2. PERIOPERATIVE HYPERTENSION The Role of DA-1 Agonists (Fenoldopam) R. Sheinbaum M.D. O. Wenker M.D.

3. Perioperative HTN Incidence u Definition Wide range of definitions systolic >110-170 diastolic95-100-107 % change in BP –Leslie JB Acta Anaesthesiol Scand 1993; 37: 5-9

4. Perioperative HTN Incidence u Patient Factors underlying risk factorsunderlying risk factors increasing age base of populationincreasing age base of population higher risk procedureshigher risk procedures u Type of Surgery cardiac 40-60 %cardiac 40-60 % non cardiac 5 %non cardiac 5 % –Estafanos FG Am Heart J 1973 ; 85 : 732-738 –Viljoen JF J Thorac Cardiovasc Surg 1976 ; 71 : 548 –Leslie JB Acta Anaesthesiol Scand 1993 ; 37 : 5-9

5. Perioperative HTN Etiology u Primary HTN u Secondary HTN u Surgically Associated HTN u Anesthesia Related HTN u Other

6. Perioperative HTN Significance u Organ Damage heartheart brainbrain kidneykidney u Surgical Considerations u Morbidity

7. Hypertension Treatment BP = Q x SVR Q = HR x SV SV  preload, contractility, afterload SVR  viscosity, vessel radius

8. Blood Pressure Sympathetic Nervous System Regulation of Blood Pressure Adrenergic Tone Baroreceptor Reflexes Volume/ Pressure Renin/Angiotensin Preload Cardiac Output Catecholamines Adrenal Gland CNS VeinsArteries Capacitance Resistance Heart Kidney Afterload

9. Anti HTN Agents FENOLDOPAM u Ideal Characteristics –effective –predictable onset –easily titratable –few side effects –metabolically inert

10. u Comparison to Nitroprusside just as effective in reaching target BPjust as effective in reaching target BP just as quick in reaching target BPjust as quick in reaching target BP Panacek EA Acad Emerg Med 1995 ; 2 : 959-965 Anti HTN Agents FENOLDOPAM

11. Fenoldopam versus Nitroprusside Benefits HeartHeart > EF, CI> EF, CI < PCWP, PVR< PCWP, PVR minimal change in HR (dose related)minimal change in HR (dose related) RenalRenal > renal blood flow, Na excretion> renal blood flow, Na excretion > Cr Cl> Cr Cl Elliot WJ Circulation 1990 ; 81 : 970-977 Shusterman NH Am J Med 1993 ; 96 : 161-168 Hill AJ J Cardiothorac Vasc Anesth 1993 ; 7 : 279-284

12. Comparison of Renal Effects in Severe Hypertension 140 Fenoldopam Nitroprusside Change from Baseline (%) 0 20 40 60 80 100 120 -10 Urinary Flow RateSodium Excretion Creatinine Clearance Elliott WJ, et al. Circulation 1990;81:970-977

13. CONTROL

14. CORLOPAM Advantages u Control u Effectiveness u End Organ Benefits u Unique Action u Potential Renal Benefits

15. Perioperative HTN Summary u Incidence u End Organ Effects u Impact on Morbidity/ Mortality u Treatment Impact u Treatment Options