Cardiac Arrest during Total Hip Arthroplasty in a Patient on an Angiotensin Receptor Antagonist

Abstract

Angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor antagonists (ARA) are effective and well-tolerated first-line drugs in the therapy of hypertension and, therefore, are frequently encountered in the perioperative setting. Hemodynamic compensation for volume depletion seen in the perioperative period is normally mediated by the renin–angiotensin system, which is blocked by ACEI/ARA. These drugs may contribute to severe hypotension during anesthesia induction and may have contributed to the cardiac arrest seen in this patient. Additional factors such as increased intra-abdominal pressures and respiratory obstructive episodes leading to diminished venous return, as well diuretic use and the fasting state, common in the perioperative orthopedic patient, are likely to have contributed as well. Medication use may be an easily modifiable risk factor for severe hypotension and possible cardiac arrest in the perioperative setting.

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Each author certifies that he or she has no commercial associations (e.g., consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article.

Each author certifies that his or her institution has approved the reporting of this case, that all investigations were conducted in conformity with ethical principles of research.

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Correspondence to Susan M. Goodman MD.

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CME questions for “Cardiac arrest during total hip arthroplasty in a patient on an angiotensin receptor antagonist”

1. What factors may complicate stopping ACE inhibitors perioperatively:

a. Intra and postoperative hypertension.

b. Postoperative hypotension

c. Difficulty in converting to other antihypertensive agents effectively and timely.

d. a & c

e. all of the above

2. Which factor can contribute to postoperative hypotension in patients on ACE inhibitors:

a. Postoperative pain

b. Intra and postoperative anemia and blood loss

c. perioperative anxiety

d. Prolonged NPO status

e. b & d

f. all of the above

3. Intra and postoperative hypertension increases the risk of:

a. surgical blood loss

b. cardiac arrhythmias

c. stroke

d. all of the above

4. ACEI inhibit the synthesis of angiotensin II. The effect of AII includes:

a. vasodilation

b. vasoconstriction

c. vasopressor potentiation

d. a & c

e. b & c

5. Significant hypotension at the time of anesthesia induction is most common in patients treated with:

a. calcium channel blocking agents

b. beta blocking agents

c. ACEI

d. Angiotensin receptor antagonists

6. Acute kidney injury is a common complication of cardiac surgery. Risk factors include:

a. increased age

b. Diabetes

c. neurologic disease

d. ACEI/ARA therapy

e. b & c

f. all of the above

7. Medications which should be continued and taken on the morning of surgery in a patient with hypertension, angina, and normal cardiac function:

a. metoprolol

b. furosemide

c. lisinopril

d. Plavix

8. The Betzold –Jarisch reflex, mediated by cardiopulmonary vagal fibers, results in paradoxical bradycardia and precipitous hypotension. This is accentuated with:

a. prolonged standing

b. hypovolemia

c. anemia

d. all of the above

9. Beta blockers have a protective effect on patients in the intra and postoperative period, decreasing the incidence of which of the following:

a. myocardial infarction

b. stroke

c. hypotension

d. wound dehiscence

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First Name:

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Specialty (ie Orthopaedics, Rheumatology, Pediatrics)

Please indicate your profession:

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Discuss and be able to use appropriate chemical messenger systems, such as the Renin Activating System, in maintenance of hemodynamic stability in the setting of regional anesthesia and orthopaedic surgery.

1 2 3 4 5 6 7

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Describe antihypertensive agents, such as Angiotensin converting enzyme inhibitors (ACEI) and Angiotensin receptor antagonists (ARA), and their interactions with the Renin Activating System blockade, and how they are less likely to produce profound hypotension for patients in the orthopaedic setting.

1 2 3 4 5 6 7

□ □ □ □ □ □ □

Discuss factors, such as dehydration and anemia, which may magnify the potential for hypotension in orthopaedic patients undergoing regional anesthesia.

1 2 3 4 5 6 7

□ □ □ □ □ □ □

Describe the mechanism by which an increase in intra-abdominal and intra-thoracic pressure can diminish venous return and further increase the importance of Renin Activating System mediated compensation.

1 2 3 4 5 6 7

□ □ □ □ □ □ □

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Goodman, S.M., Krauser, D., Mackenzie, C.R. et al. Cardiac Arrest during Total Hip Arthroplasty in a Patient on an Angiotensin Receptor Antagonist. HSS Jrnl 8, 175–183 (2012). https://doi.org/10.1007/s11420-011-9225-0

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Keywords

  • cardiac arrest
  • perioperative antihypertensive therapy
  • Angiotensin converting enzyme inhibitors
  • Bezold –Jarisch reflex
  • intra-operative hypotension
  • renin angiotensin system (RAS)