1) The document discusses the management of anesthesia for patients with hypertension. It outlines evaluating patients preoperatively, maintaining stable blood pressure during induction and maintenance of anesthesia, and monitoring patients postoperatively. 2) Several antihypertensive drugs are presented that can be used intraoperatively to control blood pressure, including sodium nitroprusside, labetalol, nicardipine, and hydralazine. General principles are to avoid large swings in blood pressure and prevent hypotension. 3) Postoperative care involves ensuring patients continue their antihypertensive medications, monitoring blood pressure, and treating reversible causes of hypertension like pain or anxiety.

2. Management of anaesthesia
in patients with hypertension
by
Dr. Mohamed Said

3. Hypertension Why Important ?
• Common disorder
• High risk factor for cardiovascular diseases
• End organ damage – Heart
Brain & Kidney
• Alteration in cerebral & renal blood flow

5. New classification
• Borderline 140-159 90-99
• Mild 140-159 90-99
• Mod. 160-179 100-109
• Sever 180-209 110-119
• Very sever >210 >120

6. Main Items
• Preoperative evaluation
• Induction of anaesthesia
• Maintenance of
anaesthesia
• Postoperative
management

7. • Preanesthetic evaluation
• Perioperative risk reduction
• Premedication
• Balanced anesthesia
• Proper monitoring
• Parenteral medications
Preoperative Evaluation

8. Preanesthetic evaluation
• History
• Physical examination
• Adequacy of blood pressure control

9. Perioperative risk reduction
• Effective control of blood pressure
• Anti Hypertensive drug therapy
• Hydration
• Choice of anesthetic agent
• Adequate analgesia
• Miscellaneous (psychological support)

10. Agent Dosage Onset Duration
Nitroprusside 0.5 – 10 ug/kg/min 30-60sec 1-5 mins
Nitroglycerine 0.5 – 10 ug/kg/min 1 min 3 – 5mins
Esmolol 0.5mg/kg in 1 min
50 – 300 ug/kg/min
infusion
1 min 12-20 mins
Labetolol 5-20 mg 1-2mins 4-8 hrs
Propranalol 1-3 mg 1-2 mins 4-6 hrs
Trimethaphan 1-6 mg / min 1-3 mins 10-30 mins
Fentolamine 1-5 mg 1 – 10 mins 20-40 mins
Diazoxide 1-3 mg /kg slowly 2-10 mins 4 – 6 hrs
Hydralazine 5-20 mg 5-20 mins 4-8 hrs
Nifidepine s/l 10 mg 5-10 mins 4 hrs
Methyl dopa 250 – 1000 mg 2-3 hrs 6-12 hrs
Nicardipine 0.25 – 0.5 mg 1-5 mins 3-4 hrs
Enalapril 0.625 – 1 mg10 6-15 mins 4-6 hrs
Fenoldopam 0.1 – 1.6 ug/kg/min 5 mins 5 mins

11. 1 Urgent reduction of severe acute hypertension Sodium nitroprusside
infusion 0.3 – 2 mic.g/kg/min
2 HT with ischemia with poor LV NTG infusion 5 – 100
mic.g/kg
3 HT with ischemia with Tachycardia a. Esmolol bolus or
infusion 50 – 250
micg/kg/min
b. Labetolol bolus orr
infusion 2 – 10 mg;
25 – 30 mic. G /kg
4 HT with heart failure Enlapril at 0.5 – 5mg bolus,
1.25 mg/6 hours given over
5 mins. Response within 15
mins
5 HT without cardiac complications Nifidepine – 5 – 10 mg S/l
Nicardipine infusion – 5 – 15
mg/hr
Hydralazine 5 – 10 mg bolus
5 HT with Phaeochromocytoma Labetolol – Bolus 2 – 10mg
Infusion 2.5 – 30 mic
g/kg/min
Phentolamine 1-4mg bolus

12. General principles
Cardiovascular stability is important during anaesthesia
and the perioperative period. Hypertensive patients are
at risk of greater swings of blood pressure than the
normal population and it has been shown that blood
pressure lability can be associated with increased
cardiovascular morbidity and mortality postoperatively,
particularly in patients with severe uncontrolled
hypertension.
Patients who have hypertension require a higher blood
pressure for adequate organ perfusion than
normotensive patients – this is particularly in the
elderly. Avoidance of hypotension may prevent
complications of under-perfusion..

13. Induction
Significant hypertension in the induction area often settles
with a small dose of intravenous sedation (midazolam 1 –
3mg).
Persistently elevated blood pressure can prove challenging
during anaesthesia. Abrupt and marked reductions in blood
pressure may occur on induction of anaesthesia, and large
increases during stimulating procedures such as laryngoscopy,
intubation and pain. It is possible to augment induction with
other pharmacological agents. Short acting opioids such as
fentanyl 1mcg/kg with induction agents will diminish
stimulatory effects.
Intraoperative blood pressure monitoring may be non-invasive
or invasive. Standard non-invasive blood pressure monitoring is
mandatory for anaesthesia, with a minimal interval of five
minutes. High risk patients undergoing major surgery can, in
addition, have intra-arterial monitoring to improve control and
allow early pharmacological intervention.

14. Maintenance
Patients with underlying organ dysfunction need careful
consideration of anaesthetic agents. For example
underlying renal failure, will alter metabolism and excretion
of drugs. Recent or significant end organ damage, for
example recent myocardial infarction may necessitate
surgical delay.
Effective opioid analgesia, regional anaesthetic techniques
and avoiding hypoxia, hypercarbia and light anaesthesia all
aid to reduce episodes of hypertension intraoperatively.
Vasopressor agents and intravenous fluids may be required
if hypotension results from cardiac depression. Spinals or
epidurals may increase intraoperative hypotension,
particularly in hypertensive patients who are dehydrated or
those receiving vasoldilator drugs..

15. Recovery
Monitoring should include ECG, blood pressure and
SpO2. Coughing on emergence of anaesthesia may
produce hypertension, and preoperative lignocaine
spray on the endotracheal tube or deep extubation may
improve this. Patients may develop hypertension due to
pain, bladder distension or anxiety. It is also important
to remember some patients will be confused and
disorientated after anaesthesia and this may worsen
blood pressure values. This highlights the importance of
the recovery room being a suitably calm environment
with staff trained to anticipate and treat these problems.
After reversible causes have been treated (pain, urine
retention) treatment of continuing hypertension may be
reaquired.

16. Postoperative care
Patients must be followed up after anaesthesia to
ensure post operative complications are minimized and
treated appropriately if they occur. It is important to
ensure patients continue their antihypertensive after
surgery and alternative routes of administration are
considered for those patients who are nil by mouth.
Patients with severe hypertension must be closely
monitored and ward and anaesthetic staff alerted if
management becomes difficult or is uncontrolled. High
risk patients should also be given supplementary oxygen
to prevent hypoxia and therefore reduce ischemic
episodes after anesthesia. The continuation of
prevention of hypertensive triggers on the ward must
also be highlighted.

17. HOME MASSAGE
• Patient with diatolic B.P 110 mmHg can do
elective surgery but the best make B.P
160/100 is the key number for decision.
• Premedication for HTN patient is mandatory
but avoid oversedation.
• NO hypotnsive anesthesia for uncontrolled
HTN pt.
• Golden role………keep B.p withen 10%-20% of
the preoperative level.

18. Questions
• 1-What are the anesthetic goals for
hypertensive patients?
• 2- D.D and management of postoperative
hypertension?