Download Low-Dose Vasopressin and Analogues to Treat

Low-Dose Vasopressin and Analogues to
Treat Intraoperative Refractory Hypotension
in Patients Prescribed Angiotensin-Converting
Enzyme Inhibitors Undergoing General
Anesthesia: A Systematic Review
Kara F. Hedman, DNP, CRNA
Carrie L. Mann, DNP, CRNA
Cheryl Spulecki, DNAP, MS, RN, CRNA
Jessica Castner, PhD, RN, FAEN, CEN, AE-C
This review assessed the utility of vasopressin and
vasopressin analogues for the treatment of refractory
hypotension associated with angiotensin-converting
enzyme (ACE) inhibitors in the perioperative setting.
A systematic review of the literature was conducted
using MEDLINE, Embase, and ProQuest.
Six randomized controlled trials met eligibility criteria. In the perioperative setting, continued use of
ACE inhibitors within 24 hours before surgery remains
controversial. Authors of the reviewed studies suggested that the morning dose of the ACE inhibitor be
held, and those patients experienced decreased catecholamine use postoperatively and shorter duration
of decreased mean arterial pressure. No incidence of
refractory hypertension from withholding the morning dose of the ACE inhibitor was mentioned. All
I
nadequate systemic blood pressure can cause renal
impairment, neurocognitive changes, and organ failure.
Therefore, it is of the utmost importance to maintain
adequate systemic blood pressures in the perioperative
setting. A minimum mean arterial pressure of 50 to
60 mm Hg should be maintained to preserve organ perfusion, and even higher mean arterial pressures are required
for patients who experience preexisting renal dysfunction,
coronary artery disease, diabetes, and hypertension.1
Hypertension is a common condition in many patients
who require surgery with general anesthesia. Patients
treated for hypertension may be taking an angiotensinconverting enzyme (ACE) inhibitor for blood pressure
control and may have taken the medication the night
before or the morning of their procedure. Many of these
patients prescribed an ACE inhibitor are possibly combining an ACE inhibitor with other antihypertensives as
part of a multimodal regimen.2 A patient who receives an
ACE inhibitor within 24 hours of general anesthesia may
experience hypotension intraoperatively that is refractory
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of the patients receiving vasopressin demonstrated
improved hemodynamic stability with small, intermittent doses, without profound ischemic changes.
For management (prevention and treatment) of ACE
inhibitor–associated hypotension in the perioperative
setting, all studies showed statistically significant
success with vasopressin or vasopressin analogues
for improvement of systemic blood pressures. Before
vasopressin is widely accepted as a standard of care,
further studies are needed to confirm these findings
and assess the general utility of vasopressin in surgical
populations for management of ACE inhibitor–associated refractory hypotension.
Keywords: Angiotensin-converting enzyme inhibitor,
perioperative, refractory hypotension, vasopressin.
to standard treatments such as a fluid bolus, ephedrine,
or phenylephrine.2 Angiotensin-converting enzyme inhibitors induce a decrease in adrenergic receptor sensitivity, limiting the clinical effect of adrenergic drugs such
as ephedrine. Chronic blunting of the renin-angiotensinaldosterone system necessitates an increase in dose as
well as the refractory effect.3 Further hypotension is associated with the interference of anesthesia on the sympathetic system, which creates angiotensin dependence
of the arterial blood pressure. This state of autonomic
dysfunction is also referred to as “vasoplegia,” in which
the patient experiences low systemic vascular resistance
and high cardiac output.4 Although ACE inhibitor–associated refractory hypotension in the perioperative setting
is a recognized problem, guidelines regarding its management are lacking.2
Currently, there is a paucity of literature regarding
withholding or continuing use of ACE inhibitors before
surgery, and a consensus has not been reached regarding
a standardized protocol.5 Suggestions have been made to
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Figure 1. Site of Action for Angiotensin-Converting
Enzyme (ACE) Inhibitors
Abbreviations: ACEI, angiotensin-converting enzyme inhibitor; AT1,
angiotensin II receptor, type 1; AT2, angiotensin II receptor, type 2.
