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HYPERTENSION

Definition

The American Society of Hypertension has defined


hypertension as a progressive cardiovascular syndrome arising from complex and interrelated
etiologies.
hypertension cannot be classified solely by discrete BP thresholds.

Normal BP
Adult : < 120/80 mmHg

Adolescent : 100/75 mmHg

Early childhood : 85/55 mmHg

Infant : 70/45 mmHg

Etiopathophysiology

1. Primary (essential):

> 95% of cases

Familial incidence and biochemial abnormalities

Increased sympathetic nervous system activity in response to stress

Overproduction of sodium retaining hormones and vasoconstrictors

High sodium intake

Inadequate dietary intake of potassium and calcium

Increased renin secretion

Deficiencies endogenous vasodilators (prostaglandins and nitric oxide)

Diabetes mellitus and obesity

Salt and water retention (final pathway)

2. Secondary Hypertension

<5% of cases

Renal artery stenosis leading to renovascular hypertension (most common cause)


Hyperaldosteronism

Aortic coarctation

Pheochromocytoma

Cushings Syndrome

Renal parenchymal disease

Pregnancy- induced hypertension

Isolated Systolic Hypertension: Predominantly affecting individual > 60 yrs old

White Coat Hypertension

Surge in BP when sphygmomanmetry particularly performed by doctor

Risk of cardiovacular disease < sustained HTN but > normotensive patients

What is white coat hypertension?


White coat effect (WCE) or white coat phenomenon, is the transient rise in BP from before to during
the visit to the doctors clinic, which settles down after a period of rest.

Risk factors:

Sedentary lifestyle
Smoking
Diabetes
Family history
Obesity

Pathophysiology

Not applicable:

Pediatrics
Pregnancy
Emergency surgeries

Cardiac surgeries

Classification of HTN (JNC 7)

JNC 8 Recommendation

In the general population, pharmacologic treatment should be initiated

In adult 60 yrs with BP 150/90 mm Hg

In adult <60 yrs with BP 140/90 mm Hg

In patients with hypertension and diabetes, pharmacologic treatment should be initiated when BP
140/90 mm Hg, regardless of age.

Treatment

Non-pharmacological (Lifestyle modification)

1. Weight reduction

2. Adopt DASH (dietary approach to stop HTN) eating plan

3. Dietary sodium reduction

4. Physical activity

5. Decrease alcohol consumption

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 emergencies are more common with essential hypertension

Hypertensive emergencies may present:

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.

Perioperative Evaluation and Management

Evaluation of the patient

History

Risk factors

Severity and duration

Drug therapy (dose, duration, adverse effects)

Presence or absence of end organ damage

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

Compliance with drug regimen


Examination

General survey

BP in both arms, Orthostatic changes


Pulse in upper and lower extremities (symmetric pulsation, RR and R-DF delay first then R-F
delay if R-DF abnormal)

Ophthalmoscopy changes in retinal vasculature parallel the severity and progression of


atherosclerosis and damage to other organs

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)

RFT- serum creatinine, BUN (to look for diabetic nephropathy)

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)

Urine R/E: proteinuria.

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

When to Postpone Surgery?

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%

Poorly controlled HTN with a DBP >110 mm Hg.

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

The etiology of secondary HTN is undiagnosed.


Pre-operative preparation

NPO advice

Premedication

Repeat electrolytes (if indicated)

Advice on current drug therapy

Premedication

Benzodiazepines:

Reduce preoperative anxiety

Mild to moderate HTN resolves following therapy

Clonidine :

Decreases sympathetic outflow and reduces plasma catecholamine, aldosterone and renin

Decreases anesthetic requirement and hemodynamic lability

Associated with profound intraoperative hypotension and bradycardia.

Beta blockers:

Limit chronotropic and inotropic effects

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.

Reduces incidence of myocardial ischemia

Reduces cardiac risk in the immediate and delayed post-operative periods.

Advice on current drug therapy

All antihypertensive should be continued upto the time of surgery

Continuation of ACE inhibitors or ARB perioperatively is reasonable. If held before surgery, it is


reasonable to restart as soon as clinically feasible postoperatively. (2014 ACC/AHA Perioperative
Guidelines)

Beta blockers to continue, if stopped enhanced sensitivity to sympathetic stimulation

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

Enalapril (long acting)low plasma converting enzyme activityexaggeration of hypotension


Nifidepine: causes peripheral edema, tachycardia

Clonidine withdrawal ass. with rebound HTN

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

Effect of Antihypertensive drugs on conduct of anesthesia:

ACE inhibitors: marked intra-op hypotension and bradycardia.

Diuretics: hypovolemia and dyselectrolytemia.

-blockers: up regulation of receptors and cause marked rebound HTN if stopped.

CCBs potentiate the action of muscle relaxants.

Intra operative management

Goal:

To maintain an appropriate stable blood pressure range

Arterial blood pressure within 20% of preoperative levels.

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

ST segment changes for detection of introp myocardial ischemia

Intra-arterial pressure monitoring and CVP:

extensive surgery associated with rapid or marked changes in cardiac preload and afterload

patients with wide swings in BP

evidence of left ventricular dysfunction or other significant end-organ damage.

