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The Anesthetic Hazards in Patients on Antihypertensive Therapy

D. LeRoy Crandell, M.D.
[+] Author Affiliations

Read before the Section on Anesthesiology at the 110th Annual Meeting of the American Medical Association, New York City, June 28, 1961.


Winston-Salem, N.C.

Associate Professor and Chairman of the Section on Anesthesiology of the Department of Surgery, Bowman Gray School of Medicine of Wake Forest College and the North Carolina Baptist Hospital.


JAMA. 1962;179(7):495-500. doi:10.1001/jama.1962.03050070017004
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Antihypertensive drugs interfere with hemodynamic adjustments and can cause profound cardiovascular collapse when a patient is subjected to the stress of anesthesia and surgery. They constitute an insidious hazard to surgical patients. In patients who have received antihypertensive medication the primary problem is to determine the availability of the intrinsic catechol amines and the patient's ability to respond to them. This problem is solved by using the ephedrine response test (ERT). The test consists of 2 intravenous injections of ephedrine; the first injection of 10 mg. is followed promptly by additional 5 mg. If the ERT does not elicit a rise of at least 20 mm. Hg in blood pressure, the patient is believed to be unprepared for the cardiovascular stress of general, spinal, or spidural anesthesia.

REFERENCES

Price, H. L.:  Circulatory Actions of General Anesthetic Agents and Homeostatic Roles of Epinephrine and Norepinephrine in Man , Clin Pharmacol Ther 2:163-176 ( (March) -April) 1961;.
Price, H. L.:  General Anesthesia and Circulatory Homeostasis , Physiol Rev 40:187-218 ( (April) ) 1960;.
Aleksandrow, D.; Wysznacka, W.; and Gajewski, J.:  Influence of Chlorothiazide upon Arterial Responsiveness to Norepinephrine in Hypertensive Subjects , New Engl J Med 261:1052-1055 ( (Nov. 19) ) 1959;.
Aleksandrow, D.; Wysznacka, W.; and Gajewski, J.:  Studies on Mechanism of Chlorothiazide , New Engl J Med 260:51 ( (Jan. 8) ) 1959;.
Brodie, B. B., and Kantzman, R.:  Pharmacological Consequence of Selective Depletion of Catechol Amines by Antihypertensive Agents , Amer NY Acad Sci 88:939-943 ( (Oct.) ) 1960;.
Costa, E., et al.:  Role for Ganglionic Norepinephrine in Sympathetic Synaptic Transmission , Science 133:1822-1823 ( (June 9) ) 1961;.
Kaneko, Y.; McCubbin, J. W.; and Page, I. H.:  Mechanism by which Serotonin, Norepinephrine and Reserpine Cause Central Vasomotor Inhibition , Circulat Res 8:1228-1234 ( (Nov.) ) 1960;.
