Anesthetic Consideration in

Hypertensive Patient
 Hypertension
• May indicate serious endocrine problem (DM,
thyrotoxicosis, phaeochromocytoma) or renal
problem.
• Risk factor for cardiovascular and renal
diseases.
• Increase risk for anesthetic complications
• Increase cancellation of surgery
Classification of Hypertension
Category (JNC7) SBP DBP
(mmHg) (mmHg)

Normal <120 And <80

Pre HT 120-139 Or 80-89

Stage 1 HT 140-159 Or 90-99

Stage 2 HT 160 Or 100

 End Organ Dysfunction
1. HEART

Hypertension   LV afterload and causes strain to heart muscle.

afterload → hypertrophy → dilatation → heart failure
Dilated heart → contractility  → stroke vol  (Starling law).
Compensation: HR ↑ → O2 demand ↑→ ischaemia

2. BRAIN
Autoregulation in hypertension: shift to the right. CBF  and → cerebral
ischaemia.
Cerebral autoregulation can’t be measured:
–  MAP 25% reaches the lower limit of autoregulation
–  MAP 55% will reach symptomatic brain hypoperfusion
 End Organ Dysfunction
3. KIDNEY
Hypertension affects autoregulation in the same way as the brain.
End organ damage : glomerular sclerosis, abnormal distribution of renal blood flow,
GFR . Sudden & sustained BP causes renal ischaemia (prerenal hypoperfusion),
leads to postoperative renal insufficiency, even failure
 Preoperative Hypertension
AHA & ACC : SBP 180 mmHg and DBP 110 should be cancelled
HOW TO DECREASE PERIOPERATIVE RISK
1. Control BP adequately if possible
Continue all medication prior to surgery, except diuretics.
Postpone if SBP >200 or DBP >120 mmHg.
2. Attenuate haemodynamic response to surgical/ anesthesia pain stimuli. (opioid,
lignocaine, antihypertensive)

3. Optimal hydration prior to induction .

 Intraoperative Consideration
Use drugs with minimal effects on haemodynamic & suits to patient condition, in
example :
• fentanyl or meperidine than morphin
• midazolam than propofol
• vecuronium than pancuronium
• isoflurane than halothane

Intraoperative hypertension, most common cause :

• inadequate anesthesia
• pre-existing hypertension (especially untreated hypertension)
 Intraoperative Consideration
• Check the depth of anesthesia : signs of light anesthesia (tears,
movement, etc).
• Check appropriateness of anesthesia maintenance (vaporizer,
leak/ obstruction of breathing circuits, timing of giving
increment iv drugs, etc).
• Check all infusion fluid/ drugs, recalculate the dose.
• Check adequate ventilation/ oxygenation. Check the CO2
absorber, tidal volume, RR. Blood Gas Analysis if necessary.
• Confirm any vasoconstrictor given by the surgeon.
• Recognize any procedure possibly causes
hypertension(tourniquet, pneumoperitoneum).
• Measure body temperature.
 Treatment For Intraoperative
Hypertension
1. Vasodilator (contraindicated in coarct. Aorta)
SNP 0.5 – 0.8 g/kg/min, titrated.
NTG 0.5 g/kg/min, titrated.
2.  agonist
Clonidine 150 g, iv bolus.
Dexmedetomidine
3. blocker
Esmolol 0.5 mg/kg, rapid iv bolus (via nearest vein to the heart)
Atenolol, 1 – 2 mg iv
4. Drugs to decrease ICP
Mannitol 0.5 – 2 g iv/kg
Furosemide 5 – 20 mg iv
+ mild to moderate hyperventilation
TERIMA
KASIH