avoid intraoperative hypotension by stopping use of the
medications before surgery, usually on the day of surgery
or the day before the procedure.5 Further suggestions
have been made to continue use of the ACE inhibitor
on the day of surgery to avoid rebound hypertension.6
However, according to the large, prospective randomized
controlled trial by Twersky et al,7 discontinuing use of
ACE inhibitors and angiotensin renin blockers (ARBs)
in patients on the day of surgery did not result in an increased incidence of pre- or postoperative hypertension
compared with those patients who continued use of these
medications on the morning of surgery. Therefore, it is
safe to discontinue use of ACE inhibitors and ARBs on the
day of surgery without increasing the potential for adverse
hemodynamic changes. According to Smith and Jackson,8
ACE inhibitors and ARBs increase the likelihood of intraoperative hypotension and should be held on the day of
surgery; however, if these instructions seem to confuse
patients, they should be told to take all their medications rather than risk missing their β-blocker or calcium
channel blocker. These reviewers were not referring to
refractory hypotension, commenting that most hypotension can be reversed by standard treatment modalities.
Controversy also surrounds the use of ACE inhibitors on the day of surgery because of the probability of
the medication causing upper airway complications. As
shown in Figure 1, ACE inhibitors increase the total
tissue bradykinin, which has the potential to increase
cough, angioedema, and bronchospasm. Turan and colleagues5 concluded there were no significant associations
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between preoperative ACE inhibitor use and intraoperative or postoperative respiratory complications.
Angiotensin-converting enzyme inhibitors block the
renin-angiotensin-aldosterone system by inhibiting the
conversion of angiotensin I to angiotensin II.9 By blocking
this stage of the body’s blood pressure regulation center,
systemic blood pressure is decreased. Receiving an ACE
inhibitor before surgery can result in marked hypotension
because the half-life is more than 10 hours. Perioperative
hypotension may also be associated with other medications administered in the operating room, such as propofol and inhaled anesthetic agents. These agents inhibit the
sympathetic nervous system, resulting in a decrease in the
overall cardiac output and systemic vascular resistance,
further contributing to the vasodilatory shock.9 Patients
presenting on the day of surgery are also volume depleted
as a result of fluid restrictions before surgery, which may
exacerbate their hypotensive state.
In recent years, vasopressin and vasopressin analogues
have been documented as treatment options for patients
experiencing vasoplegia in the perioperative setting.2
Vasopressin is a neurohypophysial hormone naturally
occurring in humans. Its primary functions are to retain
water and to constrict the blood vessels, leading to an
increase in the overall fluid load in the intravascular
compartment.9 The vasopressin system is the only endogenous vasopressor system that is not blocked during
general anesthesia in patients receiving ACE inhibitors,
which may be the reason vasopressin has been a potential
successful treatment modality.2
A systematic review regarding vasopressin and its
analogues for the treatment of refractory hypotension in
neonates has been completed10; however, this was not
specific to the adult surgical population, and the documented hypotension was not a specific response to the
use of ACE inhibitors. Although studies have been documented to address the efficacy of vasopressin for treating
ACE inhibitor–associated refractory hypotension in the
perioperative setting, a systematic review of the literature
in populations other than neonates has yet to be conducted. To address this gap in the literature, the purpose of
this systematic review was to examine evidence regarding
vasopressin and vasopressin analogues for the treatment
of refractory hypotension associated with ACE inhibitors
in the perioperative setting.
Materials and Methods
We conducted a systematic review of the literature,
aiming to examine the best available current knowledge of
vasopressin and vasopressin analogues for the treatment
of refractory hypotension associated with ACE inhibitors
in the perioperative setting. A protocol for this review was
developed in collaboration with a health service librarian
(online supplemental content). Search terms were developed using the synonyms listed in Table 1.
