[Angiotensin-converting enzyme inhibitors and anesthesia].

The increasing usage of ACE-inhibitors in the treatment of hypertension and chronic heart failure may increase the incidence of adverse anaesthetic occurrences. Four such cases are described. In two of these cases, the patient reacted with severe hypotension when general anaesthesia was supplemented with epidural bupivacaine. Another patient suffered a heart fatality after severe hypotension in conjunction with the administration of a spinal anaesthetic. Finally, one patient suffered sudden fatal pulmonary oedema after completion of uneventful general anaesthesia, possibly due to late resumption of ACEI-treatment. The cases are discussed in detail, with particular reference to the possible underlying mechanisms. Preoperative discontinuation of ACEI-treatment is controversial. We present some of the issues involved. Most authors lean towards continuing ongoing treatment, even though there is firm evidence that this increases the risk of hypotensive episodes due to hypovolaemia, arguing that such events may be predicted and antagonized with fluid therapy.