Prophylactic Vasopressin in Patients Receiving the Angiotensin-Converting Enzyme Inhibitor Ramipril Undergoing Coronary Artery Bypass Graft Surgery

Hasija, Suruchi; Makhija, Neeti; Choudhury, Minati; Hote, Milind; Chauhan, Sandeep; Kiran, Usha

doi:10.1053/j.jvca.2009.08.001

« Previous Next »Journal of Cardiothoracic and Vascular Anesthesia
Volume 24, Issue 2 , Pages 230-238, April 2010

Prophylactic Vasopressin in Patients Receiving the Angiotensin-Converting Enzyme Inhibitor Ramipril Undergoing Coronary Artery Bypass Graft Surgery

Suruchi Hasija, MD
- Department of Cardiac Anaesthesia, Cardiothoracic Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
Neeti Makhija, MD
- Department of Cardiac Anaesthesia, Cardiothoracic Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
- Address reprint requests to Neeti Makhija, MD, 7th Floor, Department of Cardiac Anaesthesia, Cardiothoracic Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India
Minati Choudhury, MD
- Department of Cardiac Anaesthesia, Cardiothoracic Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
Milind Hote, MS, MCh
- Department of Cardiothoracic and Vascular Surgery, Cardiothoracic Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
Sandeep Chauhan, MD
- Department of Cardiac Anaesthesia, Cardiothoracic Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
Usha Kiran, MD
- Department of Cardiac Anaesthesia, Cardiothoracic Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India

published online 29 October 2009.

Objective

The purpose of this study was to compare the effects of continuation versus discontinuation of the angiotensin-converting enzyme (ACE) inhibitor ramipril and assess the efficacy of prophylactic vasopressin infusion on hemodynamic stability and vasoactive drug requirements in patients undergoing coronary artery bypass graft (CABG) surgery.

Design

A prospective, randomized, double-blinded, single-center clinical study.

Setting

Tertiary care hospital.

Participants

Forty-seven patients on the ACE inhibitor ramipril for 6 weeks before undergoing elective primary CABG surgery on cardiopulmonary bypass (CPB).

Interventions

Patients were randomly divided into 3 groups: group A (n = 16), patients discontinued ramipril 24 hours before surgery; group B (n = 16), patients continued ramipril until the morning of surgery; and group C (n = 15), patients continued ramipril until the morning of surgery and received vasopressin infusion (0.03 U/min) from the onset of rewarming until the hemodynamics were stable without vasopressor agents. The anesthetic technique and conduct of CPB were standardized for all the groups. Hemodynamic parameters and vasoactive drug requirements were recorded for 3 days postoperatively.

Measurements and Main Results

Patients in group A maintained stable mean arterial pressure (MAP) and systemic vascular resistance (SVR). In group B, MAP and SVR decreased after the induction of anesthesia and remained so throughout surgery (p < 0.05). In group C, MAP and SVR decreased upon the induction of anesthesia (p < 0.05) but normalized after CPB.

Conclusions

Preoperative ACE inhibitor continuation predisposed to hypotension upon the induction of anesthesia and in the post-CPB period. Prophylactic low-dose vasopressin infusion prevented post-CPB hypotension. Low-dose vasopressin can be considered as potential therapy in these patients.

Key Words: angiotensin-converting enzyme inhibitor, hemodynamic, vasoactive, vasopressin, coronary artery bypass graft surgery