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PopulationInterventiona
Type of study
Patients taking ACE inhibitors AND refractory hypotension
Vasopressin
CCT and RCT
Refractory hypotension
Vasopressin
Trial
Vasoplegic syndrome
Pitressin
Random
Vasodilatory shock
Antidiuretic Hormone
Control
ACE inhibitors ADH
Double blind
Angiotensin-converting enzyme inhibitors
arginine vasopressin
Allocate
Benazepril
AVPProspective
Captopril
ArgipressinComparative
Enalapril
Vasopressin agonists
FosinoprilTerlipressin
Lisinopril
Perindopril
Ramipril
Table 1. Population, Intervention, Type of Study Search Term Synonyms
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Records identified through
database searching
(n = 24)
Additional records identified
through other sources
(n = 26)
Screening
Records screened
(n = 47 )
Records excluded
(n = 40)
Eligibility
Records after duplicates removed
(n = 47)
Full-text articles assessed
for eligibility after
screening abstracts
(n = 7)
Full-text articles excluded
(n = 1)
Studies included
(n = 6)
Reasons for exclusion:
After full text review, 1
article did not meet
randomized controlled
trial or clinical controlled
trial criteria.
Included
We structured our search using the PICOT method,
which stands for patient population, intervention, comparison intervention, outcome, and type of study.11
The reviewers included studies with a patient population that received an ACE inhibitor within 24 hours of
the induction of general anesthesia. In particular, we
focused on studies of hypotension resistant to standard
treatment modalities. The interventions of interest included the administration of vasopressin or vasopressin
analogues (terlipressin) alone or in combination with
another medication for the prevention or treatment of
ACE inhibitor–associated refractory hypotension. The
comparison interventions, or standard treatment medications, for hypotension in the operative setting included
ephedrine and phenylephrine. The primary efficacy
outcomes included in this review are the achievement of
normotension and hemodynamic stability as described by
the original studies’ authors. We included studies with
randomized controlled trial (RCT) or controlled clinical
trial designs as the type of study. We did not exclude any
comorbid conditions or disease states in the review.
The search strategy was aimed to find both published and unpublished studies. We searched MEDLINE,
Embase, and ProQuest theses and dissertations databases,
limited to English-language articles and human studies.
We did not limit the year of publication in MEDLINE
and Embase, but used a 10-year limit in ProQuest to
narrow results. The reference lists from the identified
RCTs and controlled clinical trials were reviewed for
additional studies. A Preferred Reporting Items for
Systematic Reviews and Meta-Analyses (PRISMA)12 flow
diagram (Figure 2) depicts the process for screening
and selecting studies. Initially, 2 review authors (K.F.H
and C.L.M.) independently read through each of the
Identification
Abbreviations: ADH, antidiuretic hormone; AVP, arginine vasopressin; CCT, controlled clinical trial; RCT, randomized controlled trial.
aComparison intervention is no vasopressin, and outcome is normotension/hemodynamic stability.
Figure 2. Study Selection and Inclusion
study’s titles and abstracts to determine if the study met
inclusion and exclusion criteria. Any differences were
resolved by discussion to consensus. If no consensus was
reached, the study was included in the full text screening. We abstracted the sample size, purpose, and key
findings from each study. The evidence was appraised
using a domain-based approach,12 in which the study
was assessed for risk of bias in random sequence generation, allocation concealment, blinding of participants
and personnel, blinding of outcomes assessment, incomplete outcomes data (both short term and long term),
and selective reporting.13
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Results
From a total of 47 potential studies, 6 RCTs met eligibility criteria, with a pooled sample size of 216 individual
patients.9,13-17 Table 2 summarizes the study sample
size, purpose, and key findings for each of the 6 included studies. All the studies included were RCTs. The
studies included had the same general purpose, that is,
to understand the efficacy of vasopressin or vasopressin
analogues in maintaining blood pressure in patients who
received an ACE inhibitor before general anesthesia. Half
of the included studies sought to compare vasopressin
or terlipressin with standard modalities for the treatment of refractory hypotension.9,13,16 The remaining
studies examined the role of vasopressin or terlipressin at a low dose to prophylactically inhibit refractory
hypotension.14,15,17 Hasija et al,14 Morales et al,15 and
Papadopoulos et al17 included only patients undergoing coronary artery bypass, whereas Meersschaert et al,9
Boccara et al,13 and Morelli et al16 included only patients
undergoing vascular surgery.
