关于术前依那普利类药物的应用

jigang

最近听说依那普利类药物术前应提前停药，具体原理是术中对血压影响较大，此说法是否确实存在？如若存在请问术前应停药多长时间？谢谢！

pinglelee

依那普利属于血管紧张素转化酶抑制剂(ACEI)，ACEI主要的药理作用是抑制ACE活性，减少血管紧张素Ⅱ的生成，减少缓激肽的水解，导致血管舒张、血容量减少血压下降，对肾血管性高血压特别有效，对心肾脑等器官有保护作用；能减轻心肌肥厚，能阻止或逆转心血管病理性重构。
   那就不能不提肾素-血管紧张素-醛固酮（RAS）系统，RAS系统对血压的调节有着极其重要的意义，但其激活也是机体应激的标志，抑制了该系统可降低血压，也可抑制机体的代偿功能，比如可能大量失血的手术，容量不足时，由于抑制了血管紧张素2和醛固酮的释放，不利于升高血压及维持容量；
    再者，ACEI对肾小球的入球血管扩张大于出球血管，降低肾小囊囊内压（这正是对肾小球三高患者缓解肾小球高灌注压、减少蛋白尿、减轻肾脏负担的机理所在），但在低血压、低血容量时就不能维持有效的肾小球灌注压，可能增加肾功能不全的风险。-----------这是个人的推测，呵呵。
    国外研究：对于拟行CABG患者来说，术前应用ACEI会使死亡风险增加一倍，同时还会增加术后肾功能不全和房颤发生风险、增加正性肌力药物应用需求，为了改善患者早期预后，术前2~3天至术后2天停服ACEI也许更合理。
   以上所说手术为术中可能发生低血压、低血容量者，特别是心血管系统手术，一般小手术应该没有问题。当然，如果停用该类药物，最好换其他降压药物，尽量避免围术期血压的剧烈波动。------个人觉得应该这样吧。
   希望有这方面经验或是文献支持的朋友不吝赐教！谢谢。

j10

根据2007ACC/AHA非心脏手术患者围手术期心血管系统的评估指南，一些学者主张高血压病人血管紧张素转化酶抑制剂在术晨可以不用，以避免术中发生严重的低血压。

mj5472111

我感觉ACEI类药物手术前用椎管内麻醉可能出现低血压，我们有好几例了，可麻醉教科书直说利血平和ß受体阻滞剂不能用，前者使儿茶酚胺衰竭，手术中血压下降很难提压，后者由于ß受体“反跳”，可引起高血压。ACEI类药物我推测主要是通过体液调节使减少血管紧张素Ⅱ的生成，减少缓激肽的水解，导致血管舒张、血容量减少血压下降，手术前进食水往往血容量不足，导致双重降压效应。外科住院高血压病人经常口服北京降压0好，为复方利血平胺苯喋喋。含有利血平和利尿剂，所以最好不用，此外长期服用此类药物要注意利尿剂引起低血钾和血容量不足。

qiuhuanrong

We routinely administer all antihypertensive drugs preoperatively, except ACE inhibitors or angiotensin II antagonists (AIIAs), which we tailor to the individual patient. Coriat and colleagues[122] found that ACE inhibitors were associated with hypotension in 100% of patients during induction versus about 20% in whom ACE inhibitors were withheld on the morning of surgery. Bertrand and coworkers performed a prospective randomized study in which it was demonstrated that more severe hypotensive episodes requiring vasoconstrictor treatment occur after induction of general anesthesia in patients chronically treated with an AIIA and receiving the drug on the morning before surgery than in those in whom AIIAs were discontinued on the day before surgery.[123] Kheterpal and colleagues performed a propensity-matched analysis of 12,381 noncardiac surgery cases.[124] Patients with chronic ACE inhibitor/angiotensin receptor blocker and diuretic therapy showed more periods with a mean arterial BP lower than 70 mm Hg, periods with a 40% decrease in systolic BP, periods with a 50% decrease in systolic BP, and vasopressor boluses than patients receiving diuretic therapy alone did. If these drugs are continued, vasopressin is the drug of choice for refractory hypotension. Although the long-term adverse effects of withholding therapy on the morning of surgery were not assessed, we withhold therapy until either oral fluid is able to be consumed (ambulatory patients) or we can convert to intravenously or nasogastrically administered alternatives (patients who remain NPO postoperatively). We even administer the patient's chronic diuretics on the morning of surgery because the major effect of diuretics after 1 week of therapy is arteriolar vasodilation and assessment of urine output may be inaccurate if the diuretic is abruptly discontinued on the morning of surgery.摘自Miller Anestehsia.7th edition.

小麻将123

直到手术当天早上