HTN: when is high too high for Anesthesia

seinfeld · Apr 22, 2008

Had an 84 y/o female with Basal cell cancer coming for rotational flap to the nose to replace the big wack they took out a month ago. Claims to have no medical hx, takes only Multivitamins. Preop NIBP 205/100. Anesthetic a month ago preop BP 160/90. Denies hx of HTN but looking back at office notes BP ranged from 160-190's systolic with HR ranging from 80-90's. Placed A-line gave 50mg of labetalol (titrated over 5-10 minutes ) and some sedation and bp now 170's but when you talk to her it goes back up to near 200.

I wanted opinions on at what BP would you cancel surgery if you ever would. I should note she is otherwise asymptomatic. I also know she needs a good PCP to do some investigation and work on her BP.

jetproppilot · Apr 22, 2008

seinfeld said:
Had an 84 y/o female with Basal cell cancer coming for rotational flap to the nose to replace the big wack they took out a month ago. Claims to have no medical hx, takes only Multivitamins. Preop NIBP 205/100. Anesthetic a month ago preop BP 160/90. Denies hx of HTN but looking back at office notes BP ranged from 160-190's systolic with HR ranging from 80-90's. Placed A-line gave 50mg of labetalol (titrated over 5-10 minutes ) and some sedation and bp now 170's but when you talk to her it goes back up to near 200.

I wanted opinions on at what BP would you cancel surgery if you ever would. I should note she is otherwise asymptomatic. I also know she needs a good PCP to do some investigation and work on her BP.

I'm comfortable up to about 110 diastolic. Theres no majic number as you know.....205/100 wouldnt bother me much. I see that fairly commonly.

50 mg labetolol IV is a huge dose for an 84 year old..actually a huge dose for anyone.....is that a typo?

seinfeld · Apr 22, 2008

unfortunately not a typo FIFTY mg of Labetalol, I was explicit with the family that her PCP needs to work this up.

Jeff05 · Apr 22, 2008

ACC/AHA 2007 Guidelines on Perioperative Cardiovascular
Evaluation and Care for Noncardiac Surgery:
Executive Summary
Circulation. 2007;116:1971-1996

Hypertension
For stage 3 hypertension (systolic blood pressure
greater than or equal to 180 mm Hg and diastolic blood
pressure greater than or equal to 110 mm Hg), the
potential benefits of delaying surgery to optimize the
effects of antihypertensive medications should be
weighed against the risk of delaying the surgical
procedure. With rapidly acting intravenous agents,
blood pressure can usually be controlled within a
matter of several hours. One randomized trial was
unable to demonstrate a benefit to delaying surgery in
chronically treated hypertensive patients who pre-
sented for noncardiac surgery with diastolic blood
pressure between 110 and 130 mm Hg and who had
no previous MI, unstable or severe angina pectoris,
renal failure, pregnancy-induced hypertension, LV
hypertrophy, previous coronary revascularization,
aortic stenosis, preoperative dysrhythmias, conduc-
tion defects, or stroke.23
Several authors have suggested withholding
angiotensin-converting enzyme inhibitors and angio-
tensin receptor antagonists the morning of sur-
gery.24 26 Consideration should be given to restarting
angiotensin-converting enzyme inhibitors in the post-
operative period only after the patient is euvolemic, to
decrease the risk of perioperative renal dysfunction.

militarymd · Apr 22, 2008

Have you read the reference from which those numbers come from...circa 1970's?

Jeff05 said:
ACC/AHA 2007 Guidelines on Perioperative Cardiovascular
Evaluation and Care for Noncardiac Surgery:
Executive Summary
Circulation. 2007;116:1971-1996

Hypertension
For stage 3 hypertension (systolic blood pressure
greater than or equal to 180 mm Hg and diastolic blood
pressure greater than or equal to 110 mm Hg), the
potential benefits of delaying surgery to optimize the
effects of antihypertensive medications should be
weighed against the risk of delaying the surgical
procedure. With rapidly acting intravenous agents,
blood pressure can usually be controlled within a
matter of several hours. One randomized trial was
unable to demonstrate a benefit to delaying surgery in
chronically treated hypertensive patients who pre-
sented for noncardiac surgery with diastolic blood
pressure between 110 and 130 mm Hg and who had
no previous MI, unstable or severe angina pectoris,
renal failure, pregnancy-induced hypertension, LV
hypertrophy, previous coronary revascularization,
aortic stenosis, preoperative dysrhythmias, conduc-
tion defects, or stroke.23
Several authors have suggested withholding
angiotensin-converting enzyme inhibitors and angio-
tensin receptor antagonists the morning of sur-
gery.24 26 Consideration should be given to restarting
angiotensin-converting enzyme inhibitors in the post-
operative period only after the patient is euvolemic, to
decrease the risk of perioperative renal dysfunction.

