A CASE OF

HYPERTESION
AND ANESTHETIC
MANAGEMENT
By
Dr Ritu Pradhan
MD anaesthesiology 2nd year resident
NAMS ,BIR HOSPITAL
Moderator :Prof Dr G R Bajracharya
HYPERTENSION
 Systolic and diastolic blood
pressure 140/90 mmHg or more on
at least two occasions measured at
least 1 to 2 weeks apart in adult
(>18yr)
Ref. JNC VI Arch Intern Med 1997;157:2413-20
Classification of systemic
blood pressure
Category Systolic Diastolic
BPmmHg BPmmHg
Optimal <120 <80
Normal <130 <85
High Normal 130-139 85-89
Systemic HTN

Stage I(mild) 140-159 90-99

StageII(mode 160-179 100-109
rate)

Stage3 ≥180 ≤110

SYSTEMIC HTN
 Significant risk factor for IHD
and major cause for
CHF,CVA, arterial aneurysm
and end stage renal diseae.
 Risk for perioperative mobidity
through the extent of end
organ damage and not the
manifestation of disease itself.
Case history
 Karma suri Gharti 53yr
female,admitted for elective open
cholecystectomy with diagnosis of
cholelithiasis on 2066/4/30.Her
chief complain was pain abdomen
for 4-5 months on and off. She had
history of hypertension for 10
months and diabetes mellitus for
last 5 years.
 Medications:Metformin 500mg BD
for 10yrs,
 Tab glicazide 40mg BD for
2years
 Tab ramipril 7.5mg HS for
10months
 No history of chest pain,dyspnea,
shortness of breath, PND
,orthopnea,syncope.
 No h/o asthma, PTB,COPD
 H/o operation for uterine tumor 10
years ago under GA
 LMP 2066/4/14
 No other significant medical history
 No h/o smoking and alcohol
On examination
 GC : fair
 J(-)A(-)Cy(-)Cl(-)O(-)D(-)

Weight:57kg
Pulse: 86/min
BP :130/90mmhg
RR :16/min
Peripheral veins : accessable
AIR WAY EVALUATION
 Mouth opening :3fingers(approx)
 Thyromental distance :3
fingers(approx)
 TMJ :free
 Teeth :intact
 Neck mobility : no restriction
 NO neck swelling
 Mallampati grade III
Systemic examination
 Cardiovascular:NAD
 Respiratory:B/L air entry ,no added
sounds
 P/A :soft
 CNS/spine :NAD
 Hb :11.7gm%,TC: 4700cells/cumm
 Platelets:242,000cells/cumm
 Fasting blood glucose: 105mg%
 R blood glucose:128mg%
 Urea: 31mg%
 Creatinine:0.8mg%
 Na+ :144mg%
 K+:4.5mg%
 PT:11.7sec, control :12sec,INR :1
 HBA1C: 4.6%
 CXR : NAD
 ECG : HR 85bpm,sinus rhythm
 ECHO: LV ejection fraction:60%
LV diastolic dysfunction
normal LV systolic function
Preoperative concerns
 Etiology of HTN
 Severity
 Medications/compliance
 Sequelae of HTN/end organ
damage
Etiology

 Primary/essential HTN
- accounts for >95%of all causes
- cause for increased BP cannot de
identified
- Strong family history of HTN
Secondary HTN
 Renal
 Endocrine