Figure 3 depicts the quality of evidence using a
domain-based approach to summarize the risk of bias in
the individual studies.12 All the studies displayed a low
risk of selection bias.9,12,14-17 Most of the studies also
displayed a low risk of performance and detection bias.
The risk of attrition bias was unclear, because most of the
studies did not address outcomes data after the postoperative recovery period. There was a mix between unclear
risk and higher risk of reporting bias among the studies.
Discussion
This review examined the best available current knowledge of vasopressin and vasopressin analogues for the
treatment of refractory hypotension associated with ACE
inhibitors in the perioperative setting. This study adds
to the existing literature, in which only a review using
neonates was previously found.10
Of the 6 studies included in our review, all were
RCTs with reasonably little bias.9,13-17 Although all of
the studies reported a sample between 27 and 50 subjects, the samples were adequate to achieve statistically
significant differences in each study. In addition, some
studies specifically reported an adequate number of
subjects to achieve power analyses greater than 75% and
90%. Therefore, it is reasonable to consider the clinical utility of vasopressin and vasopressin analogues for
the treatment of ACE inhibitor–associated hypotension
in the perioperative setting. However, this evidence is
limited to patients undergoing coronary artery bypass or
vascular surgery, and research in other surgical populations is needed.
For the management (prevention and treatment) of
ACE inhibitor–associated hypotension in the perioperative setting, each of the studies reviewed demonstrated
success with vasopressin or terlipressin for improvement
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of systemic blood pressures. Boccara and colleagues13
state that 1 to 2 U of intravenous vasopressin is appropriate for the management of refractory hypotension
intraoperatively once the standard doses of ephedrine
and phenylephrine have been tried without success. The
benefit of using vasopressin to treat hypotension far
outweighs the deleterious effect of profound hypotension. Discontinuation of the ACE inhibitor on the day
of surgery does not put the patient at risk of profound
hypertension and should be considered the preferred
method of blood pressure regulation for patients prescribed this medication presenting on the day of surgery.
In common clinical practice, clinicians may have also
encouraged the use of an anticholinergic medication
such as atropine or glycopyrrolate. However, these medications were not included in the studies reviewed here.
This could possibly be due to the concurrent tachycardia
that patients may exhibit in their vasoplegic state. Future
studies should incorporate anticholinergic agents as an
additional comparison outcome.
Although terlipressin was used frequently in the
research and shown to be efficacious in maintaining
systemic blood pressure, it is not currently available in
the United States.2 Therefore, additional studies may be
necessary to determine comparative doses of vasopressin
agonists available in the United States. Morelli and colleages16 did suggest the potential detrimental effects of terlipressin on the gastrointestinal mucosa, stating that a decrease in gastric mucosal perfusion was detected by laser
Doppler flowmetry over 30 minutes, but this decrease
was notable only with a continuous infusion of vasopressin. Future research would be useful to assess for the
potential negative outcomes associated with vasopressin
or terlipressin when used intermittently for the treatment or prevention of ACE inhibitor–associated refractory hypotension in the perioperative setting. However,
it can be inferred from the included studies that patients
who exhibit refractory hypotension and are taking an
ACE inhibitor may exhibit more hemodynamic stability
if administered a dose of vasopressin intraoperatively.
Synergism between vasopressin and ephedrine is also a
proposed method of increased arterial blood pressure.14
The studies reviewed did not address long-term
outcomes data, introducing some potential long attrition bias. The studies reviewed included only patients
undergoing coronary artery bypass14,15,17 or vascular
surgery.9,13,16 Therefore, findings of the studies may
not be representative of all surgical patients who experience ACE inhibitor–associated refractory hypotension. Limitations also include the generalizability of the
studies included in the systematic review due to a small
sample size limited to coronary artery bypass and vascular surgeries. However, this is currently the evidence
available for review, and a larger meta-analysis or randomized control trial is warranted.
