Hypotension in the first minutes after induction is driven mainly by the induction agent's vasodilation and loss of sympathetic tone, particularly in older patients and those on antihypertensives. The most reliable preventive steps are pharmacological: dose reduction, slower titration and having a vasopressor ready.
Patients on ACE inhibitors or angiotensin receptor blockers taken on the morning of surgery are more prone to refractory hypotension, and local policy on withholding them deserves to be followed and checked.
- Reduce and titrate the induction dose in older, frail or hypertensive patients.
- Have a drawn-up vasopressor such as phenylephrine or ephedrine at hand before induction.
- Check whether ACE inhibitors or angiotensin receptor blockers were taken that morning.
- Consider an arterial line before induction in patients with severe cardiac or cerebrovascular disease.
- Treat hypotension promptly rather than waiting for incision to provide stimulation.
Why it matters
Even short periods of low pressure after induction have been associated with organ injury in high-risk patients.
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