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Refractory Hypotension During General Anesthesia Despite Withholding Telmisartan
Takayuki Hojo DDS, PhD,
 Makiko Shibuya DDS, PhD,
 Yukifumi Kimura DDS, PhD,
 Yuki Otsuka DDS, and
 Toshiaki Fujisawa DDS, PhD
Article Category: Case Report
Volume/Issue: Volume 67: Issue 2
Online Publication Date: Jul 06, 2020
DOI: 10.2344/anpr-67-02-02
Page Range: 86 – 89
Angiotensin receptor blockers (ARBs) are commonly prescribed for the management of hypertension. However, refractory hypotension during general anesthesia caused by renin-angiotensin system blockade is a well-known potential complication in patients concurrently taking ARBs or angiotensin-converting enzyme inhibitors. 1 – 5 Therefore, it has been recommended that ARBs preferably be withheld for 24 hours prior to the induction of general anesthesia. 1 – 5 However, some reports suggest that continued preoperative administration of ARBs does
Ventricular Tachycardia Following Ephedrine During Dexmedetomidine Dental Procedural Sedation
Shota Abe DDS,
 Kanami Suzuki DDS,
 Maki Hamamura DDS,
 Takashi Tamanoi DDS,
 Koji Takahashi DDS,
 Keiichiro Wakamatsu DDS,
 Kenji Yoshida DDS, PhD,
 Hiroyoshi Kawaai DDS, PhD, and
 Shinya Yamazaki DDS, PhD
Article Category: Case Report
Volume/Issue: Volume 70: Issue 4
Online Publication Date: Jan 15, 2024
Page Range: 184 – 190
Administration of dexmedetomidine (DEX) is associated with the onset of bradycardia, biphasic blood pressure responses (brief hypertension followed by hypotension), and other cardiovascular complications. 1 – 4 Cardiovascular agonists must be appropriately used for treatment in the event of such issues. However, literature regarding ventricular tachycardia (VT) caused by cardiovascular agonists in patients under DEX-induced sedation is scarce. We present the case of a patient who received intravenous (IV) ephedrine to treat low
Caitlin M. Waters DDS,
 Kristen Pelczar DMD,
 Edward C. Adlesic DMD,
 Paul J. Schwartz DMD, and
 Joseph A. Giovannitti Jr DMD
Article Category: Case Report
Volume/Issue: Volume 69: Issue 3
Online Publication Date: Oct 06, 2022
Page Range: 30 – 35
individuals on antihypertensive therapy, consideration should be given to patients taking ACEIs or ARBs who present for ambulatory dental surgery under general anesthesia. Continued perioperative use of ACEIs and ARBs has been associated with reduced or abnormal physiological responses to common intraoperative vasopressors, such as ephedrine, phenylephrine, and epinephrine, and is otherwise known as refractory hypotension. 3 We present the cases of 2 patients taking an ACEI or ARB with refractory hypotension successfully managed with the addition of vasopressin
Takayuki Hojo DDS, PhD,
 Yukifumi Kimura DDS, PhD,
 Keiji Hashimoto DDS,
 Takahito Teshirogi DDS, and
 Toshiaki Fujisawa DDS, PhD
Article Category: Case Report
Volume/Issue: Volume 68: Issue 4
Online Publication Date: Dec 15, 2021
Page Range: 220 – 223
We previously described the case of a patient with primary hypertension managed with telmisartan in which refractory hypotension during general anesthesia was not avoided despite withholding telmisartan for 24 hours before induction. 1 Telmisartan has the longest half-life of angiotensin receptor blockers (ARBs), and in that particular patient's case, withholding telmisartan for 5 days before a second general anesthetic positively resulted in the avoidance of severe refractory hypotension. Azilsartan has the second longest half-life of all
Yoshiki Shionoya DDS, PhD,
 Eishi Nakamura DDS,
 Gentaro Tsujimoto DDS, PhD,
 Takayuki Koyata DDS,
 Asako Yasuda DDS, PhD,
 Kiminari Nakamura DDS, PhD, and
 Katsuhisa Sunada DDS, PhD
Article Category: Research Article
Volume/Issue: Volume 68: Issue 3
Online Publication Date: Oct 04, 2021
Page Range: 141 – 145
predominates when combined with epinephrine, causing dilation of peripheral blood vessels in skeletal muscle and inducing hypotension. Therefore, epinephrine-containing local anesthetics should be carefully administered in patients concurrently taking antipsychotics, such as those with schizophrenia, autism, intellectual disability, and dementia. The Japanese Dental Society of Anesthesiology conducted a retrospective survey on the administration of epinephrine-containing lidocaine for dental patients taking antipsychotic medications at dental school hospitals and
Takuro Sanuki DDS, PhD,
 Naotaka Kishimoto DDS, PhD,
 Hidetaka Kuroda DDS, PhD, and
 Kanta Kido DDS, PhD
Article Category: Article Commentary
Volume/Issue: Volume 70: Issue 2
Online Publication Date: Jun 28, 2023
Page Range: 91 – 92
in dentistry (>60%) 6 and is often induced by fear of or pain during the injection of local anesthesia. 7 VVS stems from abrupt changes in autonomic activity: increased parasympathetic activity (ie, increased vagal tone) that leads to bradycardia and decreased sympathetic activity that causes arterial relaxation resulting in hypotension. If the drop in cardiac output and blood pressure (BP) is severe, cerebral blood flow is substantially reduced, and loss of consciousness may occur. Because VVS is a reflex, signs and symptoms are usually observed rapidly (seconds
Figure 1.; Trend of cardiovascular vitals for case 1. Vasopressin stabilized labile hypotension unresponsive to standard vasopressors in a patient who continued angiotensin receptor blocker (ARB) therapy preoperatively.
Caitlin M. Waters,
 Kristen Pelczar,
 Edward C. Adlesic,
 Paul J. Schwartz, and
 Joseph A. Giovannitti Jr
Figure 1.
Figure 1.

Trend of cardiovascular vitals for case 1. Vasopressin stabilized labile hypotension unresponsive to standard vasopressors in a patient who continued angiotensin receptor blocker (ARB) therapy preoperatively.


Figure 2.; Trend of cardiovascular vitals for case 2. Vasopressin stabilized labile hypotension unresponsive to standard vasopressors in a patient who continued angiotensin-converting enzyme inhibitor (ACEI) therapy preoperatively.
Caitlin M. Waters,
 Kristen Pelczar,
 Edward C. Adlesic,
 Paul J. Schwartz, and
 Joseph A. Giovannitti Jr
Figure 2.
Figure 2.

Trend of cardiovascular vitals for case 2. Vasopressin stabilized labile hypotension unresponsive to standard vasopressors in a patient who continued angiotensin-converting enzyme inhibitor (ACEI) therapy preoperatively.


Daniel E Becker and
 Daniel A Haas
Figure 2.
Figure 2.

Hypotension algorithm. Hypotensive patients will generally respond to leg elevations or intravenous fluid administration. When drug therapy is indicated, the choice of drug is predicated on heart rate.


Caitlin M. Waters,
 Kristen Pelczar,
 Edward C. Adlesic,
 Paul J. Schwartz, and
 Joseph A. Giovannitti Jr
Figure 4.
Figure 4.

Mechanism of vasopressinergic vs adrenergic vasoconstriction. Vasopressin (V1) receptor activation by vasopressin produces short-term vasoconstriction that increases vascular resistance and mean arterial pressure (MAP). 14 V1 receptor agonists are effective in patients with severe hypotension and renin-angiotensin-aldosterone system (RAAS) blockade when conventional adrenergic treatment fails. 15


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