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Definition
Normal BP
Adult : < 120/80 mmHg
Etiopathophysiology
1. Primary (essential):
2. Secondary Hypertension
<5% of cases
Aortic coarctation
Pheochromocytoma
Cushings Syndrome
Risk of cardiovacular disease < sustained HTN but > normotensive patients
Risk factors:
Sedentary lifestyle
Smoking
Diabetes
Family history
Obesity
Pathophysiology
Not applicable:
Pediatrics
Pregnancy
Emergency surgeries
Cardiac surgeries
JNC 8 Recommendation
In patients with hypertension and diabetes, pharmacologic treatment should be initiated when BP
140/90 mm Hg, regardless of age.
Treatment
1. Weight reduction
4. Physical activity
Pharmacological
Diuretics
ACE inhibitors
ARB
Calcium channel antagonist
Anti adrenergic : blocker , blockeror and blockers
Endothelin receptor antagonist
Vasodialtor
Dopaminergic agonists
Hypertensive Crisis
Hypertensive Emergency : severe elevation in BP (>180/120 mmHg) complicated by evidence of
impending or progressive target organ dysfunction and damage
Hypertensive Urgency: severe elevation in BP without acute target organ dysfunction or damage
Hypertensive encephalopathy
Intracerebral hemorrhage
Acute myocardial infarction
Acute left ventricular failure with pulmonary edema
Unstable angina pectoris
Dissecting aortic aneurysm
Eclampsia
Management
Hypertensive emergency require immediate BP lowering (25%) within minutes to an hour and then
gradually to 160/110 mmHg over next 2 to 6 hours (to prevent or limit target organ damage).
Rapid lowering of BP to near normal levels is avoided (lead to renal, cerebral and coronary
ischemia).
In contrast, for hypertensive urgency, BP can be lowered gradually over 24-48 hours.
History
Risk factors
Questioned regarding chest pain, exercise tolerance, shortness of breath, dependent edema, postural
lightheadedness (and other history of autonomic neuropathy), syncope, episodic visual disturbances,
episodic neurologic symptoms, claudication
General survey
Systemic- S4 gallop is common in LVH; pulmonary rales and S3 gallop late finding
Carotid bruit
Investigations
Hemoglobin (Allowable blood loss calculation; Anemia imposes a stress on the cardiovascular
system that may exacerbate myocardial ischemia and aggravate HF)
Electrolytes (S. K for pts on diuretics or Digoxin (may be decreased) hypokalemia in absence of
diuretic therapy hyperaldosteronism. Hyperkalemia pts taking K sparing diuretics or ACE
inhibitors)
Blood glucose, Lipid profile (deranged then the patients may be having increased perioperative
cardiovascular events)
Chest X-Ray (Cardiomegaly, pulmonary vascular congestion) But, Normal does not exclude LVH
ECG (Ischemia, conduction abnormalities, old infarction, LVH or strain) normal does not exclude
CAD or LVH
Echocardiography (sensitive test) Ventricular systolic and diastolic function, regional wall motion
abnormalities
ECG: LVH- tall R waves (>25mm) in Lead V5-6 and deep S wave in V1 or V2, Inverted T waves in
Lead I, aVL, V6 sometime in V5 , V4 left axis deviation
No concensus!!
BP <180/110 mmHg: not an independent risk factor for perioperative cardiovascular complications.
(ACC/AHA 2007)
Elective surgery should be delayed for severe HTN (200/115) until BP < 180/110
Delaying surgery to optimize should be weighed against the risk of delaying surgery
An emergency procedure is one in which life or limb is threatened if not in the operating room,
where there is time for no or very limited or minimal clinical evaluation, typically within <6
hours.
An urgent procedure is one in which there may be time for a limited clinical evaluation, usually when
life or limb is threatened if not in the operating room, typically between 6 and 24 hours.
A time-sensitive procedure is one in which a delay of >1 to 6 weeks to allow for an evaluation and
significant changes in management will negatively affect outcome. Most oncologic procedures
would fall into this category.
An elective procedure is one in which the procedure could be delayed for up to 1 year.
A low-risk procedure is one in which the combined surgical and patient characteristics predict a risk
of a major adverse cardiac event (MACE) of death or myocardial infarction (MI) of <1%
Evidence of end-organ damage not previously discovered, which can be improved by postponement
to the extent that the perioperative risk would be considerably decreased
NPO advice
Premedication
Premedication
Benzodiazepines:
Clonidine :
Decreases sympathetic outflow and reduces plasma catecholamine, aldosterone and renin
Beta blockers:
Limit the shear stress across atheromatous plaques in the coronary circulation.
Reduce the incidence of plaques in the coronary circulation reduce the incidence of plaque
rupture coronary arterial thrombosis.