Planktonmd · Apr 22, 2008

Although many people consider HTN an independent risk factor for post op morbidity and mortality, I don't cancel cases for hypertension unless there is acute end organ damage.
So if the BP is high and there is chest pain, pulm. edema, acute neurological changes, acute visual changes or acute renal failure then no surgery, otherwise control BP and proceed.

amyl · Apr 22, 2008

Planktonmd said:
otherwise control BP and proceed.

yeah absolutely...but in this case the BP wasn't controlled... I don't know anything (yet!) but would have a hard time taking a patient for an elective procedure (with minimal risk to the patient if the surgery is not done today) with a BP of 200 after meds. i suppose that is the wrong answer and the surgeon would freak.... guess i have a lot to learn.

coprolalia · Apr 22, 2008

What about non-elective? No issue?

I got called to an "airway emergency" on a guy with hemoptysis who'd previously had a lung procedure. Upon arrival, his BP was 290/130.

I'm not making this up. He was beat red and could only stare at me. He was able to respond by nodding his head. He couldn't (or wouldn't) talk.

I got into a small argument with the medicine senior about treating this hypertensive crisis. He felt it wasn't my domain. I was there to stick the tube in. I told him I wasn't sticking the tube in until the pressure came down. The guy was already apoplectic, and I could literally almost hear the pontine arteries popping inside the guy's head.

I ended up gaving him 30mg IV labetalol before we intubated. I got his pressure down to about 170/90 after about 15 minutes of standing at the bedside. We then sedated and intubated, and post-intubation his pressure was about 140/70 (his "norm" range had been 160/90).

Right or wrong, I felt I had no choice and had to step in and control this dude's pressure. Never ceases to amaze me how chickensh*t some people are about pushing drugs when the consequences of not doing so might be disastrous. I hope that medicine senior learned something that day.

-copro

Noyac · Apr 22, 2008

Depends on the surgery, elective or not, etc. And on how easy or difficult the Bp is to treat. More than what the actual BP is.

So in this scenario, the case is elective and the BP appears quite difficult to control, 50mg Labetolol. I'd probably send her to her PCP and tell them to get a clue and do their job.

pd4emergence · Apr 22, 2008

seinfeld said:
Had an 84 y/o female with Basal cell cancer coming for rotational flap to the nose to replace the big wack they took out a month ago. Claims to have no medical hx, takes only Multivitamins. Preop NIBP 205/100. Anesthetic a month ago preop BP 160/90. Denies hx of HTN but looking back at office notes BP ranged from 160-190's systolic with HR ranging from 80-90's. Placed A-line gave 50mg of labetalol (titrated over 5-10 minutes ) and some sedation and bp now 170's but when you talk to her it goes back up to near 200.

I wanted opinions on at what BP would you cancel surgery if you ever would. I should note she is otherwise asymptomatic. I also know she needs a good PCP to do some investigation and work on her BP.

You've treated it, bp now in 170's, just don't talk to her, if general keep her bp's 150-160 range which may be hard after 50 of labetolol. usually after about 20 or 25 I go to something else like clonidine or hydralazine. It seems that for whatever reason she just wasn't digging the labetolol. This is a pretty low risk procedure blood loss wise. You should be able to keep her pressure up.

Pd4

Pd4

Jeff05 · Apr 22, 2008

militarymd said:
Have you read the reference from which those numbers come from...circa 1970's?

just relaying a practice guideline suggested by aca/aha.

seinfeld · Apr 22, 2008

pd4emergence said:
You've treated it, bp now in 170's, just don't talk to her, if general keep her bp's 150-160 range which may be hard after 50 of labetolol. usually after about 20 or 25 I go to something else like clonidine or hydralazine. It seems that for whatever reason she just wasn't digging the labetolol. This is a pretty low risk procedure blood loss wise. You should be able to keep her pressure up.

Pd4

Pd4

Thats always my issue with pre operative treatment of BP, get a "normal" bp preop then induce and turn on some gas and struggle with hypotension, really wasnt the case here but in the past it has been. Sometimes i feel like i should just induce and then deal with it intraop post induction.

