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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
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