 Pregnancy induced

 Neurological dysfunction

 Drugs

-glucocorticoids
Mineralocorticoids
Sympathomimetics
-tyramine/MAO inhibitors
-nasal decongestant
-sudden withdrawl of antiHTNsive
drugs(centrally acting and ß
adrenergic antagonist)
 Isolated systolic HTN /pulse
pressure HTN
-age associated rigidity
-increased CO –
thyrotoxicosis,anemia,AR
Severity/duration
 Ideally should be normotensive
before any elective surgery
 End organ damage is associated
with severity and duration
 There are evidences of incidence
of perioperative hypertensive
episodes and post operative
cardiac complication depending
upon pre operative systemic BP
status
 Optimal BP <170/95mmHg for
elective surgery
 Ref;critical analysis of data od
Asidda and collegaes study –
patients who have high BP before
durgery are likely to have high BP
after surgery.
 In moderate hypertensive patient
with end organ damage
preoperative blood pressure
should be normalised as much as
possible.
 Goldman et al found that patients
with mild to moderate HTN(diastlic
BP<110mmHg) were not at risk of
vascular complication unless they
have other risk factor like CAD
 Elective surgery should be
postponded for patients with
severe hypertension (diastolic
BP>110mmhg) or with severe
isolated hypertension(systolic
BP>200mmHg)until Bp is below
180/110mmHg
 Reduction of blood pressure within 4 to 6
weeks is advisable.
 Acute reduction is not advised because
auto regulation curve of cerebral blood
flow is shifted toward left and so more
pressure dependent.
 Ref:Yao and Artusio’s Anesthesiology
problem oriented pateint management .
6thedition,page no:311.
Medications
 Drugs –which drug to continue
-which drug to stop
Adverse effects of drugs-electrolyte
imbalance
Drugs affecting anaesthetic agents
-ca channel blockers, drug having
sedative and anxiolytic property
like beta blocker,clonidine
 Drug affecting autonomic nervous
system
 Alpha1 antagonist;prazosin
 Alpha and beta antagonist;labetolol
 ACE inhibitors and Angiotensin II
Antagonist are usually stopped
 Cause the increase in the potential
hypotensive effect of induction of
anaesthesia
Sequele of HTN
 Cardiac:IHD,Angina,CCF
 DX :CXR –
cardiomegaly,pulmonary vascular
congestion, ECG-LVH,ischaemic
conduction abnormalities,old
infarction,strain
 CNS;TIA,CVA,
 Renal: glomerulosclerosis
,decrease GFR,renal insufficiency
 Peripheral vascular disease
 retinopathy
Preoperative preparations
 Premedication was done with
diazepam 10mg po Hs
 Ramipril was stopped
 Metformin and glicazide was
stopped
 Blood glucose fasting,electrolyte
was sent at 6am on the day of
surgery
Pre operative status
 Vitals: BP 120/80mmHg
 pulse :80/min
 Spo2:100%
 Investigations:
 Fasting blood glucose 106mg%
 Na+:140meq/l
 K+ :3.6meq/l
INSIDE OT
 Iv cannulation
 Preloading with NS
 Monitors: NIBP,ECG,SPO2
 Premedication :Inj Mida 2mg iv,
 Inj pethidine 50mg
inj xylocard 60mg
 Induction :propofol 100mg
 Muscle relaxant:100mg sux
 ETCT 7mmid
 Muscle relaxant maintenance:Nor
6mg +1mg+1mg+1mg+1mg
 Maintenance with o2+halo+IPPV
 Intra operative vitals were almost
stable
 Reversal :inj atropine 1.2mg +inj
neostigmine 2.5mg iv
 Extubation
 Post extubation vitals stable
 Patient awake
 Patient was transferred to PACU
 O2 supplementation with
mask@5L/min
INDUCTION
 Depletion of intravascular volume
especially in diastolic hypertension
 Induction
Agents;propofol,sodiumthiopentone,(NO
KETAMINE)
 Exaggerated stress response to
laryngoscopy and tracheal intubation
 Duration of laryngoscopy ;
<15secs
 Blunting of reflexes :
 Lidiocaine: 1mg/kg I v 1min before
induction
 Beta blocker :esmolol 100-
200mcgabout 15 secs before
induction
 Topical lignocaine spray 4%
 Opiods :fentanyl 50-150mcg/kg iv
3min before induction
 Ramifentanyl 1mcg/kg iv before
induction
 Alfentanyl 15 to 30mcg
MAINTENANCE
 GOAL: to adjust the depth of
anaeshesia to minimise wide
fluctuation in systemic blood
pressure
 inhalational agents(halothane ,
isoflurane, sevoflurane,desflurane)
 Opiods+N2O+inhalational agent
Monitoring
 Noninvasive
-ECG
-NIBP
-SPO2
-temp
-ETCO2
 Invasive
 CVP
 PAC
 Intra arterial line
 TEE
POST OPERATIVE
 Development of post opeative
systemic hypertension warrants
prompt assessment and t/t to
decrease the risk of MI,cardiac
dysarrythmias, CCF,stroke and
bleeding
CAUSES
 PAIN
 HYPOXIA
 HYPERCARBIA
 EMERGENCE EXCITEMENT
 URINARY RETENSION
 SHARP INSTRUMENTS
PERSISTENT HTN
 Inj nitroprusside 0.5 to 10
mcg/kg/min in titrated dose to
produce desired SBP with the help
of continous intra arterial BP
monitoring
 Or
 Inj labetolol 0.1 to 0.5mg /kg iv
every 10 min with monitoring
References
 Robert K stoelting ,S F Dierdorf
.Anesthesia and coexisting disease ,4th
edition:churchhill living stone 2007.
 Yao and Artusio’sAnesthesiology
promblem oriented patient
management,6th edition:lippincott willim
and wilkins 2008
 G E morgan,M s Mikhail,M J
murray.Clinical Anesthesiology,4th
edition:Mc GrawHill ,2008
 Millers anesthesia 6th edition
Thank


you