by sevoflurane < 1.5% inspirated concentration and vecuronium for muscle relaxation (0.1 mg/
kg). Fentanyl was also given in a dose of 2 ug/kg.
premedication (T0). The other measurements
were taken 2 minutes after induction (T1), 1 minute after intubation (T2) and 3 minutes after intubation (T3). Blood pressure was monitored with
a non-invasive automatic method using a Dameca
anesthetic monitor (Denmark). Episodes of
hypotension were defined as SBP < 100 mm Hg,
DBP < 50 mm Hg, or a decrease of > 30% preinduction (baseline) values. These episodes were treated
routinely with administration of fluids. The study
was approved by the local Bioethical Committee of
the Medical University of Bialystok.
Statistical Analysis
Values were compared using Student’s
unpaired t-test and changes over time were compared with ANOVA and the Kruskall-Wallis
test, as well as Dunn’s multiple comparison test.
Frequency of hypotensive episodes was measured
with a Fisher test. Data was expressed as a mean
(SD) and p < 0.05 was considered the level of statistical significance.
Results
Hemodynamic Parameters
Measurement
Blood pressure (SBP, DBP) and heart rate
(HR) were measured at admission (Ta), after treatment (Tt), while the baseline was measured after
The three groups of patients were similar with
regard to demographic characteristics but in group
B the values of systolic and diastolic pressures (Ta)
were higher (p < 0.01) (Tab. 1).
Table 1. Clinical characteristics of patient on admission
Tabela 1. Kliniczna charakterystyka pacjentów przy przyjęciu
Group (Grupa)
A
B
C
Number (Liczba)
48
54
50
Age – years (Wiek – lata)
44 ± 7 40 ± 4
39 ± 7
Weight – kg
(Masa ciała – kg)
82 ± 7 89 ± 10
78 ± 9
Sex, n – male/n – -female
(Płeć, n – mężczyźni/n – kobiety)
28/10
32/8
38/12
SBp – mm Hg
(Ciśnienie skurczowe – mm Hg)
154 ± 15
174 ± 18**
138 ± 12
dBp – mm Hg
(Ciśnienie rozkurczowe – mm Hg)
86 ± 14
112 ± 11**
83 ± 11
HR – beats/min
(Częstość akcji serca – uderzeń/min)
78 ± 10
84 ± 7 74 ± 8
n – number/liczba pacjentów, SBP – systolic blood pressure, DBP – diastolic blood pressure,
HR – heart rate, A – patients chronically treated with ACE-I/pacjenci otrzymujący ACE-I chronicznie,
B – patients received short term treatment of ACE-I/chorzy leczeni krótkotrwale ACE-I, C – normotensive patients/pacjenci z prawidłowym ciśnieniem tętniczym
332
M. Malinowska-Zaprzałka et al.
Enalapril introduced after admission reduced (p
< 0.01) SBP and DBP (Tt) in group B after four doses
(Fig. 1). On the day of surgery after premedication
was given there were no differences in the baseline
values (T0) of SBP, DBP (Fig. 1) and HR (Fig. 2). In
group A, the induction of anesthesia (T1) was associated with a decrease of SBP from 134 ± 10 to 111 ±
7 mm Hg (p < 0.05). Similar changes were observed
in B group (from 130 ± 7 to 96 ± 16 mm Hg; p < 0,05).
In control groups no significant changes were noted.
DBP lowered after induction in all examined groups
(Fig. 1). Laryngoscopy and intubation (T2) induced
changes in HR in both hypertensive groups (p < 0.01)
(Fig. 2). The values of SBP in group B in times T2–T3
remained lower than the values in group A just as in
the control group (Fig. 1).
Comparing the number of hypotensive episodes in all groups the authors noticed that in
group A three patients exhibited a decrease of SBP
after induction of more than 30% from baseline
values, while in group B there were 4 such patients
(Tab. 2). Two hypotensive episodes were noted in
patients from the control group. Also the number of
patients with lower DBP did not differ significantly.
All the patients responded well to fluid treatment
and there was no need to use other medicaments.
Discussion
This study demonstrated that short-term (3–4
doses) ACE inhibition with enalapril allows the
successful reduction of high systolic and diastolic
blood pressures until the day of surgery, and generates lower SBP during the induction period of
anesthesia than chronic treatment. The authors
also confirmed that induction of anesthesia may
cause a marked decrease in systolic and diastolic
blood pressures in chronically treated patients.
Heart rate increase after intubation was comparable in both examined hypertensive groups and
did not depend on the type of treatment.
