Terlipressin versus norepinephrine to counteract anesthesia-induced hypotension in patients treated with renin-angiotensin system inhibitors: effects on systemic and regional hemodynamics.
BACKGROUND
Terlipressin has been suggested as the ideal drug to treat anesthesia-induced hypotension in patients under long-term renin-angiotensin system inhibitor treatment for arterial hypertension. The authors compared the effects of terlipressin and norepinephrine on systemic hemodynamic parameters and gastric mucosal perfusion using a laser Doppler flowmetry technique in patients treated with renin-angiotensin system inhibitors who experienced hypotension at induction of anesthesia.


METHODS
Thirty-two patients scheduled for carotid endarterectomy under general anesthesia and treated with renin-angiotensin system inhibitors had hypotension after induction of general anesthesia. They were randomized to receive 1 mg of terlipressin (n = 16) or norepinephrine infusion (n = 16) to counteract anesthesia-induced hypotension. A laser Doppler probe was introduced into the gastric lumen. All measurements were performed just before surgery, during hypotension, at 30 min, and at 4 h.


RESULTS
Terlipressin produced an increase in mean arterial pressure and a decrease in gastric mucosal perfusion detected by laser Doppler flowmetry (P < 0.05) over 30 min that were sustained for 4 h. During the infusion, norepinephrine produced an increase in mean arterial pressure and in gastric mucosal perfusion detected by laser Doppler flowmetry (P < 0.05). If compared to norepinephrine, terlipressin reduced oxygen delivery and oxygen consumption (P < 0.05) and increased arterial lactate concentrations (P < 0.05).


CONCLUSIONS
This study showed the efficacy of terlipressin in the treatment of hypotension episodes in anesthetized patients chronically treated with renin-angiotensin system inhibitors, angiotensin converting-enzyme inhibitors, and angiotensin II receptor antagonists. However, the negative effects on gastric mucosal perfusion and the risk of iatrogenic oxygen supply dependency of terlipressin need to be taken into account.
Morelli
Andrea
A
Department of Anesthesiology and Intensive Care, University of Rome La Sapienza, Rome, Italy. andrea.morelli@uniroma1.it
Tritapepe
Luigi
L
Rocco
Monica
M
Conti
Giorgio
G
Orecchioni
Alessandra
A
De Gaetano
Andrea
A
Picchini
Umberto
U
Pelaia
Paolo
P
Reale
Carlo
C
Pietropaoli
Paolo
P
D000368:Aged; D000758:Anesthesia / Q000009:adverse effects*; D057911:Angiotensin Receptor Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use; D000959:Antihypertensive Agents / Q000627:therapeutic use; D004452:Echocardiography; D004562:Electrocardiography / Q000187:drug effects; D005260:Female; D005753:Gastric Mucosa / Q000098:blood supply; D006439:Hemodynamics / Q000187:drug effects*; D006801:Humans; D007022:Hypotension / Q000139:chemically induced* / Q000188:drug therapy*; D017078:Laser-Doppler Flowmetry; D008236:Lypressin / Q000009:adverse effects / Q000031:analogs & derivatives* / Q000627:therapeutic use*; D008297:Male; D009638:Norepinephrine / Q000009:adverse effects / Q000627:therapeutic use*; D010101:Oxygen Consumption / Q000187:drug effects; D011446:Prospective Studies; D012039:Regional Blood Flow / Q000187:drug effects; D012084:Renin-Angiotensin System / Q000187:drug effects*; D000077585:Terlipressin; D014662:Vasoconstrictor Agents / Q000009:adverse effects / Q000627:therapeutic use*
D057911:Angiotensin Receptor Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors; D000959:Antihypertensive Agents; D014662:Vasoconstrictor Agents; D008236:Lypressin; D000077585:Terlipressin; D009638:Norepinephrine