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To test the administration of terlipressin
with ephedrine vs ephedrine alone to
restore blood pressure in ACE inhibitor–
treated patients undergoing anesthesia
40
Meersschaert,
et al,9 2002
To examine the possible role of prophylactic infusion of low-dose vasopressin
during and for 4 hours after cardiopulmonary bypass to reduce vasoplegic
shock for patients currently receiving
ACE inhibitors with a low ejection fraction
To compare effects of terlipressin
and norepinephrine on systemic and
regional hemodynamics when used to
treat anesthesia-induced hypotension
in patients treated long term with ACE
inhibitors or angiotensin II receptor
blockers
32
50
In patients undergoing cardiopulmonary
bypass, this study sought to examine
whether initiation of vasopressin before
bypass would diminish hypotension
postoperatively by avoiding vasopressin
deficiency
27
Abbreviation: ACE, angiotensin-converting enzyme.
Key findings
• Catecholamine infusion time was significantly lower in the vasopressin group.
• Increased 24-hour diuresis in the patients in the vasopressin group.
•S
howed that pulmonary vascular resistance and mean pulmonary artery pressure were not affected by
the vasopressin infusion.
• Cannot conclude an appropriate dose of vasopressin because of lack of evidence.
• Incidence of vasodilatory shock was significantly lower in the vasopressin group (4%) compared with
the control group (20%).
• Terlipressin did not increase the heart rate significantly; however, norepinephrine did increase the heart
rate.
• Terlipressin was associated with an overall reduction in oxygen consumption as well as gastric mucosal
perfusion, but an increase in mean arterial pressure.
• Norepinephrine group experienced increased mean arterial pressures as well as an increase in gastric
mucosal perfusion as noted by Doppler flowmetry.
• Vasopressin increases cytosolic calcium levels through inositol trisphosphate second messenger system and antagonizes the vasodilatory mechanisms of shock.
• Vasopressin reduced the number of hypotensive episodes and decreased the duration of catecholamine
infusions, leading to earlier extubation.
• With a partially blocked endogenous response to hypotension, the use of a vasopressin analogue is
useful in maintaining intraoperative blood pressure.
•H
ypotensive episodes may be unresponsive to ephedrine administration, and the combination of
ephedrine and terlipressin is a more effective treatment of hypotension occurring in these patients.
•H
ypotensive episodes requiring vasoconstrictive treatment are frequent after the induction of general
anesthesia in patients treated long term with ACE inhibitors.
• No ischemic complications were noted, and urine output in patients who received vasopressin was
similar to that in the control group.
• The low-dose vasopressin group required lower norepinephrine doses and had fewer hypotensive episodes and shorter intubation times.
• Patients who discontinued use of their ramipril the morning of their surgery had higher mean arterial
pressures and systemic vascular resistance compared with those who continued use of their ramipril
the morning of surgery.
• Proposed fluid loading before induction and titration of propofol to obtain hemodynamic stability.
• Terlipressin was not associated with undesirable arterial blood pressure increase or heart rate response.
• Terlipressin was more effective than norepinephrine and had more prolonged action in controlling arterial blood pressure without any significant adverse effects.
• Terlipressin and norepinephrine corrected hypotension in all cases. Time spent with systolic blood pressure < 90 mm Hg was less in the terlipressin group.
