B.1. How would you evaluate this patient preoperatively?

In addition to the routine systemic preoperative physical and history, special attention should be paid
to the following: etiology and severity of hypertension, current therapy, and the end-organ damage
by chronic hypertension.

The underlying cause of hypertension should be clear. Surgical mortality is relatively high in patients
with renovascular hypertension. Moreover, failure to diagnose a pheochromocytoma preoperatively
may prove fatal, because anesthetic agents are well known to precipitate a crisis in such patients.
Meanwhile, the severity of hypertension alters anesthetic risk.

Antihypertensive drugs have different anesthetic implications. Diuretics frequently cause chronic
hypokalemia and hypomagnesemia, which may increase the risk of arrhythmia. Therefore, serum
electrolytes should be checked preoperatively.

The presence of target-organ damage in the brain, heart, and kidney signifies longstanding, poorly
controlled hypertension.

For cardiac evaluation, electrocardiogram (ECG) and chest x-ray film serve as minimal tests. The
echocardiogram will be helpful. LVH can increase the risk of perioperative myocardial ischemia from
imbalances of myocardial oxygen supply and demand regardless of the presence or absence of
coronary artery disease. Some authorities believe that hypertensive patients without evidence of LVH
or other risk factors are at a lower perioperative cardiac risk and do not require further evaluation for
most operations. Patients with severe hypertension are also at increased risk for CHF and pulmonary
edema.

For renal evaluation, urinalysis, serum creatinine, and blood urea nitrogen should be measured to
define the presence and extent of renal parenchymal disease. If chronic renal failure exists,
hyperkalemia and elevated plasma volume should be considered.

For cerebrovascular evaluation, a history of CVAs and TIAs and the presence of hypertensive
retinopathy should be looked for.

B.2. Would you postpone the surgery? Why? What BP would you like the
patient to achieve before surgery?

Yes. I would postpone the elective surgery because the BP was 230/120 mm Hg. In general, elective
surgery should be delayed for patients with severe hypertension (diastolic BP greater than 115 mm
Hg) or with severe isolated systolic hypertension (systolic BP greater than 200 mm Hg) until the BP is
below 180/110 mm Hg. If time permits, the BP should be lowered over 6 to 8 weeks to 140/90 mm
Hg. Acute control within several hours is inadvisable before elective surgery, because this practice
may put the cerebral or other circulations at risk for ischemia.
In moderate hypertensive patients with severe end-organ involvement, preoperative BP should be
normalized as much as possible, although in asymptomatic patients with mild to moderate
hypertension (diastolic BP less than 110 mm Hg), elective surgery may proceed without increased
cardiovascular risks.