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Hypertension
Preoperative Assessment and Perioperative Management
LAWRENCE LASLETT, MD, Davis, California
Presented at the University of California, Davis, conference, Medical Evaluation of the Preoperative Patient, in Carmel, California, October 1993.
Hypertension is a frequently encountered abnormality in patients being prepared for surgical procedures. This condition complicates anesthetic and postoperative management, but careful monitoring and treatment allow hypertensive patients to tolerate surgery safely. Particular attention should be directed toward continuing antihypertensive medicine until the time of the surgical procedure or initiating treatment before it, monitoring the blood pressure frequently after the operation, and controlling postoperative hypertension with one of many parenteral agents available. The possibility of the presence of secondary hypertension and cardiovascular complications of hypertension should be considered during the preoperative assessment.
(Laslett L: Hypertension-Preoperative assessment and perioperative management. West j Med 1995; 162:215-219)
Hypertension is a common abnormality, being present in 50 million Americans."'Pl'2 It is thus frequently detected among patients undergoing preoperative evaluation for surgical procedures-in a quarter of instances in one study.2 Hypertension in these patients raises several concerns, including the propensity to have more difficult hemodynamic control during anesthesia, a perceived risk of increased intraoperative and postoperative cardiovascular events, difficulties with blood pressure management immediately after the procedure, and the fact that hypertension is a risk factor for the presence of other cardiovascular diseases that may be silent. It is prudent, then, for physicians, surgeons, and anesthesiologists to carefully evaluate the finding of increased blood pressure in patients presenting for surgical procedures. Assessing Blood Pressure Physicians must first confirm that patients' hypertension actually exists. Patients may be anxious, fearful, in pain, or rushed during an initial evaluation, all of which can induce a "physiologic" increase in blood pressure not representing true hypertension.3 Generally a physician can determine this by putting the patient at ease with reassurance and a calm environment, relieving pain if it exists, allowing a period of time to pass, then repeating the blood pressure measurement. In addition, the long-term state of the blood pressure may be determined by reviewing the patient's medical records. In these ways, a patient initially thought to be hypertensive may be found to have a normal blood pressure.
The basic principles of blood pressure measurement, such as the use of a proper-sized cuff, must not be forgotten. Although a patient found hypertensive only transiently on admission may not need specific antihypertensive therapy to be prepared for a surgical procedure, this finding alone does indicate a propensity to become hypertensive during anesthesia and surgical therapy and should alert those caring for the patient to be prepared for the possible need to treat excessive rises in blood pressure.4 Particularly for patients undergoing a serious surgical procedure, blood pressure is often monitored directly through an intra-arterial catheter beginning immediately before anesthesia and continuing into the early postoperative course. This ensures that rapid changes in the blood pressure are detected and obviates the possibility of inaccurate cuff measurements due to body habitus or upper extremity vascular rigidity. Blood Pressure Response to
Surgical Procedures
If a patient is found preoperatively to have a truly elevated blood pressure, possible risk from this can be considered in two phases-the anesthetic and the postoperative periods. It is not unusual for a patient undergoing anesthesia to have a fall in blood pressure during induction, followed by a pressor response and tachycardia with intubation, a stabilization of blood pressure and heart rate during anesthesia, and another rise in these measurements during awakening and extubation. In a patient with hypertension, these changes are
From the Division of Cardiovascular Medicine, Department of Internal Medicine, University of California, Davis, School of Medicine. Reprint requests to Lawrence Laslett, MD, Division of Cardiovascular Medicine, UCD Professional Bldg, 4301 X St, Sacramento, CA 95817.
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Hypertension-Laslett
exaggerated.5 This is most prominent in patients with untreated hypertension who are seen for surgical therapy, but to a lesser extent it also occurs in those whose blood pressure, though treated, remains uncontrolled. Although persons with effectively treated hypertension have blood pressure changes more similar to those with normal blood pressures,5 they, too, may have problematic lability in pressure. These excessive swings in blood pressure and heart rate place a patient with coronary artery disease or left ventricular dysfunction at risk for ischemia or heart failure.' Indeed, hypertensive patients have shown an increased incidence of ST-segment depression during surgical procedures while electrocardiographically monitored.7 In addition, chronic hypertension resets cerebral circulatory autoregulation so that in these patients intraoperative and postoperative blood pressure reductions to otherwise benign levels may induce cerebral ischemia.8"
ing the blood pressure and heart rate responses during anesthesia. 13-Blockade also was shown to notably limit the magnitude of blood pressure rise during intubation and the amount of ischemic changes on electrocardiographic monitoring during a surgical procedure."6"7"9 This benefit likely also results from using other agents shown to smooth intraoperative hemodynamics,2" because excessive blood pressure and heart rate changes are the probable stimuli of most episodes of intraoperative ischemia.
