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DELIBERATE HYPOTENSION
IN HEAD AND NECK SURGERY
C. F. WARD, MD, DAVID D. ALFERY, MD,
L. J. SAIDMAN, MD, and J. WALDMAN, MD
n
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25 75 125 115
MAP (torr)
Figure 1 , Cerebral blood flow (CBF) versus mean arterial pressure (MAP). Dashed line represents
minimum acceptable CBF versus MAP. Solid line remesents MAP of 50 torr, demonstrating no
reduction in CBF.
EEG monitoring to provide some estimate of ad- is not increased in hypertensive patient^.^? How-
equate perfusion. The minimum MAP of 50 torr ever, these patients do present an increased risk-
usually corresponds to a systolic pressure of 65- even when a n elevated MAP is accounted for-
70 torr. and hypertension therefore poses a relative con-
The preceding discussion refers to the adult traindication to deliberate hypoten~ion.'~
patient; much less is known about the control of
CBF in the child. Extrapolation of laboratory data Myocardial Circulation. Myocardial oxygen de-
in the fetal and the newborn coupled mand is determined mainly by ventricular wall
with a normally lower MAP and an absence of tension, cardiac rate, and contractile perfor-
vascular disease in the child, all support the con- mance. Coronary blood flow is dependent upon
cept that a MAP of 50 torr is acceptable. mean aortic blood pressure and coronary vascular
The hypertensive patient deserves special resistance.6 Control of coronary blood flow is au-
comment, since it has been shown that this pa- toregulated predominantly by means of altera-
tient population has an autoregulation curve that tions in coronary vascular resistance that are
is shifted higher a t both ends, proportional to the made t o meet myocardial oxygen demand. The
elevation in resting MAP.66Theoretical safe lim- coronary circulation differs from the cerebral cir-
its of hypotension may be calculated based on this culation in that, as arterial pressure and cardiac
shifted curve. Also, a recent study has shown that output fall, there is reduction in myocardial oxy-
the risk of precipitating infarcts by hypotension gen consumption. However, patients with coro-
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8
8
I MODERATE DOSE
8
i 0-
8
8
0
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8
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U 8
8 0 iOW DOSE
m H8
0 0
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0 I# 0 / /' I CONSCIOUS
50 150
MAP (torr)
F/gure 2 Cerebral blood flow (CBF) and volatile anesthetrcs Diagramatic presentation of the leftward
sh/ft of autoregulat/on with dose-dependent rnod/f/cat/onof the curve
nary artery disease may have some areas of the Pulmonary Circulation and Gas Exchange. De-
myocardium that are entirely dependent upon creased arterial oxygen tensions and increased
pressure t o supply adequate blood flow. Hypoten- alveolar-arterial oxygen gradients have been ob-
sion in these patients is accompanied by signifi- served during anesthesia with deliberate hypo-
cant risk of intraoperative myocardial i n f a r ~ t i o n . ~ ~tension. The probable mechanism involves a ven-
The electrocardiogram (ECG) provides a con- tilatiodperfusion mismatch in the lungs" as well
stant, albeit imperfect, monitor of the adequacy as an increase in physiologic dead space.3 Pul-
of coronary flow during deliberate hypotension. monary shunting is generally ~ n c h a n g e d As-
.~~
Several studies have documented that transient, sumption of the head-up position and the use.of
nonspecific ST-segment and T-wave changes oc- agents that blunt hypoxic pulmonary vasocon-
cur in patients with no known coronary artery striction (such as sodium nitroprusside-SNP)
diseases while they are undergoing deliberate hy- further aggravate these En-
potension, but that there are no serious sequel- riched oxygen mixtures should be administered,
ae;57*61*72
however, these changes may indicate that and controlled ventilation may be required when
the demandflow relationship has become unfa- deliberate hypotension is produced. Arterial blood
vorable. The appearance of definite ECG changes gases should be monitored; this is particularly a
indicative of ischemia suggests the need to reev- course of action that should be taken with those
aluate the indication for producing hypotension, patients who are known to have a history of
and it probably should be discontinued. preexisting pulmonary disease.