Urine output:

in patients with renal impairment undergoing surgery expected to last >2 hours

Blood loss

Anesthesia technique:

Regional anesthesia can be used in hypertensive patients.

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.

Additive circulatory depressant effects of anesthetic agents and antihypertensive agents

Many hypertensive patients are volume depleted

Preload/coloading

Titrated dose of drugs

Adequate depth of anesthesia before laryngoscopy

Brief duration of laryngoscopy and intubation:

Direct laryngoscopy that does not exceed 15 seconds in duration helps minimize blood pressure
changes.

Blunt the hypertensive response to laryngoscopy and intubation

Techniques to blunt hypertensive response to laryngoscopy:

Deepening anesthesia with a potent volatile agent

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.

Using topical anesthesia in airway

Choice of induction agent:

R Propofol, barbiturates, benzodiazepines and etomidate are equally safe.

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

R Volatile agent alone or with nitrous oxide

R Balanced technique (opioids + nitrous oxide + muscle relaxant)

R Total intravenous technique (propofol infusion)

Volatile anesthetics produce a dose-dependent decrease in blood pressure, which reflects a


decrease in systemic vascular resistance and/or myocardial depression

Muscle relaxant:

Any other muscle relaxant can be routinely used.

Pancuronium induced vagal blockade and neural release of catecholamines can exacerbate
hypertension in poorly controlled patients

Intraoperative Hypertension

Common causes of HTN intraop:

1. Light plane of anesthesia, inadequate analgesia, coughing, straining, bucking.

2. Pre-existing HTN either not treated at all or treated but inadequately.

3. Hypoxia, hypercarbia.

4. Overinfusion.

5. Drugs-Ketamine, pancuronium, adrenaline

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.

Selection of hypotensive agents depends on severity, acuteness, cause of hypertension, baseline


ventricular function, heart rate, presence of bronchospastic pulmonary disease, anesthetic
familiarity
- blockers: good choice for patient with good ventricular function and elevated heart rate.
Contraindicated in patient with bronchospastic disease

Nicardipine and clevidipine preferable for patient with bronchospastic disease

Nitroprusside: most rapid and effective agent

Nitroglycerin: may be less effective, but useful in treating and preventing myocardial ischemia

Fenoldopa: dopamine agonist, increases renal blood flow

Hydralazine: sustained blood pressure control, delayed onset, reflex tachycardia

Intraoperative Hypotension

Decrease depth of anesthesia


Increase intravenous fluids
Sympathomimetic drugs : ephedrine or phenylephrine

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.

Patients taking sympatholytics preoperatively may exhibit a decreased response to vasopressors,


particularly ephedrine.

Vasopressin as a bolus or infusion can also be used.

Extubation

In deep plain of anesthesia

Pain free

Warm
Avoid bucking or coughing

Blunt the hypertensive response to extubation

Postoperative management

COMMON CAUSES OF POST-OP HTN AND TACHYCARDIA :

1. Pain

2. Hypoxia

3. Hypercarbia

4. Agitation

5. Urinary retention

6. Sharp instrument

7. Peripheral vasoconstriction due to bleeding or cold ambient atmosphere

Common and should be anticipated in poorly controlled HTN

Can lead to - myocardial ischemia, CCF, cardiac dysrhythmias, stroke, wound hematomas, disruption of
vascular suture lines

Adequate analgesia and treatment of underlying cause

Intravenoues antihypertensive agents if necessary

Preoperative Anesthetic Concerns Goals and Management

Concerns Goals Management

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

Hypotension (during Maintain blood pressure perioperatively Adequate preloading, titrating


induction, dose of induction agents, Manage
intraoperative blood volume loss with IV fluids and
loss) blood products

Hypertension Avoid surge in blood pressure Maintain adequate depth,


(laryngoscopy, blunting during laryngoscopy
intubation, light plain (gentle), quick intubation (<15
of anesthesia,
extubation,
inadequate analgesia, sec), avoid precipitating cause,
hypoxia, judicious fluid administration
hypercarbia, fluid
overload,
sympathomimetic
drugs, endobronchial
intubation,
infiltration

with vasopressors,
raised ICP)

Lability of blood Maintain blood pressure in optimal range -do-


pressure

Perioperative Maintaining normal sinus rhythm


arrhythmias

Excessive surgical Maintaining blood pressure, hemostasis Fluid, blood products


bleeding

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

patients prone for


CVA)

Postoperative Monitoring
adverse
cardiovascular events Adequate pain management,
avoid hypoxia, hypercarbia,
judicious fluid management,
continue antihypertensives as
soon as possible

Anesthetizing a patient with hypertension:

PAC: Advice to continue antihypertensive drugs

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.

Intubation and Laryngoscopy:


Blunting drugs
1. Opioids (Fentanyl 2.5 mcg/kg to 5 mcg/kg, alfentanyl 15 to 25 mcg/kg, remifentanil 0.5-1
mcg/kg)
2. Beta blockers: Esmolol (0.3 to 1.5 mg/kg, metoprolol 1-5 mg, labetalol 5-20 mg)
3. Magnesium sulphate
4. Alpha 2 agonists: Clonidine, Dexmedetomidine (0.5 mcg-1 mcg/kg)
5. Lignocaine (1.5 mg/kg)
Gentle laryngoscopy
Quick intubation

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