Table 2. Matrix of Studies, Sample Size, Purpose, and Key Findings
Papadopoulos
et al,17 2010
Morelli et
al,16 2005
Morales et
al,15 2003
To compare the effects of continuation
vs discontinuation of the ACE inhibitor ramipril and assess the efficacy of
prophylactic vasopressin infusion on
hemodynamic stability and vasoactive
drug requirements in patients undergoing coronary bypass surgery
47
Hasija et al,14
2010
Purpose
42
Boccara et
al,13 2013
To compare terlipressin to the standard
vasopressor agent (norepinephrine) for
treatment of refractory hypotension
after general anesthesia in patients
undergoing carotid surgery and treated
long term with ACE inhibitors or angiotensin II blockers
Sample
size (N)
Author,
year
Selective reporting (reporting bias)
Incomplete outcomes data (attrition bias),
long term > 6 weeks
Incomplete outcomes data (attrition bias),
short- term 2-6 weeks
Blinding of outcome assessment (detection
bias), all-cause mortality
Blinding of outcomes assessment (detection
bias), patient-reported outcomes
Blinding of participants and personnel
(performance bias)
Allocation concealment
(selection bias)
Random sequence generation
(selection bias)
Author, Year
Boccara,13 2003
Hasija,14 2010
Meersschaert,9
2002
Morales,15 2003
Morelli,16 2005
Papadopoulos,17
2010
Figure 3. Risk of Bias Summary Using Domain-Based Approach
Abbreviations: Plus sign, present; question mark, unknown; minus sign, not present.
Another possible limitation in the review is the patients’ compliance when asked to discontinue use of
their medications on the day of their procedure and to
continue use of other medications such as β-blockers.
Confusion among patients regarding their preoperative
instructions could limit the findings of the 6 studies
mentioned. There is also potential for the patient’s record
to be augmented, especially in the paper charts where
providers may omit low blood pressures. Terlipressin also
remains unavailable in the United States, which does not
allow for practitioners to administer the vasopressin analogue. Further research is needed with the use of computer charting as well as addressing clear patient instructions
in the preoperative interview regarding the continuation
or discontinuation of their current medications.
Conclusion
Each of the included studies provides evidence to suggest
success with small bolus doses of vasopressin or terlipressin for improvement of systemic blood pressure in the
perioperative period for patients taking an ACE inhibitor
24 hours before surgery. Suggested dosing for vasopressin
according to Boccara and colleages13 was 1 or 2 U for in-
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traoperative hypotension refractory to standard doses of
phenylephrine or ephedrine. Before vasopressin is widely
accepted as a standard of care, further studies would be
beneficial to assess the general utility of vasopressin in
surgical populations for treatment or prevention of ACE
inhibitor–associated refractory hypotension. However,
suggestions can be made for its use intraoperatively in
a patient experiencing refractory hypotension currently
receiving an ACE inhibitor.
REFERENCES
1. Bojar RM. Manual of Perioperative Care in Adult Cardiac Surgery. 5th
ed. Chichester, UK: Blackwell-Wiley; 2011.
2. Thoma A. Pathophysiology and management of angiotensin-converting enzyme inhibitor-associated refractory hypotension during the
perioperative period. AANA J. 2013;81(2):133-140.
3. Licker M, Neidhart P, Lustenberger S, et al. Long-term angiotensinconverting enzyme inhibitor treatment attenuates adrenergic responsiveness without altering hemodynamic control in patients undergoing cardiac surgery. Anesthesiology. 1996;84(4):789-800.
4. Iribarren J, Jimenez J, Brouard M, et al. Vasoplegic syndrome after
cardiopulmonary bypass surgery–associated factors and clinical outcomes: a nested case-control study. Crit Care. 2007;11(suppl 2):1-2.
5. Turan A, You J, Shiba A, Kurz A, Saager L, Sessler DI. Angiotensin
converting enzyme inhibitors are not associated with respiratory
www.aana.com/aanajournalonline
complications or mortality after noncardiac surgery. Anesth Analg.
2012;114(3):552-560.
6. Comfere T, Sprung J, Kumar MM, et al. Angiotensin system inhibitors
in a general surgical population. Anesth Analg. 2005;100(3):636-644.
7. Twersky RS, Goel V, Narayan P, Weedon J. The risk of hypertension
after preoperative discontinuation of angiotensin-converting enzyme
inhibitors or angiotensin receptor antagonists in ambulatory and
same-day admission patients. Anesth Analg. 2014;118(5):938-944.
