Perioperative use of β-blockers in patients at high risk
Despite a better understanding of what the predictors and signaling systems underlying the pathophysiology of chronic heart failure and despite the improving results of treatment, a significant number of patients, especially the elderly, do not receive effective treatment. Patients with this pathology usually require additional volume diagnosis and significant extension of the range of anesthetic action in the intensive care unit. It remains debatable whether to continue or discontinue therapy with preoperative angiotensin converting enzyme (ACE) inhibitors. Patients treated with ACE inhibitors were prone to hypotension during induction and maintenance of general anesthesia, most likely as a result of intravascular volume deficit and the inability of angiotensin II to be a natural counterbalance the effects of the sympathetic nervous system (including increased venous return, reduced cardiac output, and reduced arterial blood pressure). Some studies report 22 % of cases of severe hypotension in patients not receiving ACE on the day of operation. Complications in the form of instability of blood pressure and heart rate after induction was also stated in patients receiving ACE inhibitors on a regular basis, regardless of the presence of left ventricular systolic dysfunction. The literature presents reports of hypotension in patients receiving ACE inhibitors, and pain relief was as spinal, epidural or combined anesthesia. It remains unclear whether the use of ACE inhibitors is associated with a particular technique of anesthesia, or indicates probable adverse drug interactions. Prolonged treatment with ACE inhibitors prevents the decrease in blood pressure associated with spinal anesthesia, possibly because the concentration of vasopressin and norepinephrine are sufficient to compensate the negative effects of blood loss. Nonetheless, the temporary withdrawal of ACE inhibitors can prevent or reduce intraoperative hypotension and hypovolemia. Restoration of blood pressure control through the renin-aldosterone system can be realized due to violations of regional circulation. 88 patients were randomized to show that administration of enalapril after induction of anesthesia before the start of cardiopulmonary bypass does not lead to a reduction of cardiac enzyme release, compared with the use of clonidine, enoximone or placebo. In the group of patients with captopril preparation for 2 days, who underwent coronary artery bypass surgery, renal plasma flow and glomerular filtration rate were preserved better during cardiopulmonary bypass compared with the placebo group. In addition, in patients operated for aortic and abdominal pathology, with previous administration of enalapril before induction, there was defined a less significant decrease in cardiac output and glomerular filtration rate during the clamping of the aorta and significantly higher creatinine clearance on the first day after surgery compared with placebo group. Anesthesiologists have to improve perioperative anesthesia during surgeries. Preparations of beta-blockers are prescribed for the treatment of perioperative hypertension, ischemia and arrhythmias determined preoperatively in patients, who had not received such treatment. Perioperative use of β-blockers in patients at high risk is not enough. However, the question whether beta-blockers should be re-applied in the preoperative period only to prevent the negative effects of chronic heart failure remains very disputable.
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