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LETTER TO THE EDITOR

Recommendations for Postinduction Hypotension: Are They Supported by the Evidence?

Critical Care Directorate, Royal Wolverhampton NHS Trust, New Cross Hospital, Wolverhampton, UK, pellahee{at}yahoo.com

To the Editor:

We read Reich et al.'s article (1) with great interest. However, we do not believe that the recommendations made were warranted.

We propose that hypovolemia is a major contributor to postinduction hypotension, particularly when propofol is used. Hypovolemia, not factored into this analysis, is commonly a result of preoperative starvation and inadequate fluid resuscitation. There are few published data on this subject, using small numbers in the main, with conflicting results (2,3).

The finding that postinduction hypotension caused by propofol was dose independent conflicts with other published literature (4,5). We suggest that inadequate stratification of propofol doses accounts for the loss of the dose-dependent relationship. Based on the recommendations of the British National Formulary (6), we would consider a propofol dose larger than 1.5 mg/kg excessive in patients older than 55 yr old.

Finally, we question whether the authors have demonstrated that postinduction hypotension is clinically important. Alterations in arterial blood pressure are significant only if end-organ perfusion is adversely affected (e.g., myocardial, cerebrovascular, or renal ischemia), and this has not been correlated with postinduction hypotension.

The recommendations concerning postinduction hypotension may well be justified, but they must be based on more robust evidence than Reich et al. have presented.

References

1. Reich DR, Hossain S, Krol M, et al. Predictors of hypotension after induction of general anesthesia. Anesth Analg 2005;101:622–8.[Abstract/Free Full Text]
2. el-Beheiry H, Kim J, Milne B, et al. Prophylaxis against the systemic hypotension induced by propofol during rapid sequence intubation. Can J Anaesth 1995;42:875–8.[Web of Science][Medline]
3. Turner RJ, Gatt SP, Kam PCA, et al. Administration of a crystalloid fluid preload does not prevent the decrease in arterial blood pressure after induction of anaesthesia with propofol and fentanyl. Br J Anaesth 1998;80:737–41.[Abstract/Free Full Text]
4. Hug CC, McLesky CH, Nahrwold ML, et al. Hemodynamic effects of propofol: data from over 25,000 patients. Anesth Analg 1993;7:S21–9.
5. Dundee JW, Robinson FP, McCollum JSC, et al. Sensitivity to propofol in the elderly. Anaesthesia 1986;41:482–5.[Web of Science][Medline]
6. British National Formulary. London: British Medical Association and the Royal Pharmaceutical Society of Great Britain, 2005:620–6.

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