title: Terlipressin-ephedrine versus ephedrine to treat hypotension at the induction of anesthesia in patients chronically treated with angiotensin converting-enzyme inhibitors: a prospective, randomized, double-blinded, crossover study.
abstract: In patients chronically treated with angiotensin converting-enzyme inhibitors (ACEI), typically selected doses of ephedrine do not always restore arterial blood pressure when anesthesia-induced hypotension occurs. We postulated that the administration of terlipressin, an agonist of the vasopressin system, with ephedrine more effectively restores pressure in this setting than the administration of ephedrine alone. This prospective, randomized, cross-over, double-blinded study compared terlipressin combined with ephedrine (n = 19) with ephedrine alone (n = 21) in treating hypotension at the induction of anesthesia in 40 ACEI-treated patients undergoing hypotension (mean arterial blood pressure [MAP] <65 mm Hg or <30% of baseline value) after standardized anesthetic protocol (target-controlled IV anesthesia with propofol). Data are mean +/- SD. Patient characteristics, MAP, and heart rate before and after the induction of anesthesia during hypotensive episodes were not significantly different between the two groups. After the first bolus, MAP was significantly greater in the Terlipressin-Ephedrine group (72 +/- 12 mm Hg versus 65 +/- 8 mm Hg, P < 0.05). The occurrence of a second hypotensive episode (5% versus 71%, P < 0.001), the duration (2 +/- 1 min versus 3 +/- 1 min, P < 0.01) of hypotensive episodes, and the median dose of ephedrine (3 versus 6 mg, P < 0.05) were significantly less in the Terlipressin-Ephedrine group. In conclusion, terlipressin combined with ephedrine is more effective than ephedrine alone for treating anesthesia-induced hypotension in ACEI-treated patients. We conclude that this patient population with a partially blocked endogenous response to hypotension may be good candidates for successful use of a vasopressin analog to counteract intraoperative refractory hypotension.
  
  
  CONCLUSIONS
  Vascular surgical patients chronically treated with drugs that inhibit the functioning of the renin-angiotensin system may experience hypotension unresponsive to conventional therapy. This double-blinded, cross-over study demonstrated that in these patients the use of a vasopressin analog, terlipressin given with ephedrine, was effective in reversing intraoperative systemic hypotension refractory to ephedrine.
authors.affiliation: Department of Anesthesiology and Critical Care, Centre Hospitalier Universitaire Pitié-Salpétrière, Assistance-Publique-Hôpitaux de Paris, Pierre et Marie Curie University, Paris, France.
authors.forename: Karoline
authors.initials: K
authors.lastname: Meersschaert
authors.forename: Luc
authors.initials: L
authors.lastname: Brun
authors.forename: Maximilien
authors.initials: M
authors.lastname: Gourdin
authors.forename: Stéphane
authors.initials: S
authors.lastname: Mouren
authors.forename: Michèle
authors.initials: M
authors.lastname: Bertrand
authors.forename: Bruno
authors.initials: B
authors.lastname: Riou
authors.forename: Pierre
authors.initials: P
authors.lastname: Coriat
mesh_terms: D000368:Aged; D000771:Anesthesia, Intravenous / Q000009:adverse effects*; D018686:Anesthetics, Intravenous / Q000009:adverse effects; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use*; D001794:Blood Pressure / Q000187:drug effects; D018592:Cross-Over Studies; D004311:Double-Blind Method; D004359:Drug Therapy, Combination; D004809:Ephedrine / Q000008:administration & dosage*; D006801:Humans; D007022:Hypotension / Q000188:drug therapy* / Q000209:etiology; D007431:Intraoperative Complications / Q000188:drug therapy*; D008236:Lypressin / Q000008:administration & dosage* / Q000031:analogs & derivatives; D015742:Propofol / Q000009:adverse effects; D011446:Prospective Studies; D000077585:Terlipressin; D014662:Vasoconstrictor Agents / Q000008:administration & dosage*
chemical_list: D018686:Anesthetics, Intravenous; D000806:Angiotensin-Converting Enzyme Inhibitors; D014662:Vasoconstrictor Agents; D008236:Lypressin; D000077585:Terlipressin; D004809:Ephedrine; D015742:Propofol