• Medicine · Nov 2023

    Case Reports

    Severe refractory hypotension during induction of general anesthesia in patient after 48 hours of azilsartan discontinuation: A case report.

    • Ji Hye Lee, Yu Yil Kim, Hyun Joo Heo, Gwanbeom Kim, and Changhwan Oh.
    • Department of Anesthesiology and Pain Medicine, Presbyterian Medical Center, Jeonju, Jeollabuk-Do, Korea.
    • Medicine (Baltimore). 2023 Nov 24; 102 (47): e36126e36126.

    RationaleAngiotensin II receptor blockers (ARBs) are currently considered first-line antihypertensive drugs, effectively inhibiting the renin-angiotensin-aldosterone system. However, ARBs have been associated with intraoperative hypotension during general anesthesia. Although it is recommended to discontinue ARBs for 24 hours before surgery, the optimal duration of discontinuation remains unclear. We present a severe refractory hypotension encountered during general anesthesia despite discontinuing ARBs for 48 hours before anesthesia.Patient ConcernsA severe refractory hypotension occurred during the induction of general anesthesia for cranioplasty in a 66-year-old male patient (170 cm/75 kg). The patient was taking azilsartan, angiotensin receptor blocker, for hypertension, which was discontinued 48 hours before anesthesia induction. Despite repeated administration of ephedrine and continuous infusion of norepinephrine, hemodynamic instability did not improve. Therefore, the surgery was postponed.DiagnosisThe patient was diagnosed with angiotensin receptor blocker-induced refractory hypotension.InterventionsBefore the second surgery, the angiotensin receptor blocker was discontinued 96 hours prior to the surgery. Invasive blood pressure monitoring was performed before anesthesia induction, and vasopressin was prepared. General anesthesia was induced using remimazolam and maintained with desflurane.OutcomesThe surgery was completed successfully without occurrence of refractory hypotension.LessonsRefractory hypotension induced by Angiotensin receptor blockers can still occur even after discontinuing the medication for 48 hours before induction of general anesthesia. Despite withholding the medication, caution should be practiced regarding hypotension during general anesthesia in patient taking ARBs.Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.

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