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Perioperative Management of Hypertension

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Hypertension is most common medical reason for postponing surgery.How important is peri-operative hypertension?Hypertensive comorbidities associated with adverse perioperative outcomes .New Guidelines for managing patients with high blood pressure before surgery

Consequences of anesthesia on blood pressure regulation.

Publié dans : Santé & Médecine
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Perioperative Management of Hypertension

  1. 1. Magdy El-Masry Prof. of Cardiology Tanta University
  2. 2. Peri-operative Hypertension Hypertension occuring in the pre-operative, intra-operative or post-operative period. What is meant by peri-operative? Peri-operative generally refers to the three phases of surgery: pre-operative, intra- operative, and post-operative.
  3. 3. Hypertension is most common medical reason for postponing surgery Peri-operative hypertensives are very very common
  4. 4. How important is peri-operative hypertension? The effect of chronic hypertension on perioperative risk is determined primarily by the presence of target organ damage , that is, coronary artery disease, stroke, heart failure, and renal failure, all of which are known to affect perioperative morbidity and mortality .
  5. 5. It is not clear if increased BP has an independent effect. Target organ damage associated with hypertensive disease and total cardiovascular risk, rather than high BP per se appear to determine perioperative risk. Hypertensive comorbidities associated with adverse perioperative outcomes include occult CAD(Q waves on the ECG),heart failure, LVH, serum creatinine higher than 2.0 mg/dL, and cerebrovascular disease
  6. 6. Hypertension is not included
  7. 7. Laryngoscopy & intubation are known causes of hypertension( Sympathetic activation )
  8. 8. Consequences of anesthesia on blood pressure regulation. Blood pressure is a compromise between cardiac output and systemic vascular tone. Blood pressure regulation depends therefore on heart rate (HR), left ventricle stroke volume (LVSV) and vascular resistance. The sympathetic nervous system is the main regulatory system, which is blunted by anesthesia (general, or medullary). Fortunately, the backup systems, renin angotensin system and vasopressin, can compensate the sympathetic nervous system impairment. Colson and Gaudard. J Hypertens Manag 2016, 2:013
  9. 9. To operate or not to operate, that is the question.
  10. 10. When assessing patients for anaesthesia who have elevated blood pressure, a number of questions must be answered. Is the patient known to be hypertensive on a previous occasion? Are they on antihypertensive medication? Does the patient have a treatable cause for their hypertension? Does the blood pressure control need alteration before surgery? Does the patient have “white coat” hypertension?
  11. 11. Therefore, it may be helpful in some cases to contact the referring physician in order to obtain more accurate arterial pressure values than the ones measured at hospital admission (white coat HTN).
  12. 12. Increased complications including myocardial infarction , myocardial ischemia, dysrhythmias, cerebrovascular events , and renal failure have been reported if the preoperative diastolic blood pressure is 110 mmHg or higher . The patients with preoperative isolated systolic hypertension(where the pressure is greater than 180 mmHg or the pulse pressure is greater than 80 mmHg) had a 40% increase in perioperative cardiovascular events.
  13. 13. Common reasons for delayed surgery in patients with hypertension Poorly controlled blood pressure of grade 3 according to ESC (systolic blood pressure ≥ 180 mmHg and/or diastolic blood pressure ≥ 110 mmHg) Discovery of end-organ damage that has not previously been evaluated or treated Suspicion of secondary hypertension without properly documented aetiology
  14. 14. There are no randomized clinical trial data showing what the optimal blood pressure should be at the time of surgery.
  15. 15. What do guidelines tell us?
  16. 16. New Guidelines for managing patients with high blood pressure before surgery The Association of Anaesthetists of Great Britain and Ireland (AAGBI)
  17. 17. Why was this guideline developed? This guideline aims to prevent the diagnosis of hypertension being the reason that planned surgery is cancelled or delayed. Anaesthetists are more focused on immediate complications, in the perioperative period. Cardiologists are concerned with the long- term reduction in rates of CVD, particularly strokes.
  18. 18. Primary care blood pressure assessment of patients before referral for elective surgery.
  19. 19. Secondary care blood pressure assessment of patients after referral for elective surgery. Patients who present to pre-operative assessment clinics without documented primary care blood pressures should proceed to elective surgery if clinic blood pressures are below 180 mmHg systolic and 110 mmHg diastolic
  20. 20. The latest 2014 ACC/AHA Perioperative Guidelines do not mention hypertension. The 2007 version stated, “Numerous studies have shown that stage 1 or stage 2 hypertension (systolic blood pressure below 180 mm Hg and diastolic blood pressure below 110 mm Hg) is not an independent risk factor for perioperative cardiovascular complication
  21. 21. Recommendations on peri-operative hypertension In patients with grade 1 or 2 hypertension (systolic blood pressure ˂ 180 mmHg; diastolic blood pressure ˂ 110 mmHg), there is no evidence of benefit from delaying surgery to optimize therapy. In such cases, antihypertensive medications should be continued during the perioperative period.
  22. 22. Preoperative antihypertensive medications management Most antihypertensive drugs should be continued to the day of surgery and restart as soon as possible (when the patient will be able to swallow). Only agents that affect the RAS should be cancelled — ACEIs and ARBs The physical status of patients ≥ 3 according to American Association of Anesthesiologists is a more significant predictor of aggressive hypotension than receiving antihypertensive medication.
  23. 23. The American Society of Anaesthesiology classification of physical status(ASA)
  24. 24. Recommendations on use of ACEIs and ARBs
  25. 25. Recommendations on beta-blockers d Treatment should ideally be initiated between 30 days and (at least) 2 days before surgery, starting at a low dose, and should be continued post-operatively. The target is a resting heart rate 60– 70 bpm, and systolic blood pressure >100 mm Hg.
  26. 26. Perioperative use of beta-blockers may benefit only patients at highest risk and may harm other patients.
  27. 27. Among perioperative complications, acute postoperative hypertension (APH) is the most frequent one. If it is left untreated, the APH is a major risk factor for adverse events such as postoperative bleeding, cerebrovascular damage, myocardial ischemia , arrhythmias, myocardial failure with congestive pulmonary edema , breakup of vascular anastomoses. The APH that occurs is manifested in the first 20 minutes of the postoperative period and lasts an average of 3 hours
  28. 28. Parenteral antihypertensive agents for treatment of perioperative hypertension Abbreviation: CI, continuous infusion. To solve an APH, several pharmacological solutions turned out to be efficient.
  29. 29. Preoperative Intraoperative Postoperative SAP ≤ 180 mmHg, DAP≤110 mmHg MAP not lower than 25–30% of awake Resume antihypertensive drugs upon oral intake or substitute i.v. ECG, serum creatinine, electrolytes (diuretics) search for target organ damage (heart, brain, kidney) Attenuate sympathetic response to laryngoscopy (or use laryngeal mask) Measure blood pressure every 5–15 min first hour then every 30 min until 3 h postoperative Antihypertensive drugs; continue day of surgery: b-blockers, CCB; stop day of surgery: diuretics, ACEI, ARB Consider use of noninvasive cardiac output monitoring and near-infrared spectroscopy (NIRS) Treat postoperative hypertension to MAP > 100 and <130 mmHg and HR 50 bpm; Metoprolol: repeat 2–5 mg bolus i.v.; labetolol: repeat 10–20 mg bolus i.v.; nicardipine: 0.5–1 ug/kg/min i.v.; nitroglycerine: 0.1–5 ug/kg/min i.v. Recommendations for the perioperative management of patients with hypertensive disease (opinion based) Current Opinion in Anaesthesiology. 29(3):397-402, JUN 2016