Postoperative Management
Although patients with hypertension engender the concern already discussed of ischemia during a surgical procedure, it is during the hours and first few days after an operation that most episodes of surgically related myocardial infarction occur.'," Several factors may contribute to this risk, including oxygenation problems, tachycardia, and altered thrombotic potential, but prominent is hypertension. Hypertension directly raises the myocardial oxygen demand. In the presence of coronary artery disease, this demand may not be able to be met. Postoperative hypertension may also cause a ventricle with systolic dysfunction-for which chronic hypertension is a risk factor-to fail and result in pulmonary edema. Diastolic dysfunction from a "stiff," often hypertrophied, ventricle resulting from chronic hypertension may lead to intolerance of tachycardia, often seen postoperatively, because of inadequate ventricular filling time, resulting in hypotension and inadequate cardiac output. Fortunately, postoperative control of the blood pressure is almost always feasible. Essential to this goal is careful and frequent monitoring of this measurement
21 7 Hypertension-Laslett 2I
Hyerenio-ase
during the first several days after a surgical procedure, often using an intra-arterial catheter for direct and continuous monitoring and evaluating the patient for possibly reversible contributing causes of the hypertension. Among these are pain and other discomfort, anxiety and fear, hypercarbia, and volume overload.' Pain is a particularly important contributor toward postoperative hypertension; newer approaches toward pain management, such as epidural narcotic infusion, may be useful in patients with postoperative pain. If these factors are corrected as much as possible and the patient remains hypertensive, additional pharmacologic intervention will almost certainly achieve normotension. Medical antihypertensive therapy is especially likely to be needed for patients who are hypertensive preoperatively, whether or not the hypertension had been controlled. A wide range of nonoral medicines is now available for blood pressure management when a patient is not able to use oral agents. Table 1 lists these with suggested dosing ranges. The drug of choice for a specific patient depends on that patient's circumstances. Often, if the patient has been effectively treated with antihypertensive medicine preoperatively, a parenteral or cutaneous form of that agent will be effective. Other concurrent problems may suggest the use of particular agents: If a patient is also volume overloaded, administering parenteral furosemide may treat both conditions; tachycardia and hypertension may both respond to an intravenous 1-blocker27; patients with hypertension and heart failure may have both conditions improved with intravenous angiotensin-converting enzyme inhibition; anxious patients with hypertension may gain some sedation as well as a lowering of their blood pressure with cutaneous clonidine; and patients exhibiting evidence of active myocardial ischemia likely would have lessening of the ischemia directly and indirectly through blood pressure reduction, with the use of intravenous nitroglycerin or a 1-blocker. If hypertension is moderately severe to severe, agents that produce predictable rapid control would be preferred, such as intravenous sodium nitroprusside. As the patient regains the ability to tolerate oral intake, nonparenteral agents can again be used.
Hypertension Evaluation When hypertension is detected during the preoperative evaluation, by measurement or history, attention to two other issues besides control of the blood pressure is important. First, screening needs to be done for evidence of secondary hypertension (generally by further history and chart review). Second, hypertension should be considered as a marker of other cardiovascular disease. Although secondary hypertension is uncommon, some forms can have serious implications for safe perioperative management of the patient. Pheochromocytoma, although rare, can produce disastrous complications during a surgical procedure.'29 Pharmacologic and physical stimuli of a patient during and after anesthesia can induce severe swings in blood pressure that are difficult to control and can lead to myocardial infarction,
heart failure, or stroke. Long-term excess catecholamine stimulation usually produces a vasoconstriction hypovolemia that may be difficult to detect and seriously complicate proper management of perioperative fluids. If pheochromocytoma is suspected, nonemergent surgical therapy should be delayed until it is known whether the condition is present; if present, such surgical procedures should not be done until the pheochromocytoma preferably is resected or at least its effects optimally blocked by long-term ot- and 3-adrenergic blockade and volume repletion. For truly emergent operations, immediate aggressive adrenergic blockade is necessary, knowing that the difficulties with blood pressure control are likely to be incompletely prevented. Patients with Cushing's disease may have problems with postoperative healing and glucose intolerance and a tendency toward hypokalemia. Patients with primary hyperaldosteronism characteristically have hypokalemia that may predispose them to postoperative arrhythmias or weakness. Those with nephropathy may have deterioration of renal function after the stress of a surgical procedure or protein wasting