8. Smith I, Jackson I. Beta-blockers, calcium channel blockers, angiotensin converting enzyme inhibitors and angiotensin receptor blockers:
should they be stopped or not before ambulatory anaesthesia? Curr
Opin Anaesthesiol. 2010;23(6):687-690.
9. Meersschaert K, Brun L, Gourdin M, et al. Terlipressin-ephedrine
versus ephedrine to treat hypotension at the induction of anesthesia
in patients chronically treated with angiotensin converting-enzyme
inhibitors: a prospective, randomized, double-blinded, crossover
study. Anesth Analg. 2002;94(4):835-840.
10. Shivanna B, Rios D, Rossano J, Fernandes CJ, Pammi M. Vasopressin and its analogues for the treatment of refractory hypotension in
neonates. Cochrane Database Syst Rev. 2013;(3):CD009171.
11. Higgins JPT, Green S, eds. Cochrane Handbook for Systematic Reviews of
Interventions. Version 5.0.2. ebook: The Cochrane Collaboration; 2008.
12. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items
for systematic reviews and meta-analyses: the PRISMA statement. Ann
Intern Med. 2009;151(4):264-269.
13. Boccara G, Ouattara A, Godet G, et al. Terlipressin versus norepinephrine to correct refractory arterial hypotension after general anesthesia in patients chronically treated with renin-angiotensin system
inhibitors. Anesthesiology. 2003;98(6):1338-1344.
14. Hasija S, Makhija N, Choudhury M, Hote M, Chauhan S, Kiran U.
Prophylactic vasopressin in patients receiving the angiotensin-converting enzyme inhibitor ramipril undergoing coronary artery bypass
graft surgery. J Cardiothorac Vasc Anesth. 2010;24(2):230-238.
15. Morales DLS, Garrido MJ, Madigan JD, et al. A double-blind randomized trial: prophylactic vasopressin reduces hypotension after cardiopulmonary bypass. Ann Thorac Surg. 2003;75(3):926-930.
www.aana.com/aanajournalonline
16. Morelli A, Tritapepe L, Rocco M, et al. Terlipressin versus norepinephrine to counteract anesthesia-induced hypotension in patients
treated with renin-angiotensin system inhibitors: effects of systemic and
regional hemodynamics. Anesthesiology. 2005;102(1):12-19.
17. Papadopoulos G, Sintou E, Siminelakis S, Koletsis E, Baikoussis NG,
Apostolakis E. Perioperative infusion of low- dose of vasopressin for
prevention and management of vasodilatory vasoplegic syndrome in
patients undergoing coronary artery bypass grafting—a double-blind
randomized study. J Cardiothorac Surg. 2010 Mar 28;5:17.
AUTHORS
Kara F. Hedman, DNP, CRNA, attended the University at Buffalo, Buffalo,
New York, at the time of writing of this article. She is now a staff nurse
anesthetist at the University of Rochester Medical Center, Rochester, New
York. Email: [email protected].
Carrie L. Mann, DNP, CRNA, attended the University at Buffalo, Buffalo, New York, at the time of writing of this article. She is now a staff
nurse anesthetist at the University of Rochester Medical Center, Rochester,
New York.
Cheryl Spulecki, DNAP, MS, RN, CRNA, is the assistant program
director and clinical coordinator at the University at Buffalo School of
Nursing Nurse Anesthesia Program, Buffalo, New York.
Jessica Castner, PhD, RN, FAEN, CEN, AE-C, is an assistant professor
at the University at Buffalo School of Nursing, Buffalo, New York and is
the associate editor of the Journal of Emergency Nursing.
DISCLOSURES
The authors have declared they have no financial relationships with any
commercial interest related to the content of this activity. The authors did
discuss off-label use within the article.
ACKNOWLEDGMENTS
The authors would like to thank Sharon Murphy, BSN, MLS, for her support and guidance and Elexa Kopty, LSW, for assistance in manuscript
preparation.
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