Bougie · Apr 22, 2008

so....if she is a chronic hypertensive who normally lives in the 180-200 systolic wouldn't dropping her below 15% of this possibly cause vital organ ischemia since her autoregulation mechanisms are dead and she is pressure dependent for perfusion? Wouldn't that mean you would have to keep her at 15% of this, regardless of the case even if it the surgeon is requesting MAP 60-62? Please educate since this has always befuddled me.

urge · Apr 22, 2008

For any noninvolved case I would go ahead. However, this being a flap would make me think twice wether I want to deal with labile BP or rather cancel the case. I would make a strong argument to the surgeon about how bad for the flap this scenario is. Hopefully he cancels. If not, when the pt becomes hypotensive I would say "I told you so" and let them deal with it.

epidural man · Apr 22, 2008

jetproppilot said:
50 mg labetolol IV is a huge dose for an 84 year old..actually a huge dose for anyone.....is that a typo?

Naw, the only problem with labetolol is the 30 cc bottle it comes in is too small.

Otherwise a great drug.

I would have given her (titrated slowly) IV clonidine.

jwk · Apr 22, 2008

urge said:
For any noninvolved case I would go ahead. However, this being a flap would make me think twice wether I want to deal with labile BP or rather cancel the case. I would make a strong argument to the surgeon about how bad for the flap this scenario is. Hopefully he cancels. If not, when the pt becomes hypotensive I would say "I told you so" and let them deal with it.

This is a rotational flap - a peripheral procedure, which can be done in the office. Although her BP is not wonderful, it seems to be about where this lady lives. 205 systolic in a stressful situation vs 160-190 otherwise? Not sure it's that big a deal, although it certainly might raise an eyebrow. I might have started with esmolol and sedation. 50 of labetalol in 5-10 minutes? The first 5mg hasn't even had time to circulate yet in this old gal.

I'd never consider an a-line for this patient for this procedure. If I was that worried, then I'd cancel, ship them to their PCP, and try another day. An a-line for acutely manipulating blood pressures for a peripheral procedure just ain't on the radar.

Noyac · Apr 23, 2008

jwk said:
T I might have started with esmolol and sedation.

esmolol? Her heart rate isn't the problem from what I can tell.

Labetolol is the right medication. Clonidine is good but come on, are supposed to treat these pts acutely for such as minor case when their PCP can't seem to get it together? If I hadn't seen the office vitals as high as they were without any treatment started then I would attempt to do the case. But with office notes listing vitals that high I'm sending her back to the lazy arse with a note.

Dear Dr. Soandso. Please do your job. If you are confused, call me I can help.

georgia_aa · Apr 24, 2008

Nicardipene - 200 to 500 mcg works wonders in these patients. I rarely use hydralazine anymore for afterload reduction. It is very smooth and readily titratable. For long term management - very easy to titrate an infusion.

coprolalia · Apr 26, 2008

georgia_aa said:
Nicardipene - 200 to 500 mcg works wonders in these patients. I rarely use hydralazine anymore for afterload reduction. It is very smooth and readily titratable. For long term management - very easy to titrate an infusion.

And, a very expensive drug that you also have to start an infusion, but you maintain good coronary perfusion with it. But, it's not as easy to titrate. I've actually had to give calcium to reverse effects after discontinuing when the MAP became unacceptable. Nipride is cheaper, faster, and just as effective for short term control, but you have to watch out for coronary steal.

I only use Cardene IV in neuro cases. Cost/benefit ratio weighs in favor of using something cheaper and longer lasting.

-copro

Noyac · Apr 26, 2008

coprolalia said:
And, a very expensive drug that you also have to start an infusion, but you maintain good coronary perfusion with it. But, it's not as easy to titrate. I've actually had to give calcium to reverse effects after discontinuing when the MAP became unacceptable. Nipride is cheaper, faster, and just as effective for short term control, but you have to watch out for coronary steal.

I only use Cardene IV in neuro cases. Cost/benefit ratio weighs in favor of using something cheaper and longer lasting.

-copro

Ditto.

Don't get caught up in the fancy ****. Using that stuff exclusively and ignoring the tried and true cheaper but effective drugs is not good for anyone. Unless your sleeping with the Cardene rep.

Noyac · Apr 26, 2008

seinfeld said:
Thats always my issue with pre operative treatment of BP, get a "normal" bp preop then induce and turn on some gas and struggle with hypotension, really wasnt the case here but in the past it has been. Sometimes i feel like i should just induce and then deal with it intraop post induction.

Your right but with pressure this high I treat b/4 induction and expect some additional improvement after induction. Mildly hypertensive pts however, get treated by induction in my OR.

HTN: when is high too high for Anesthesia

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