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

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

3. 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 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.

4. One in ten – we encounter

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

7. 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

8. 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

9. 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 !!

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

12. 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.

13. 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 ?

14. 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

15. 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.

16. 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.

17. 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

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

19. 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 !!

20. 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

21. 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

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

23. 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

24. Risk factors in hypertensives
General

25. 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

27. 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

28. 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).

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

30. 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 !!

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

32. 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

33. 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

34. Hypothermia can increase intraoperative BP

35. 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

36. Drugs for hypertensive crisis
10 mic/ minute

37. 5 mg slow IV in incremental doses

38. 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

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

40. 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

41. 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