How to resume Entresto (sacubitril/valsartan) after a laparoscopic cholecystectomy?

Resuming Entresto After Laparoscopic Cholecystectomy

Entresto (sacubitril/valsartan) should be resumed 24-48 hours after laparoscopic cholecystectomy if the patient is hemodynamically stable, tolerating oral intake, and showing no signs of postoperative complications.

Assessment Before Resuming Entresto

Before restarting Entresto following laparoscopic cholecystectomy, evaluate:

1. Hemodynamic stability:

   • Blood pressure measurements (avoid resuming if systolic BP <100 mmHg)
   • Heart rate within normal range
   • No signs of hypovolemia

2. Postoperative recovery indicators:

   • Tolerating oral intake
   • No significant pain requiring high-dose opioid analgesia
   • Normal urine output
   • No signs of surgical complications

Timing of Resumption

The timing of Entresto resumption should follow a structured approach:

• Low bleeding risk cases (uncomplicated laparoscopic cholecystectomy):

  • Resume Entresto 24 hours after surgery if patient is hemodynamically stable 1
  • Start with full dose if blood pressure is adequate

• Higher risk cases (complicated surgery, elderly, or with comorbidities):

  • Resume Entresto 48-72 hours after surgery 1
  • Consider starting with a reduced dose (half the usual dose) for the first 1-2 days

Monitoring After Resumption

After restarting Entresto, monitor:

• Blood pressure measurements every 4-6 hours for the first 24 hours
• Renal function tests within 48-72 hours of resumption
• Signs of fluid retention or hypotension

Special Considerations

1. Postoperative hypotension:

   • If systolic BP <100 mmHg, delay resumption until BP normalizes 1
   • Consider IV fluid optimization before restarting

2. Renal function:

   • Check postoperative creatinine before resuming
   • If acute kidney injury is present, delay resumption until resolution

3. Electrolyte abnormalities:

   • Ensure potassium and sodium are within normal ranges before resuming

Potential Complications and Management

• Hypotension: If hypotension develops after resuming Entresto, temporarily discontinue and reassess in 24-48 hours
• Acute kidney injury: Monitor creatinine; if rising, hold medication and consult cardiology
• Postoperative ileus: May affect drug absorption; consider delaying resumption until bowel function returns 1

Clinical Pathway for Entresto Resumption

1. Day of surgery: Hold Entresto
2. POD 1: Assess vital signs, oral intake, and renal function
3. POD 1-2: Resume Entresto if:
   • Hemodynamically stable (SBP >100 mmHg)
   • Tolerating oral intake
   • No significant pain
   • No signs of surgical complications
4. POD 3-5: Follow-up assessment of blood pressure and renal function

Conclusion

Laparoscopic cholecystectomy is generally considered a low-bleeding risk procedure 1, allowing for relatively early resumption of Entresto. The key is ensuring hemodynamic stability and adequate oral intake before restarting this medication, which can cause hypotension. While no specific guidelines exist for Entresto resumption after cholecystectomy, following principles similar to those established for anticoagulants provides a reasonable framework for decision-making.