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ACE-Inhibitor or ARB-Induced Refractory Hypotension Treated With Vasopressin in Patients Undergoing General Anesthesia for Dentistry: Two Case Reports
Caitlin M. WatersDDS,
Kristen PelczarDMD,
Edward C. AdlesicDMD,
Paul J. SchwartzDMD, and
Joseph A. Giovannitti JrDMD
Article Category: Case Report
Volume/Issue: Volume 69: Issue 3
Online Publication Date: Oct 06, 2022
DOI: 10.2344/anpr-69-02-06
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

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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 1.; Mean and SEM of mean arterial pressure of the rats submitted to intravenous (IV) injection of 240 ng kg−1 of felypressin (FEL), 250 ng kg−1 of vasopressin (AVP), or 2 μg kg−1 of epinephrine (EPI) after IV injection of 0.9% NaCl, IV injection of 15 μg kg−1 of β-mercapto-β,β-cyclopentamethylenepropionyl-0 methyl-tyrosine, arginine vasopressin (β-MER), intracerebroventricular (ICV) injection of 100 ng of B-mer, or removal (APX) or sham removal (APS) of area postrema. Different letters mean a statistical difference (P < .05) between different treatments of the same group. * P < .05 versus EPI group.
Rodrigo Cecanho,
Laurival Antonio De Luca Jr, and
José Ranali
Figure 1.
Figure 1.

Mean and SEM of mean arterial pressure of the rats submitted to intravenous (IV) injection of 240 ng kg−1 of felypressin (FEL), 250 ng kg−1 of vasopressin (AVP), or 2 μg kg−1 of epinephrine (EPI) after IV injection of 0.9% NaCl, IV injection of 15 μg kg−1 of β-mercapto-β,β-cyclopentamethylenepropionyl-0 methyl-tyrosine, arginine vasopressin (β-MER), intracerebroventricular (ICV) injection of 100 ng of B-mer, or removal (APX) or sham removal (APS) of area postrema. Different letters mean a statistical difference (P < .05) between different treatments of the same group. * P < .05 versus EPI group.

Figure 2.; Mean and SEM of heart rate of the rats submitted to intravenous (IV) injection of 240 ng kg−1 of felypressin (FEL), 250 ng kg−1 of vasopressin (AVP), or 2 μg kg−1 of epinephrine (EPI) after IV injection of 0.9% NaCl, IV injection of 15 μg kg−1 of β-mercapto-β,β-cyclopentamethylenepropionyl-0 methyl-tyrosine, arginine vasopressin (β-MER), intracerebroventricular (ICV) injection of 100 ng of B-MER, or removal (APX) or sham removal (APS) of area postrema. Different letters mean a statistical difference (P < .05) between different treatments of the same group.
Rodrigo Cecanho,
Laurival Antonio De Luca Jr, and
José Ranali
Figure 2.
Figure 2.

Mean and SEM of heart rate of the rats submitted to intravenous (IV) injection of 240 ng kg−1 of felypressin (FEL), 250 ng kg−1 of vasopressin (AVP), or 2 μg kg−1 of epinephrine (EPI) after IV injection of 0.9% NaCl, IV injection of 15 μg kg−1 of β-mercapto-β,β-cyclopentamethylenepropionyl-0 methyl-tyrosine, arginine vasopressin (β-MER), intracerebroventricular (ICV) injection of 100 ng of B-MER, or removal (APX) or sham removal (APS) of area postrema. Different letters mean a statistical difference (P < .05) between different treatments of the same group.

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
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

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.

Cardiovascular Effects of Felypressin
Rodrigo CecanhoDDS, ScD,
Laurival Antonio De Luca JrScD, and
José RanaliDDS, ScD
Article Category: Research Article
Volume/Issue: Volume 53: Issue 4
Online Publication Date: Jan 01, 2006
DOI: 10.2344/0003-3006(2006)53[119:CEOF]2.0.CO;2
Page Range: 119 – 125

Felypressin (FEL), a synthetic analogue of vasopressin (AVP), has been widely used as a substitute for epinephrine (EPI) in anesthetic solutions to promote local vasoconstriction during medical and dental practices. 1 , 2 Because it has no interaction with adrenergic receptors, it is suggested that FEL has fewer side effects than EPI. 3 Hence, FEL causes fewer cardiovascular 4 and metabolic 5 side effects, and it has a higher median lethal dose (LD50) 6 than EPI. However, the mechanisms and the receptors used by FEL to induce

Figure 3.; Effects of angiotensin-converting enzyme inhibitor (ACEIs) and angiotensin receptor blockers (ARBs) on vasoconstriction. Inhibition of the renin-angiotensin-aldosterone system (RAAS) by ACEIs or ARBs inhibits hormonal regulation of blood pressure (BP), leaving only the vasopressinergic system fully functional during general anesthesia.
Caitlin M. Waters,
Kristen Pelczar,
Edward C. Adlesic,
Paul J. Schwartz, and
Joseph A. Giovannitti Jr
Figure 3.
Figure 3.

Effects of angiotensin-converting enzyme inhibitor (ACEIs) and angiotensin receptor blockers (ARBs) on vasoconstriction. Inhibition of the renin-angiotensin-aldosterone system (RAAS) by ACEIs or ARBs inhibits hormonal regulation of blood pressure (BP), leaving only the vasopressinergic system fully functional during general anesthesia.

Letter to the Editor
Stuart LieblichDMD
Article Category: Other
Volume/Issue: Volume 61: Issue 4
Online Publication Date: Jan 01, 2014
DOI: 10.2344/0003-3006-61.4.181
Page Range: 181 – 181

return to the heart. Increasing the rate via vagolytic agents only exacerbates the decreased cardiac output and can contribute to a worsening of the clinical condition. Finally, if severe hypotension and bradycardia occur during anesthesia, my suggestion is to administer a course of epinephrine (as was done in this case) but also to consider administration of vasopressin. There are more reports of epinephrine-resistant anaphylaxis reactions that do respond rapidly to vasopressin. 2 , 3 This may be due to the blunted effects of epinephrine as acidosis occurs

Refractory Hypotension During General Anesthesia Despite Withholding Telmisartan
Takayuki HojoDDS, PhD,
Makiko ShibuyaDDS, PhD,
Yukifumi KimuraDDS, PhD,
Yuki OtsukaDDS, and
Toshiaki FujisawaDDS, 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

anesthetics were performed after substantially prolonged washout periods of 5 days; however, no conclusions can likely be drawn regarding “optimal” or “minimally sufficient” washout periods based only on these 2 individual case reports. The establishment of appropriate washout periods for individual ARBs will likely require knowledge derived from future case reports and/or prospective studies. Vasopressin has been reported as an effective agent for the management of refractory hypotension. 9 Its primary functions are to increase the reabsorption of water in the