Hypertensive surgical patient Dr. S. Parthasarathy MD., DA., DNB, MD (Acu), Dip. Diab. DCA, Dip. Software statistics- PhD ( physiology), ( IDRA )

Hypertension ± hypokalemia Commonest cause of case cancellation in a preanesthetic clinic is Hypertension ± hypokalemia

Incidence The total incidence of hypertension in preoperative phase was 10.16%. Among them 64.9% being male and 35.1% female. Maximum incidence was found in age group 50-59 years i.e. 26.6%. Among the case detected maximum patients i.e. 52% were patients with newly diagnosed hypertension 61.1% were using calcium channel blockers.

One in ten – we encounter

Primary - 95 % ( Without any cause ) Secondary – 5 % renal Endocrine Neurogenic Coarctation etc..

Clinical picture ?? !! “Vasoconstricted” hypertension—in medical patient with chronic renovascular hypertension, characterized by diastolic hypertension and ↑ systemic vascular resistance with normal or even decreased cardiac output and heart rate. “Hyperdynamic” hypertension—in postoperative surgical patient, characterized by acute systolic hypertension; widened pulse pressure; and increased cardiac output, heart rate

Why we need to know Is it primary or secondary ?? End organ damage - associated A sudden intraoperative rise – ICH or LV failure !! Increased incidences of myocardial ischemic episodes On induction changes more On intubation changes more Overall cardiac risk higher

What do we note as anesthetist ? Control of hypertension – adequacy ?? Up to a Diastolic of 110 – OK 160/ 110 is ok for elective case – debate going on Pharmacology of drugs !!

Drugs Beta blockers (with vasodilation) ( HR of 60) Calcium channel blockers ACE inhibitors ARBs Diuretics -- (more in ISH) Garlic and anticoagulation

Does it matter ? co-existing hypertension may increase the incidence of postoperative myocardial reinfarction in patients with a history of myocardial infarction Incidence of neurologic complications in patients undergoing carotid endarterectomy. In hypertensive patients who exhibit signs of target organ damage, postponement of an elective procedure is justified if that end-organ damage can be improved or if further evaluation of that damage could alter the anesthetic plan.

BP of 150/90 But creatinine is 1.8 – Check if There is LVH Can we improve that ? Does it alter the anesthetic process and plan ?

Clinical pearls LVH is associated with systolic hypertension more Renal end organ damage is associated with more perioperative morbidity History of TIA,. Old CVA – look for fundus

White coat hypertension NIBP can overestimate in elderly hypertensives PAC – MGMCRI White-coat hypertension (WCHT) is defined as a nurse-taken blood pressure of <140/90 when compared with a physician-taken value of >160/95.

When to postpone ? Stage 3 hypertension – 180/ 110 or more Stage 2 hypertension with end organ damage Eg. 170/106 with nephropathy (Creat - > 2) Patients with newly diagnosed mild hypertension, treatment may be delayed till after surgery.

Cancel ?? !! when canceling a procedure for adequate BP control, one must be aware that this may take 3 to 4 weeks and in some cases, up to two months. There is no benefit in postponing the procedure for one or two days, which would only bring inconveniences for patients and the hospital. End organ damage is different

What is the procedure Cosmetic surgery Or Oncological surgery Hip fracture Medico legal issues Individualize Vascular procedure , major blood loss expected Further cardiac evaluation

Now – any idea ?? Diastolic more than 110 with dyslipidemia with smoking with proteinuria Totally elective case – can wait How long to wait ?? Aggressive treatment with anxiolytics, statins and antihypertensives – 30 days !!

drugs – to continue or not The safety of β-blockers and their benefits (prevention of hypertensive responses, dysrhythmias, and myocardial ischemia) have been long established. ACE inhibitors – hypotension on induction common – but not to discontinue – (plan regional – may stop the drug ) Better to stop ACE inhibitors if major surgery with fluid shifts expected Amlodipine – continue Diuretics also continue – but check on electrolytes and volume status

Prys robert school of thoughts Patients with atherosclerotic disease, who present with raised systolic pressure, but normal or low diastolic pressure, should not be considered as true hypertensive and should not have their surgery delayed

Goldman and Caldera school Diastolic more than 110 End organ damage Must to treat

Potassium Upto 3 =OK Less than 3 – can correct with oral or change of drugs if not any urgency Otherwise – IV potassium correction Chronic diuretic use – can we correct ? Harmful ! But chronic hypokalemia does not seem to increase perioperative complications – more Useful in patients with cardiac illness With digoxin – act

Risk factors in hypertensives General

Preoperative essence Primary or secondary Stage – treated or not – severe- white coat ? Target organ damage CVA , CAD , LVH , Creatinine X-ray in hypertensive breathless patients ECG and creatinine

Premedication Anxiolysis Beta blockers CCBs to continue ARBs – can be discontinued – refractory hypotension- possibly 10 hours Clonidine – better hemodynamics and sedation – think of withdrawal also dexmed-Better in myocardial infarction, myocardial ischemia) but an increased incidence of hypotension and bradycardia

Intraoperative hypertension Intraoperatively esmolol, where available, may be very valuable for controlling sudden tachycardia and hypertension, but remember Labetolol - if the hypertensive event is due to an excess of catecholamines, caused either by administration of adrenaline or cocaine by the surgeon, or by endogenous secretion (e.g. phaeochromocytoma).

Excess hypotension- beware ? Induction Thiopentone Propofol Etomidate – ok No to ketamine Excess hypotension- beware ?

Laryngoscopy and intubation Hypertensives made normal also show exaggerated response Agent, fentanyl, IV lignocaine ,IV nitroprusside IV esmolol – 15 seconds – put the tube Think of exaggerated hypotension than allow a small increase in BP also !!

Extubation Lignocaine Opioids Smooth Surgical stimulation Opioid Agent Local Esmolol Extubation Lignocaine Opioids Smooth

Maintenance of Anesthesia MAP – maintained between 20 % of baseline is the aim than the technique Agent Vecuronium Regional Narcotics Nitroprusside IPPV and hypocapnia can decrease cardiac output Hypocapnia can cause hypokalemia in patients receiving diuretics

Which case ? The monitoring can extend from simple manual BP monitoring to intra-arterial BP monitoring to automatic NIBP, ECG, pulse oximeter, capnography, PAWP, transesophageal echocardiography, etc Monitor under the table Monitor blood loss

Hypothermia can increase intraoperative BP

During anesthesia, exaggerated decreases in blood pressure seen with blood loss, positive pressure ventilation, or sudden changes in body position Are we dealing with drugs affecting ANS

Drugs for hypertensive crisis 10 mic/ minute

5 mg slow IV in incremental doses

Regional anesthesia Nerve blocks – good Neuraxial – Acceptable less drastic fall – epidural Intrathecal narcotics Ephedrine better than phenylephrine to counter hypo in neuraxial blocks Sometimes we need vasopressin May unmask hypovolemia

We don’t want these in post op period Hypoxemia Full bladder Shivering Pain Anxiety

Postoperative period- sometimes late Hypertension may also be the result of intravascular volume overload from excessive intraoperative intravenous fluid therapy, and persist 24 to 48 hours until the fluid has been mobilized from the extravascular space. Blood pressure can also rise due to discontinuation of blood pressure medications postoperatively

Summary Hypertension – common cause of cancellation Stages and when to intervene 4-6 weeks to normalize autoregulation End organ damage Drugs to continue Premedicate Induce and intubate – smooth – 20 % BP IPPV and PaCO2 maintain Extubate smooth Thank you all