ACE-Inhibitor or ARB-Induced Refractory Hypotension Treated With Vasopressin in Patients Undergoing General Anesthesia for Dentistry: Two Case Reports
Two case reports present the use of vasopressin for treating refractory hypotension associated with continued angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) therapy prior to general anesthesia for oral surgery. Both patients were treated in an ambulatory dental surgery clinic and took either their ACEI or ARB medication for hypertension within 24 hours prior to undergoing an intubated general anesthetic. Persistent profound hypotension was encountered intraoperatively that was refractory to treatment with traditional methods. However, the ACEI- or ARB-induced refractory hypotension was successfully managed with the administration of vasopressin.
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.
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.
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.
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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