Perioperative management of patients treated with angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers: A quality improvement audit

Previous studies have shown that patients continuing angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers on the day of surgery are more likely to have significant intraoperative hypotension, higher rates of postoperative acute kidney injury, and lower incidences of postopera...

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Bibliographic Details
Published in:Anaesthesia and intensive care 2016-05, Vol.44 (3), p.346-352
Main Authors: Vijay, A., Grover, A., Coulson, T. G., Myles, P. S.
Format: Article
Language:English
Subjects:
Acute Kidney Injury - epidemiology
Acute Kidney Injury - etiology
Acute renal failure
Aged
Angiotensin II
Angiotensin Receptor Antagonists - administration & dosage
Angiotensin Receptor Antagonists - adverse effects
Angiotensin Receptor Antagonists - pharmacology
Angiotensin-Converting Enzyme Inhibitors - administration & dosage
Angiotensin-Converting Enzyme Inhibitors - adverse effects
Angiotensin-Converting Enzyme Inhibitors - pharmacology
Atrial fibrillation
Atrial Fibrillation - epidemiology
Atrial Fibrillation - etiology
Bias
Confounding Factors (Epidemiology)
Female
Humans
Hypotension - epidemiology
Hypotension - etiology
Incidence
Kidneys
Male
Middle Aged
Perioperative Care - methods
Postoperative Complications - epidemiology
Postoperative Complications - etiology
Prospective Studies
Research Design
Treatment
Wounds and injuries
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Summary:Previous studies have shown that patients continuing angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers on the day of surgery are more likely to have significant intraoperative hypotension, higher rates of postoperative acute kidney injury, and lower incidences of postoperative atrial fibrillation. However, many of these studies were prone to bias and confounding, and questions remain over the validity of these outcomes. This observational, before-and-after quality improvement audit aimed to assess the effect of withholding these medications on the morning of surgery. We recruited 323 participants, with 83 (26%) having their preoperative angiotensin-converting enzyme inhibitor (ACEi) or angiotensin II receptor blocker (ARB) withheld on the day of surgery. There were only very small Spearman rank-order correlations between time since last dose of these medications (rho -0.12, P=0.057) and intraoperative and recovery room intravenous fluid administration (rho -0.11, P=0.042). There was no statistically significant difference between the continued or withheld groups in vasopressor (metaraminol use 3.5 [1.5-8.3] mg versus 3.5 [1.5-8.5] mg, P=0.67) or intravenous fluid administration (1000 ml [800-1500] ml versus 1000 [800-1500] ml, P=0.096), nor rates of postoperative acute kidney injury (13% vs 18%, P=0.25) or atrial fibrillation (15% versus 18%, P=0.71). This audit found no significant differences in measured outcomes between the continued or withheld ACEi/ARB groups. This finding should be interpreted with caution due to the possibility of confounding and an insufficient sample size. However, as the finding is in contrast to many previous studies, future prospective randomised clinical trials are required to answer this important question.
ISSN:0310-057X
1448-0271
DOI:10.1177/0310057X1604400305