Scherbel, A. L.:  Newer Concepts of Amine Oxidase Inhibitors , Arch Intern Med 107:37-42 ( (Jan.) ) 1961;.
Shee, J. C.:  Dangerous Potentiation of Pethidine by Iproniazid and Its Treatment , Brit Med J 2:507-509 ( (Aug. 13) ) 1960;.
Deacock, A. R., and Davies, T. D. W.:  Influence of Certain Ganglionic Blocking Agents on Neuromuscular Transmission , Brit J Anaesth 30:217-225 ( (May) ) 1958;.
Burn, J. H., and Rand, M. J.:  New Observations on Sympathetic Postganglionic Mechanism , Amer J Med 29:1002-1007 ( (Dec.) ) 1960;.
Burn, J. H., and Rand, M. J.:  Noradrenaline in Artery Walls and Its Dispersal by Reserpine , Brit Med J 1:903-908 ( (April 19) ) 1958;.
Burn, J. H., and Rand, M. J.:  Cause of Supersensitivity of Smooth Muscle to Noradrenaline after Sympathetic Denervation , J Physiol 147:135-143 ( (June 23) ) 1959;.
Beavers, W. R., and Blackmore, W. P.:  Effect of Chlorothiazide on Vascular Reactivity , Proc Soc Exp Biol Med 98:133-135 ( (May) ) 1958;.
Hershey, S. G., and Zweifack, B. W.:  Peripheral Vascular Homeostasis in Relation to Anesthetic Agents , Anesthesiology 11:145-154 ( (March) ) 1950;.
Kurland, G. S., and Freeberg, A. S.:  Potentiating Effect of ACTH and of Cortisone on Pressor Response to Intravenous Infusion of 1-Norepinephrine , Proc Soc Exp Biol Med 78:28-31 ( (Oct.) ) 1951;.
Nasmyth, P. A.:  Effect of Corticosteroids on Isolated Mammalian Heart and Its Response to Adrenaline , J Physiol 139:323-336 ( (Dec. 31) ) 1957;.
Friedman, S. M.; Friedman, C. L.; and Nakashuna, M.:  Cationic Shifts and Blood Pressure Regulations , Circulat Res 5:261-267 ( (May) ) 1957;.
Fisher, C. W.; Bennett, L. L.; and Allahwala, A.:  Effect of Inhalational Anesthetic Agents on Myocardium of Dog , Anesthesiology 12:19-26 ( (Jan.) ) 1951;.
Brewster, W. R., Jr.; Isaacs, J. P.; and Anderson, T. W.:  Depressant Effect of Ether on Myocardium of Dog and Its Modification by Reflex Release of Epinephrine and Norepinephrine , Amer J Physiol 175:399-414 ( (Dec.) ) 1953;.
Burn, J. H., and Epstein, H. G.:  Hypotension Due to Halothane , Brit J Anaesth 31:199-204 ( (May) ) 1959;.
Crandell, D. L., and Whitcher, C. E.:  Hypotension Associated with Anesthesia , N Carolina Med J 20:416-422 ( (Oct.) ) 1959;.
Coakley, C. S.; Alpert, S.; and Boling, J. S.:  Circulatory Responses During Anesthesia of Patients on Rauwolfia Therapy , JAMA 161:1143 ( (July 21) ) 1956;.
Eger, E. I., II, and Hamilton, W. K.:  Effect of Reserpine on Action of Various Vasopressors , Anesthesiology 20:641-645 ( (Sept.) -Oct.) 1959;.
Burn, J. H., and Rand, M. J.:  Action of Sympathomimetric Amines in Animals Treated with Reserpine , J Physiol 144:314-336 ( (Dec.) ) 1958;.