ACE inhibitors: SEcardiac dep, brady, enhanced neuromascular non depolarizing blockade. Some
physicians hold ACE n ARB. But holding causes increase risk of marked perioperative HTN and use
of IV anti HTN drugs
Several authors have suggested withholding ACE inhibitors and angiotensin receptor antagonists the
morning of surgery. Consideration should be given to restarting ACE inhibitors in the postoperative
period only after the patient is euvolemic, to decrease the risk of perioperative renal dysfunction
Goal:
If marked hypertension (>180/ 120 mmHg) is present preoperatively, arterial blood pressure should
be maintained in high normal range, ie 150-140/ 90-80 mmHg.
Those with long-standing or poorly controlled hypertension have altered auto regulation of cerebral
blood flow. So higher than normal mean blood pressures may be required to maintain adequate
cerebral blood flow.
Monitoring:
ECG:
Primarily Lead II and V5: Multilead ST analysis II/V5 80% detection. II/V4, V5 96% detection
extensive surgery associated with rapid or marked changes in cardiac preload and afterload
Urine output:
in patients with renal impairment undergoing surgery expected to last >2 hours
Blood loss
Anesthesia technique:
High sensory level of anesthesia with its associated sympathetic denervation can unmask unsuspected
hypovolemia.
Hypertensive patients have more exaggerated reductions in blood pressure than normotensive
patients.
Induction of anesthesia
Many patients with hypertension display accentuated hypotensive response to induction of anesthesia
and an exaggerated hypertensive response to intubation.
Preload/coloading
Direct laryngoscopy that does not exceed 15 seconds in duration helps minimize blood pressure
changes.
Opioid (fentanyl 2.5-5 mcg/kg; alfentanil 15-25mcg/ kg; sufentanil 0.25-0.5mcg/ kg; remifentanil 0.5-
1mcg/ kg)
Lidocaine 1.5mg/ kg iv
Achieving beta-blockade with esmolol 0.3-1.5mg/ kg; metoprolol 1-5mg or labetolol 5-20 mg.
Q Ketamine can precipitate marked hypertension: its sympathetic stimulating properties can be blunted
or eliminated by concomitant administration of a small dose of benzodiazepine or propofol.
Maintainance
Muscle relaxant:
Pancuronium induced vagal blockade and neural release of catecholamines can exacerbate
hypertension in poorly controlled patients
Intraoperative Hypertension
3. Hypoxia, hypercarbia.
4. Overinfusion.
Is increased in patients diagnosed with essential hypertension, even if the blood pressure was
controlled preoperatively.
Rule out reversible causes before starting antihypertensive therapy- anesthetic depth, inadequate
analgesia, hypoxemia, hypercapnia, over infusion.
Nitroglycerin: may be less effective, but useful in treating and preventing myocardial ischemia
Intraoperative Hypotension
Intraoperative hypotension in patients being treated with ACE inhibitors or ARBs is responsive to
administration of intravenous fluids, sympathomimetic drugs, and/or vasopressin.
If vasopressor is necessary to treat excessive hypotension, small dose of directly acting agent (eg:
phenylephrine 25-50 mcg) preferable to indirect agent.
Extubation
Pain free
Warm
Avoid bucking or coughing
Postoperative management
1. Pain
2. Hypoxia
3. Hypercarbia
4. Agitation
5. Urinary retention
6. Sharp instrument
Can lead to - myocardial ischemia, CCF, cardiac dysrhythmias, stroke, wound hematomas, disruption of
vascular suture lines
Target organ Maintain target organ perfusion and prevent Avoid nephrotoxic drugs,
damage; renal, CNS, further damage, avoid sympathetic Maintain urine output, avoid
CVS overstimulation hypotension, hypertension, avoid
tachycardia
with vasopressors,
raised ICP)
Cardiac ischemic
events (especially in
presence of LVH)
Arrhythmias
Presence of diastolic
dysfunction (poor
left ventricular
relaxation) make
patients prone for
pulmonary edema
Cerebral
autoregulation reset
(shift to right)
making
Postoperative Monitoring
adverse
cardiovascular events Adequate pain management,
avoid hypoxia, hypercarbia,
judicious fluid management,
continue antihypertensives as
soon as possible
Premedication:
Benzodiazepines (evening and morning dose 2 hrs before surgery), Clonidine (Clonidine provides
hemodynamic stability and reduces the risk of myocardial ischemia by reducing sympathoadrenal
activity. In addition, clonidine also causes anxiolysis, sedation and decreases the need for both inhalation
and intravenous anesthetics5 mcg/kg 2 hours before surgery)
Induction:
Adequate preloading to avoid precipitous fall in BP
Etomidate is cardiostable, STP can be given in titrating dose.
Monitoring
Standard monitoring
ECG: multilead ST analysis
Maintaenance
Liberal use
of opiates, which have minimal cardiovascular effects, will
reduce the amount of volatile agents required. Nitrous oxide
can be safely used.
Avoid hypothermia