188 Deli berate Hypotension HEAD & NECK SURGERY JarVFeb 1980
Renal Circulation. The autoregulation that nor- detections3or os~illotonometry~~) or preferably by
mally controls blood flow to the kidneys is abol- direct arterial pressure measurement. The latter
ished during general anesthesia, and a decrease allows beat-to-beat observation of pressure, elec-
in the renal blood flow and in the glomerular fil- tronically determined MAP, trend-recording on
tration rate occurs as the result of even moderate paper, and the availability of samples for testing
decreases in arterial pressures.3gUrine flow may blood gases, hematocrit, and electrolytes. The
cease when systolic pressure falls to 70 torr choice of technique for measuring blood pressure
because the effective filtration pressure is lost. will depend on the degree and duration of hypo-
The kidneys, however, are protected from paren- tension desired. While a Doppler pulse monitor
chymal damage during deliberate hypotension would prove sufficient for a short period of hypo-
because the normal stratification of renal blood tension, direct arterial measurement is prefera-
flow is maintained and because there is no intra- ble for lengthy procedures.
renal shunting.24 A series of patients who were The use of more intensive monitoring must
anesthetized with halothane and made pro- depend on the preoperative condition of the pa-
foundly hypotensive (MAP of 40 torr) suffered no tient and the anticipated extent of the surgery. A
apparent renal damage, despite cessation of urine central venous-pressure catheter is considered es-
flow for periods in excess of one sential by many anesthetists, especially during
head and neck surgery, while a pulmonary arte-
Hepatic Circulation. As arterial pressure falls, there rial catheter may be required in selected patients.
is a reduction in hepatic blood f l o ~ . ~Addition-
~.'~ The addition of either of these monitors allows
ally, anesthetic agents and techniques such as the cardiac output to be measured via dye injec-
halothane or subarachnoid and epidural blocks tion or thermal dilution, and potent hypotensive
may further diminish hepatic blood f l o ~ . ~Re- ,'~ agents such as sodium nitroprusside may be ad-
gardless of this phenomenon, deliberate hypoten- ministered directly into the central circulation.
sion seems to be well tolerated by the liver, and EEG monitoring provides useful information con-
there are no reports showing morbidity or mor- cerning general cerebral perfusion, but it is not
tality from hepatic hypoperfusion during delib- in common clinical use in most hospitals.
erate hypoten~ion.'~ If the operative site is elevated 5-10 cm above
heart level, then precautions against air emboli-
MONITORING zation are advisable. These include the insertion
There are identifiable patient reponses that should of a right atrial catheter and the detection of in-
be monitored during deliberate hypotension, by tracardiac gas via ultrasound. The ECG should be
means of a t least: continuously examined, particularly for those
Electrocardiogram leads most likely to reveal ischemia.35Finally, as
Temperature in other anesthetics the temperature, respiration,
Precordial or esophageal stethoscope and urine output (if appropriate) should be mon-
itored.
Blood pressure via oscillotonometer, ultrasound
pulse detection or arterial catheter
Other measurements are optional but may be ap- POSITION OF THE PATIENT
propiate in certain cases: A hypotensive technique may reduce peripheral
Electronically determined mean arterial pressure circulation, and the blood flow may cease alto-
Trend recording on paper gether to areas overlying weight-bearing, boney
Central venous pressure prominences. For this reason, a n additional sup-
Pulmonary artery catheter portive pad should be placed beneath the patient,
Electroencephalogram with special attention paid to the occiput, scapu-
Right atrial catheter lae, sacrum, elbows, and heels. Damage to the
Precordial Doppler monitor for air emboli skin overlying these areas is probably a function
Urine output of both the duration and the degree of hypoten-
The Riva-Rocca method is adequate for use sion, and has not been reported as a complication
with Korotkoff sounds a t normal blood pressure. of deliberate hypotension per se. Also, pressure
However, it is inadequate for measuring very low must be kept off the orbits-especially if patients
pressure3*and must be replaced by either a more are in the prone position-to avoid compromising
reliable indirect method (such as ultrasound pulse the retinal blood flow.