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Price, H. L.:  Circulatory Actions of General Anesthetic Agents and Homeostatic Roles of Epinephrine and Norepinephrine in Man , Clin Pharmacol Ther 2:163-176 ( (March) -April) 1961;.
Price, H. L.:  General Anesthesia and Circulatory Homeostasis , Physiol Rev 40:187-218 ( (April) ) 1960;.
Aleksandrow, D.; Wysznacka, W.; and Gajewski, J.:  Influence of Chlorothiazide upon Arterial Responsiveness to Norepinephrine in Hypertensive Subjects , New Engl J Med 261:1052-1055 ( (Nov. 19) ) 1959;.
Aleksandrow, D.; Wysznacka, W.; and Gajewski, J.:  Studies on Mechanism of Chlorothiazide , New Engl J Med 260:51 ( (Jan. 8) ) 1959;.
Brodie, B. B., and Kantzman, R.:  Pharmacological Consequence of Selective Depletion of Catechol Amines by Antihypertensive Agents , Amer NY Acad Sci 88:939-943 ( (Oct.) ) 1960;.
Costa, E., et al.:  Role for Ganglionic Norepinephrine in Sympathetic Synaptic Transmission , Science 133:1822-1823 ( (June 9) ) 1961;.
Kaneko, Y.; McCubbin, J. W.; and Page, I. H.:  Mechanism by which Serotonin, Norepinephrine and Reserpine Cause Central Vasomotor Inhibition , Circulat Res 8:1228-1234 ( (Nov.) ) 1960;.
Scherbel, A. L.:  Newer Concepts of Amine Oxidase Inhibitors , Arch Intern Med 107:37-42 ( (Jan.) ) 1961;.
Shee, J. C.:  Dangerous Potentiation of Pethidine by Iproniazid and Its Treatment , Brit Med J 2:507-509 ( (Aug. 13) ) 1960;.
Deacock, A. R., and Davies, T. D. W.:  Influence of Certain Ganglionic Blocking Agents on Neuromuscular Transmission , Brit J Anaesth 30:217-225 ( (May) ) 1958;.
Burn, J. H., and Rand, M. J.:  New Observations on Sympathetic Postganglionic Mechanism , Amer J Med 29:1002-1007 ( (Dec.) ) 1960;.
Burn, J. H., and Rand, M. J.:  Noradrenaline in Artery Walls and Its Dispersal by Reserpine , Brit Med J 1:903-908 ( (April 19) ) 1958;.
Burn, J. H., and Rand, M. J.:  Cause of Supersensitivity of Smooth Muscle to Noradrenaline after Sympathetic Denervation , J Physiol 147:135-143 ( (June 23) ) 1959;.
Beavers, W. R., and Blackmore, W. P.:  Effect of Chlorothiazide on Vascular Reactivity , Proc Soc Exp Biol Med 98:133-135 ( (May) ) 1958;.
Hershey, S. G., and Zweifack, B. W.:  Peripheral Vascular Homeostasis in Relation to Anesthetic Agents , Anesthesiology 11:145-154 ( (March) ) 1950;.
Kurland, G. S., and Freeberg, A. S.:  Potentiating Effect of ACTH and of Cortisone on Pressor Response to Intravenous Infusion of 1-Norepinephrine , Proc Soc Exp Biol Med 78:28-31 ( (Oct.) ) 1951;.
Nasmyth, P. A.:  Effect of Corticosteroids on Isolated Mammalian Heart and Its Response to Adrenaline , J Physiol 139:323-336 ( (Dec. 31) ) 1957;.
Friedman, S. M.; Friedman, C. L.; and Nakashuna, M.:  Cationic Shifts and Blood Pressure Regulations , Circulat Res 5:261-267 ( (May) ) 1957;.
Fisher, C. W.; Bennett, L. L.; and Allahwala, A.:  Effect of Inhalational Anesthetic Agents on Myocardium of Dog , Anesthesiology 12:19-26 ( (Jan.) ) 1951;.
Brewster, W. R., Jr.; Isaacs, J. P.; and Anderson, T. W.:  Depressant Effect of Ether on Myocardium of Dog and Its Modification by Reflex Release of Epinephrine and Norepinephrine , Amer J Physiol 175:399-414 ( (Dec.) ) 1953;.
Burn, J. H., and Epstein, H. G.:  Hypotension Due to Halothane , Brit J Anaesth 31:199-204 ( (May) ) 1959;.
Crandell, D. L., and Whitcher, C. E.:  Hypotension Associated with Anesthesia , N Carolina Med J 20:416-422 ( (Oct.) ) 1959;.
Coakley, C. S.; Alpert, S.; and Boling, J. S.:  Circulatory Responses During Anesthesia of Patients on Rauwolfia Therapy , JAMA 161:1143 ( (July 21) ) 1956;.
Eger, E. I., II, and Hamilton, W. K.:  Effect of Reserpine on Action of Various Vasopressors , Anesthesiology 20:641-645 ( (Sept.) -Oct.) 1959;.
Burn, J. H., and Rand, M. J.:  Action of Sympathomimetric Amines in Animals Treated with Reserpine , J Physiol 144:314-336 ( (Dec.) ) 1958;.
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