In general anesthesia there are two points most
dangerous of all: induction with intubation and
the end of anesthesia with extubation. Generally
one can expect slight hypotension after induction and tachycardia after intubation, however,
under some clinical circumstances these responses
may become exaggerated and therefore dangerous. Most clinical investigators are in agreement
that untreated hypertension may cause dangerous cardiovascular effects during the induction
of general anesthesia [16]. These effects include
myocardial ischaemia caused by tachycardia with
[mm Hg]
250
SBP-A
SBP-B
SBP-C
200
++
DBP-A
**
DBP-B
DBP-C
**
150
+
++
++
**
100
**
50
0
Ta _________
Tt
2 -3 days
______
1 hour
T0 ________T1
2 min.
_______T2 ________T3
2 min.
1 min.
Fig. 1. Changes in SBP and DBP in patients during induction of anesthesia pointing to hypotension after propofol.
Data show value (mean (SD)) at the time of admission (Ta), after treatment (Tt), baseline values before induction of
anesthesia (T0), 2 minutes after induction of anesthesia (T1), 1 minute after intubation (T2), 3 minutes after intubation (T3); A – patients chronically treated with ACE-I, B – patients received short term treatment of ACE-I, C – normotensive patients.
*p < 0.05; **p < 0.01; ++ – B vs A; ** – vs previous time
Ryc. 1. Zmiany wartości ciśnienia tętniczego skurczowego i rozkurczowego podczas wprowadzenia do znieczulenia
ogólnego wskazujące na spadek ciśnienia tętniczego po podaniu propofolu. Dane ukazują wartości (średnie (SD)) przy
przyjęciu pacjenta (Ta), po leczeniu (Tt), wartość wyjściową, przed wprowadzeniem do znieczulenia (T0), 2 minuty po
wprowadzeniu do znieczulenia (T1), 1 minutę po intubacji (T2), 3 minuty po intubacji (T3); A – pacjenci otrzymujący
ACE-I przewlekle, B – chorzy leczeni krótkotrwale, C – pacjenci z prawidłowym ciśnieniem tętniczym.
*p < 0,05; **p < 0,01; ++ – B vs A; ** – w odniesieniu do poprzednich okresów
333
ACE-I and Hemodynamics During Induction of General Anesthesia
[beats/min]
120
A
B
100
C
80
**
60
**
40
20
0
Ta
Tt
_________
2 -3 days
______T0
1 hour
______ T1 _______T2
1 min.
2 min.
______T3
2 min.
Fig. 2. Changes in HR in patients during induction of anesthesia pointing to bradycardia after propofol. Data show
value (mean (SD)) at time of admission (Ta), after treatment (Tt), baseline values before induction of anesthesia
(T0), 2 minutes after induction of anesthesia (T1), 1 minute after intubation (T2), 3 minutes after intubation (T3);
A – patients chronically treated with ACE-I, B – patients received short term treatment of ACE-I, C – normotensive
patients.
**p < 0.01
Ryc. 2. Zmiany w czynności serca u pacjentów podczas wprowadzenia do znieczulenia ogólnego wskazujące na bradykardię po podaniu propofolu. Dane ukazują wartości (średnie (SD)) przy przyjęciu pacjenta (Ta), po leczeniu (Tt),
wartość wyjściową, przed wprowadzeniem do znieczulenia (T0), 2 minuty po wprowadzeniu do znieczulenia (T1),
1 minutę po intubacji (T2), 3 minuty po intubacji (T3); A – pacjenci otrzymujący ACE-I przewlekle, B – chorzy leczeni krótkotrwale, C – pacjenci z prawidłowym ciśnieniem tętniczym.
**p < 0,01
Table 2. Patients with hypotensive episodes and the lowest DBP value.
Tabela 2. Pacjenci z epizodami hipotensji i najmniejszymi
wartościami rozkurczowego ciśnienia tętniczego
Group
(Grupa)
Patients with
hypotensive episodes
(Pacjenci z epizodami hipotensji)
Patients with the
lowest value of DBP
(Pacjenci
z najmniejszymi
wartościami
ciśnienia rozkurczowego)
A
(n = 48)
3
4
B
(n = 54)
4
2
C
(n = 50)
2
2
n – number/liczba pacjentów, DBP – diastolic blood
pressure, A – patients chronically treated with ACE-I/
pacjenci otrzymujący ACE-I przewlekle, B – patients
received short term treatment of ACE-I/chorzy leczeni
krótkotrwale ACE-I, C – normotensive patients/pacjenci
z prawidłowym ciśnieniem tętniczym
hypertension after laryngoscopy. The problem is
of greater importance in emergency patients or
in those with trauma, who have to be operated
on as soon as possible. Therefore, many pharmacological attempts have been made to attenuate
these undesired changes. These attempts include
strong premedication, supplementation of narcotics, i.v. lignocaine and beta-adrenoceptor blocking
drugs. One of them, a very new clinical practice, is
short-term (2–4 doses) or even acute application
of ACE-I, 1–2 days before surgery, in patients with
non treated hypertension [3].