Deli berate Hypotension HEAD & NECK SURGERY Jan/Feb 1980 191
neck surgery. Unfortunately, this is not the case. be the same for both groups of patients to elimi-
If one accepts the initial goals outlined in this re- nate technical variation. Accepting this, all cur-
view, then an "ideal" study can be constructed rent literature is inadequate. Table l follows and
with which to compare the current clinical expe- displays a broad review of this literature, with
rience. The ideal must first define hypotension the deficiencies and the strengths of each paper
and then maintain this definition throughout. noted. Several features are noteworthy: (1)over
Criteria for the assessment of patient risk and the 43,000 cases are presented, (2) approximately 40
selection must be included, and a control group of these cases present enough data to determine
of patients must be similarly assessed. Reasons mean pressure, (3) the majority of reports have no
for patient rejection from the hypotension group or poor (i.e., nonrandomized) control groups, and
should be clarified. Preoperative evaluation, pre- (4)only one study is prospective. The last point
medication, monitoring, and positioning all re- specifically refers to the 1978 study by Thompson
quire specific delineation, while anesthetic and et alG9of deliberate hypotension for total hip ar-
hypotensive techniques must be controlled. Intra- throplasty; this is the only controlled, prospective
operative and postoperative complications should study in 30 years to prove an advantage of the
be compared, and patient follow-up must be ade- technique of deliberate hypotension for a selected
quate t o evaluate the quality of the procedure. procedure. The sole deficiency of this paper is the
Finally, the surgeodanesthesiologist team should small number of patients studied.
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Table 1. Review of the literature on deliberate hypotension
Investigator No of Region of P or Pressures Techniques
(yr published) patients surgery Ra reported used Comments
Hug he^^^ 10 Headandneck R Systolic/ Gang block Methods of monitoring not reported MAP
(1951) diastolic calculable, > 50 torr throughout
Hampton et aI3O 21,125 Variable R Systolic Multiple Questionnaire distributed by mail with 48%
(1953) return Mortality of 1 459
Hampton et aI3' 6,805 Variable R Systolic Multiple Similar to those of Hampton 30
(1953)
Little43 Unknown Variable R Systolic/ Gang block Essentially anecdotal with no real data.
(1 955) diastolic Introduction of trimethaphan.
Anderson' 44 Variable R None Gang block Inadequate data; no control group. First
(1955) sizeable series in children.
Royster et alse 34 Head and neck R Systolic Gang block Inadequate data, Shows reduction in blood
(1956) loss, not operative time.
M~lndoe~~ 4,500 Variable R None Gang block Inadequate data; no control group. Mortality of
(1 956) 1:900; overwhelming positive bias.
EnderDyZ2 9,107 Variable R None Gang block Inadequate data; no control group. Mortality of
(1961) 1:1000; overwhelming positive bias.
Holme~~~ 138 Middle ear R None Gang block Inadequate data; no control group; no results.
(1961) Emphasis on patient position.
Linacre4' 1,000 Pelvis R Systolic Gang block Inadequate data; poor control group.
(1961) (range) Reasonable discussion.
Charnberlin et a19 50 Head and neck R None Gang block Inadequate data; poor control group. Use of
( 1963) EEG and systemic heparinization; reduced
blood loss and operative time.
Loewy et 24 Head and neck R None Unknown Inadequate data; poor control group. Use of
(1 963) mild hypothermia, mention of "fitness" of
patient's postoperative condition.
Eckenhoff et all8 44 Head and neck R Unknown Inadequate data; poor control group.
(1 965) Decreased blood loss, mention of "fitness"
of patient's postoperative condition.
Ma~Rae~~ Unknown Middle ear R None Nitroprusside No data. Early mention of nitroprusside
(1971)
Salem et alss 137 Variable R Systolic Gang block, Inadequate data, no control group no results
(1974) propanolol Excellent discussion
KerP 700 Middle ear R Systolic Gang block Inadequate data, no control group Pressures
(1977) propanolol reduced to 30-45 torr in head-up position
Thompson et a P 30 Hip P Mean Nitroprusside Small numbers Superb protocol with definite
(1 978) (50 torr) or halothane reduction in blood loss and time
*P = prospective study, R = retrospective study