with attendant postoperative nutritional difficulties. Coarctation of the aorta produces hypertension in the upper extremities where the blood pressure is usually measured, whereas lower body blood pressure, including that sensed by the kidneys, remains low, causing possible blood pressure regulation difficulties during and after an operation. Hypertension is a risk factor for the development of cardiovascular disease, including coronary atherosclerosis (with resulting myocardial ischemia or infarction) and cardiomyopathy (producing heart failure). Although the adverse operative and postoperative effects of hypertension itself can be mitigated by diligent hemodynamic management, these diseases associated with hypertension are clear risks for postoperative cardiovascular events.30 Every patient found to have hypertension should undergo especially careful questioning for a history or symptoms of these disorders and have close attention paid to the electrocardiogram for evidence of ischemic heart disease. Although many investigators have not found chronic stable angina to increase the risk of perioperative cardiac events, recent myocardial infarction, evidence of heart failure, and nonsinus rhythm or frequent premature ventricular contractions did. Cases of new or increasing angina were not evaluated, but logic dictates that patients with such symptoms would be at increased risk, and unstable angina has been associated with postoperative cardiac morbidity.6 It is important to elicit the cardiac history carefully, as many patients, because of denial or a misperception, will not volunteer symptoms. Symptoms often develop so gradually in patients with heart failure that they fail to recognize increasing limitations, or they ascribe them to other causes such as "getting older." Those with angina may think of their symptom as "heartburn" or "chest pressure" and not answer affirmatively when asked if they have chest pain. In addition, angina may well be felt only as discomfort in locations other than the chest, such
Hypertension-Lasiett
TABLE 1.-Parenteral Drugs for Treating Hypertension*
Drug
Trade Namet
Maintenance Dose
Repeat effective dose as needed Repeat effective dose as needed Continue effective infusion rate, adjust as needed
Lopressor
Brevibloc
Normodyne
Verapamil HCI ....... Calan Isoptin Enalaprilat........... Vasotec Hydralazine HCI...... Apresoline Methyidopa ......... Aldomet
Furosemide..........
IM = intramuscularly, IV =
5-mg boluses IV at 2-min intervals until effect 500 p.g kg-1 minfor 1 min IV, then . min-'; 50 gkg-' g repeat boluses and increase maintenance dose by 50 jig kg- minat 5-min intervals until effect 20 mg IV over 2 min, followed by 40 to 80 mg at 1 0-min intervals until response or 2 mg/min IV infusion About usual daily dose cutaneously; increase if needed 1/2 to 1 capsule contents sublingually 0.3 to 0.5 mg/kg IV over 2 to 3 min 2.5 to 10 mg IV slow push 1.25 mg IV over 5 min 20 to 40 mg IM or IV 250 to 500 mg IV (effect delayed by hours) 20 to 40 mg IV
As needed
Repeat as needed
intravenousl ly HCI = hydrochloride, *The doses given in this table are approximate and should only be used as guides. Not all of the agents listed have been approved by the US Food and Drug Administration for treating hypertension. tThe trade names given are not necessarily inclusive. Their use in this table is informational only and does not represent endorsement by the author or THE WESTERN JOURNAL OF MEDICINE.
as an arm or the neck, and be easily missed when questions are asked about chest discomfort. The preoperative electrocardiogram must be evaluated not only for arrhythmias, but also for evidence of unrecognized myocardial infarction, which occurs in about a third of cases of infarction.3' If any evidence of angina that is other than mild and stable, recent myocardial infarction, heart failure, or notable arrhythmias is found, an operation should be delayed if possible until these conditions are further evaluated and optimally treated. Vascular operations require particular caution.3233
Conclusion
Patients with mild or moderate hypertension undergoing surgical procedures pose a risk of having increased blood pressure instability during anesthesia and ischemic complications postoperatively. This risk can be reduced by preoperative and postoperative medication, including continuing a patient's ongoing antihypertensive therapy until the time of an operation, then resuming it as soon as possible postoperatively, including the nonoral forms.
The highest risk of cardiovascular complications occurring is during the first several days after an operation. With careful monitoring, the development of hypertension can be detected early during this period and treated with one or more of the many parenteral or cutaneous agents available, as listed in Table 1, individually tailored to a patient's circumstances. The preoperative evaluation of a patient with hypertension should include consideration of the possible presence of secondary hypertension and of hypertension as a marker for cardiovascular disease. By following these principles-in essence, viewing hypertension as a marker for possible hemodynamic instability and cardiovascular complications that can be ameliorated by careful monitoring and appropriate therapy-a patient with hypertension should in most instances be guided safely through the operative and
perioperative period.
REFERENCES
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