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Hypertensive patients under anesthesia

BY JOHN Y N I COL A S ( M E D - 3 ST U DENT)


AN ESTHESIA CL E R KS HIP
A M E R ICA N UN I V ERSITY OF BE I R U T, JA N UA RY 2 0 1 7.
Introduction
 Hypertension is a common preexisting diagnosis in surgical patients

 Most common medical reason for postponing surgery

 Major Risk Factor for a cardiovascular catastrophe


Pathophysiology of HTN
 Multifactorial and highly complex

 Several Factors involved in regulation of blood pressure:

o Cardiac Output and Blood Volume

o Vascular Caliber and Elasticity

o Humoral Mediators

o Neural Stimulation
Pathophysiology of HTN
 Vasoreactivity is increased in
hypertensive patients (A)

 Decrease in blood pressure results in a


decrease In organ blood flow (B)

 Fall in Left Ventricular Stroke Volume


with fall in blood pressure (C)
Anesthesia in Hypertensive Patients
Preanesthesia Consultation
 Perioperative Risk Assessment:
 Check for other risk factors associated with HTN
 Delay surgery only if diastolic BP>110 mmHg
 If acute severe HTN, treat underlying cause prior to surgery

 Determination of target blood pressure values:


 No specific values
 Maintain intraoperative BP within 20% of baseline values
Preanesthesia Consultation
 Blood Pressure Monitoring:
 More frequent BP cuff monitoring (every 1-2 mins)
 Intra-arterial catheter monitoring

 Antihypertensive medication management:


 Continue HTN medication up to time of surgery
 Highly important for Beta-blockers  to avoid withdrawal syndromes
 Stop ACE-I and ARBs 24 hrs before surgery  to avoid intraoperative hypotension
Immediate Perioperative Period
 Administration of morning antihypertensive doses

 Reduction of preoperative anxiety and pain


 Anxiety and pain may result in increased BP
 Administer anxiolytics (Midazolam or Fentanyl)
Causes of Intraoperative Hypertension
1. Laryngoscopy and endotracheal intubation:
 Activation of sympathetic responses
 Increase in systemic BP by 20 – 25 mmHg, much higher in hypertensive
 Give Short-acting hypnotic (propofol) + IV anesthetic (fentanyl)/potent
or Inhalation anesthetic such as sevoflurane.
2. Surgical Stimulation:
 Inadequate anesthetic depth in painful procedure
 Exaggerated response in patient with chronic hypertension
 Deepening anesthesia (increase inhalation anesthetic agent)
Causes of Intraoperative Hypertension
3. Emergence and Tracheal Extubation:
 Sympathetic stimulation caused by pain and emergence excitement
 Exaggerated response to stimulation of airway reflexes during
suctioning and tracheal extubation
 Ensure adequate analgesia prior to emergence (systemic opioid)
Causes of Intraoperative Hypertension
4. Hypervolemia:

 Difficult to assess in patients with longstanding hypertension

 Best done by monitoring variations in arterial pressure waveform

 Should be suspected in chronic hypertensive patients on diuretics and during

procedures with large volume of irrigation

 Intraoperative dose of IV furosemide


Causes of Intraoperative Hypertension
4. Hypoxemia and/or hypercarbia:
 Lead to hypertension and tachycardia due to sympathetic stimulation

 Administer higher fraction of inspired oxygen (FiO2) Or improve ventilation to reduce arterial

CO2.

6. Antihypertensive medication withdrawal:


 In patients on a β-blocker or clonidine

 Administer IV equivalent of missed medication intraoperatively

7. Other Causes (bladder distention, alcoholics, increased ICP, etc.)


Hypertensive Emergencies in OR
Systolic BP≥180 Acute Cardiovascular

+
mmHg and/or Emergency,
diastolic BP≥120 Neurologic signs,
mmHg Acute Renal Failure

IV antihypertensive agent immediately and intra-arterial catheter for


continuous BP monitoring
Intraoperative Hypotension
Patients with chronic hypertension have:
 Baroreceptor Desensitization

 Loss of Vascular Elasticity

 Intravascular Volume Depletion

These patients have exaggerated responses to sympathetic


inhibition caused by induction of general anesthesia
Causes of Intraoperative Hypotension
1. Hypovolemia:
 Relative hypovolemia can result in severe hypotension
 When intravascular volume depletion suspected, volume load hypertensive patients with
250-500 mL of IV crystalloid solution prior to induction of general anesthesia
2. Induction of general anesthesia:
 Hypotension post laryngoscopy and intubation
 Mostly occurs if antihypertensive or supplemental anesthetic agents given to blunt
sympathetic responses
 Use smaller doses of initial sedative-hypnotic agent (propofol) and titrate accordingly
Causes of Intraoperative Hypotension
3. Sympathectomy due to neuraxial block:
 High neuraxial anesthetic block, mostly above T6 level
 More likely in a patient with preexisting hypertension
 IV fluid boluses + phenylephrine

4. Inhibition of the renin angiotensin system:


 RAS system is relied on to maintain normotension in general anesthesia
 Increased risk of hypotension in patients on ACE-inhibitors and ARBs
 Volume Expansion + vasopressor agent
Postoperative Hypertension
Treat only if systolic blood pressure (BP) is >180 mmHg or diastolic BP is >110 mmHg

 Underlying causes should be treated before initiating therapy (noxious stimuli,

hypervolemia, withdrawal from alcohol, etc.)

 Treat with small bolus doses of rapid-acting IV agents (labetalol, metoprolol,

hydralazine, etc.)
Postoperative Hypotension
 Treated when the systolic BP is <90 mmHg, mean BP is <65 mmHg (or >20%

decrease from baseline)

 Treat with IV isotonic crystalloid solution administered in 250- to 500-mL

increments

 If necessary, use IV vasopressor agents (phenylephrine, ephedrine, etc.)


Thank you.