In our study patients with mild uncontrolled
hypertension on admission scheduled for maxillofacial trauma surgery after enalapril treatment (Tt)
presented decreased SBP and DBP values. On the
day of surgery these values were comparable to
those of patients who had been chronically treated,
as well as to healthy ones (T0).
There is data indicating that strong hypotension can occur after the first dose of ACE-I [14].
In the present study we did not observe this strong
hypotensive effect. It must be mentioned, that we
used relatively low, although effective doses of the
drug. It should be stressed, however, that the values
of SBP in the short-term treated group were significantly lower in all checked terms during the study,
334
but much more stable than in chronically treated
patients. We have chosen the following end-points
to assess cardiovascular stability: SBP after induction of anesthesia of < 90 mm Hg, SBP after laryngoscopy and intubation more than 20% of baseline values and HR after intubation exceeding 100
beats/min. Our data is in agreement with some
other authors who point to cardiovascular stability
after short-term and acute treatment with ACE-I
[4, 17, 18]. It has also been shown that the ACE-I
perindopril significantly reduces blood pressure
values more after one day of treatment than other
antihypertensive drugs (bisoprolol, verapamil, candesartan) [19]. The strong effect of ACE inhibition
is not surprising, because it has been demonstrated [11], that even after temporary interruption of
chronic ACE-I treatment, persistent inhibition of
angiotensin-converting enzyme in tissues could
be present despite the usual plasma-converting
enzyme activity (19). Furthermore, there is data
showing that this type of antihypertensive treatment demands lower doses of anesthetics for
induction to reach the successful level of anesthesia, without impairing hemodynamics [4].
It is suggested that continuing ACE-I therapy
until the day of surgery can attenuate the hemodynamic effect of anesthesia induction [10, 13,
21]. Coriat et al. have shown that the hypotensive
response to induction of anesthesia is more pronounced in patients receiving enalapril than captopril [2]. However, in animals there is evidence that
the type of ACE-I does not affect peri-operative
hemodynamic changes [3]. Furthermore, it has
been demonstrated that hypotensive episodes occur
more frequently while using angiotensin II receptor
type-1 antagonists rather than ACE-I [22]. Although
the authors did not compare the effects of different
drugs, the authors have confirmed a statistically significant decrease of SBP and DBP after induction in
both hypertensive groups treated with enalapril.
The mild hypotensive response to induction
found in own patients did not demand aggressive treatment (for example ephedrine) on top of
fluid administration. The reason for only a mild
hypotensive response may have been the design of
the study: the anesthetic given for induction was
etomidate, which is known to reduce the hemodynamic response to induction, whether hypotensive or hypertensive [12, 22, 23]. Own earlier study
M. Malinowska-Zaprzałka et al.
has shown, that another anesthetic, propofol, may
induce hypotension during induction in chronically enalapril-treated hypertensive patients [24].
One more reason could be the choice of patients:
we examined only those with mild hypertension
(DBP < 110 mm Hg) and without any other concomitant diseases, while groups in other studies
consisted of more severely ill patients i.e. with coronary artery disease, congestive heart failure, or
diabetes mellitus [4]. There is always a greater risk
of hypotension when a patient is treated with more
than one drug. It has shown recently, that chronic
diuretic treatment in hypertensive patients treated
with ACE-I may produce profound hypotenion
during anesthesia [25].
Own patients seemed to be successfully prepared for anesthesia with an antihypertensive
drug. Laryngoscopy and intubation did not significantly influence blood pressure parameters in the
study; the increase of HR was comparable in both
the short-term and the chronically treated groups
(Fig. 2). Some authors have shown that tachycardia is considered to be dangerous over 110 beats
per minute [26], but the values in our examined
patients did not exceed 100 beats/min.
The fact that the authors compared quite
a small group of patients undergoing a specific
surgery and treated with one ACE-I may be limitation of this study. Own findings may not fit average surgical patients thus further studies are needed comparing different groups of patients, kinds of
surgery and anesthetics.
In conclusion, short-term treatment with
ACE-I in hypertensive patients undergoing maxillofacial trauma surgery successfully reduces
high blood pressure until the day of surgery and
induces lower values of SBP during the induction period of anesthesia than in the chronically
treated group. The authors would suggest that this
short treatment in patients with mild hypertension on admission who are scheduled for delayed
emergency surgical procedure (i.e., two days maximum) may improve their clinical status and level
of safety during anesthesia. Own study confirmed
only mild hypotensive effect of induction of anesthesia in patients chronically treated with ACE-I,
and therefore the authors would suggest not to
interrupt the treatment before surgery to avoid
profound hypotension during induction.
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Address for correspondence:
Małgorzata Malinowska-Zaprzałka
Biopharmacy Department
Medical University of Bialystok
Mickiewicza 2C
15-222 Białystok
Poland
E-mail: [email protected]
Conflict of interest: None declared
Received: 27.01.2010
Revised: 7.04.2010
Accepted: 7.06.2010