Letters To The Editor: Letters & Announcements
We thank Pr Cedric Prys-Roberts, whose great experience in anesthesia of hypertensive patients is well known, for his interest concerning our recent article (1).
We reported on a short series of patients, results that focused on the possible interest to withdrawn angiotensin II antagonist (AIIA) on the day before a regular surgery. When given preoperatively, these drugs are associated with a risk of hypotension during induction of anesthesia and have possible detrimental effects on cerebral and coronary perfusion in patients undergoing carotid endarterectomy. We agree with Pr Cedric Prys-Roberts concerning the small difference in arterial blood pressure (AP) between both groups; however, we need to give terlipressin in 6 of the 15 patients with AIIA because a refractory hypotension deserves emphasis. Moreover, maintaining stable hemodynamics is a main goal for anesthesiologists in charge of patients undergoing carotid endarterectomy.
Concerning our study, we should have reported results concerning heart rate (HR). In fact, HR was always (but insignificantly) the slowest in patients from whom AIIA had been withdrawn. This result is confirmed by the findings of the equal dose of ephedrine used in both groups and the largest dose of neosynephrine in patients receiving AIIA, both speaking for an absence of bradycardia in patients with AIIA given.
Glycopyrrolate prevents bradycardia and hypotension during induction of anesthesia using propofol and sufentanil (2). However, one must note that results of several studies concerning glycopyrrolate are not clear. McCubbin et al. (3) reported the smallest increase in heart rate in comparison with atropine, with no change in AP in both groups. Yet, Skues et al. (1) reported that during anesthesia with propofol (1 mg/kg) and alfentanil, the increase in AP was largest in comparison with atropine; HR did not change. Finally, Sneyd and Mayall (4) reported an increase of HR without decrease in AP during anesthesia with propofol (1.7 mg/kg) in patients having a mean age of 77 yr. Obviously, examination of glycopyrrolate during anesthesia with propofol in patients from whom AIIA are withdrawn would be useful. Unfortunately, this drug is not available in France. However, we think that tachycardia is always more deleterious in patients with coronary disease in comparison with bradycardia.
In conclusion, discontinuing AIIA on the day before carotid endarterectomy seems to avoid hypotension during induction of anesthesia with propofol without detrimental effects.
1. Bertrand M, Godet G, Meersschaert K, et al. Should the angiotensin II antagonists be discontinued before surgery? Anesth Analg 2001; 92: 26–30.
2. Skues MA, Richards MJ, Jarvis AP, Prys-Roberts C. Preinduction atropine or glycopyrrolate and hemodynamic changes associated with induction and maintenance of anesthesia with propofol and alfentanil. Anesth Analg 1989; 69: 386–90.
3. McCubbin TD, Brown JH, Dewar KM, et al. Glycopyrrolate as a premedicant: comparison with atropine. Br J Anaest 1979; 51: 885–9.
4. Sneyd JR, Mayall R. The effect of pre-induction glycopyrronium on the haemodynamic response of elderly patients to anesthesia with propofol. Anaesthesia 1992; 47: 620–1.