Hypertension

Question 1

antihypertensives and anesthetic considerations

Answer 1

Beta Antagonists – rebound SNS stimulation, Avoid in asthmatics/COPD/CHF/HB/Sick sinus
Methyldopa – rebound HTN, ↓ anesthetic requirements
Clonidine – rebound HTN, ↓ anesthetic requirements
Prazosin – compensatory vasoconstriction is blocked therefore ↓BP during spinal/epidural block may be exagerrated
Hyralazine – may cause angina in pts with ischemic heart disease
ACE inhibitors (‘prils’) – associated with hemodynamic instability and ↓BP during GETA
Angiotensin II Blockers (‘artans’) – ↓BP with induction

Question 2

Hypertensive crisis

Answer 2

Acute DBP >130 mmHg
Can result in the following:
Encephalopathy
Congestive heart failure
SAH (subarachnoid hemorrhage)
Renal insufficiency
Goal is to treat DBP promptly but gradually
Decrease by 20% during first 2 hours of treatment
Ongoing treatment over 24-48 hours to decrease BP gradually

Question 3

Treatment of hypertensive crisis

Answer 3

Placement of arterial line
Nitroprusside 0.5 – 10.0 mcg/kg/min
Drug of choice 
Short duration of action
Nitroglycerin 5-200 mcg/min
Labetalol 40-80 mg q 10 min
Esmolol 50-300 mcg/kg/min

Question 4

Anesthetic Management induction, maintenance, post op

Answer 4

1. Induction
   Goal is to minimize SNS stimulation with laryngoscopy & intubation
   Attenuate laryngeal reflexes with additional narcotic, increase volatile agent, and lidocaine (topical or IV) Choice of any induction agent is appropriate. EXCEPT?? ketamine.
   Lidocaine IV 1-1.5mg/kg
   Lidocaine Topical (LTA) 2-4% (5cc)
   Opiates
   Volatile agents
2. Maintenance
   Goal is to adjust depth of anesthesia to minimize wide shifts in hemodynamics
   Choose a IA that is easily adjusted
   (low BG co-efficient)
   Balanced technique
   Have ephedrine, neosynephrine readily available.
   Consider neo gtt if unable to get adequate depth of anesthesia
3. Post-op
   Goal is to minimize SNS secondary to surgical pain and nausea/vomiting
   v

Question 5

Anesthetic management

Answer 5

Controlled vs. Uncontrolled??
Emergent vs. Elective Surgery??
Evidence of end organ damage??
   Angina  
   CHF
   CVA
   Renal insufficiency
   PVD
Drug Regimen??

Question 6

Intraoperative HYPERTENSION

Answer 6

Usually d/t PAIN!
Incidence is higher in patients with essential HTN
Treatment:
Narcotics – if pain is obvious cause
IA’s
Beta-blockers
Ntg
Nipride

Question 7

Intraoperative HYPOTENSION

Answer 7

Treatment:
Decrease anesthetic depth
Fluids 
Sympathomimetics
Check rhythm  Is it junctional?
Maintain normocapnia
Avoid high concentrations of IA’s

Question 8

Goals of emergence

Answer 8

Controlled Emergence
Minimize sympathetic outflow
Use of narcotics
Use of lidocaine 
Use of Labetolol, Esmolol, NTG
Deep extubation

Question 9

Monitoring HTN patients?

Answer 9

5 lead EKG
A-line, CVP, PA Cath if extensive surgery and ventricular dysfunction
TEE