Volume 8, Issue 1 S A M B A T A L K S - PAGE 2 June, 2008

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Need advice about a problem case in ambulatory anesthesia? Suggestions about a difficult situation in your ambulatory surgery center? A reply to questions others have raised about ambulatory anesthesia issues?

If you answered "yes" to any of these questions, or would like to share with other professionals a comment or opinion on a topic related to ambulatory anesthesia then please "Join the Discussion".

Your question, reply or comment will be published in the next available issue of SAMBA TALKS. Include your name (or initials), email address, city, and state, if you would like these published. Please note that because of the high volume of questions we receive, there is often a delay of 1 to 2 months before publication.

SAMBA Talks will include all discussion questions we receive considered of interest to the membership at large. We will endeavor to publish a response to at least one of these questions. The response will be from experts in the field, and from those willing to express a view on a particular topic, backed by experience and/or published evidence. Where email addresses are published, those individuals have indicated their interest in discussing the published questions.

Questions and responses from previous months are now available at the eNewsletter Discussion Archive. If you have any comments regarding the previous questions, please submit them to SAMBA Discussion, and they will be published here next month.

Please note: The information presented in the replies below does not represent SAMBA policy. The replies are solely the opinions of the individuals who wrote them.

?? - LAST MONTH'S QUESTION WITH REPLIES - ?? - TOP

Question

I would like to receive your input on the following two part question in regards to ACE inhibitors:

1. Does your institution have a policy to have patients hold the intake of ACE inhibitors on the day of surgery?
2. If so, does the policy differ in regards to type of anesthetic (local or MAC) or inpatient vs outpatient procedures?

Thanks

-- From: Doug Merrill, M.D., Iowa City, Iowa

Reply 1

As you know, we presented a poster at the recent SAMBA annual meeting that studied this particular question of whether patients undergoing ambulatory or same day admission should have their ACEI stopped (which is a practice that others have adopted based on the inpatient literature, worried about profound, refractory hypotension).
We reported that those patients that stopped did not appear to have any higher incidence of preoperative hypertension- something that we worry about, but wasn't studied in inpatients.
As far as having more profound hypotension, we currently don't have any data to refute the existing studies (Comfere et al), but it seems that clinicians adjust their induction drugs to attenuate the drop in blood pressures. So with our preoperative data, and the existing post induction data, it seems that stopping ACEI/ARBs might be indicated.  Our study is ongoing.

-- From: Rebecca S. Twersky MD, MPH

Reply 2

As per literature consensus, we do not hold ACE inhibitors on the day of surgery. However, we are prepared to aggressively treat hypotension should it occur.  Phenylephrine may or may not be adequate; a norepinephrine drip is also a possibility.  Some months ago, I had a case of profound hypotension with the combination of propofol and lisinopril.  The patient required norepinephrine for over an hour. If norepinephrine would have been ineffective, the reported treatment of choice would have been Terlipressin (vasopressin) 1-2 mg which I have not needed to use.

-- From: Lydia Conlay, MD, Houston, Texas

Reply 3

We do not stop ACE inhibitors, but are very cautious with induction. We believe that with caution the problems with these patients are negligible.

-- From: Girish P. Joshi, MB BS, MD, FFARCSI, Dallas, Texas

?? -- THIS MONTH'S QUESTION -- ?? - TOP

Does your ambulatory facility routinely use the BIS monitor? If not, are there specific cases that they are used for?

-- From: Anonymous

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