Pre-Op holding area hypertension: what is your approach?

[GlowInTheDark]

Had some intraoperative pimping by an attending regarding this topic and felt I'd see what other's approaches are.

I'll give the scenario I encountered, but please feel free to comment broadly as well.

75 yo M, ASA 3 d/t BMI 37, DM2, and uncontrolled HTN for a low-risk non-cardiac case. Can't recall his anti-HTN regimen but IIRC it included Toprol, Lisinopril, and HCTZ. Clinic SBPs were 130-160s, doesn't check BP at home. Day of surgery he had taken Toprol only and BP was 170-200 SBP in pre-op (multiple cuff sizes and locations) with no evidence of new/worsening/changing end organ effects.

What would your approach be? When do you consider cancellation of case?

---

Members don't see this ad.

 

[HomeSkool]

I'd treat it with propofol.

 

[nimbus]

I'd treat it with propofol.

+1

The last thing you want to do is give antihypertensive in preop, then chase it with propofol and sevo a few minutes later.

 

[facted]

Had some intraoperative pimping by an attending regarding this topic and felt I'd see what other's approaches are.

I'll give the scenario I encountered, but please feel free to comment broadly as well.

75 yo M, ASA 3 d/t BMI 37, DM2, and uncontrolled HTN for a low-risk non-cardiac case. Can't recall his anti-HTN regimen but IIRC it included Toprol, Lisinopril, and HCTZ. Clinic SBPs were 130-160s, doesn't check BP at home. Day of surgery he had taken Toprol only and BP was 170-200 SBP in pre-op (multiple cuff sizes and locations) with no evidence of new/worsening/changing end organ effects.

What would your approach be? When do you consider cancellation of case?

If diastolic is greater than 110, there is some evidence of increased events in periop period. Otherwise, do the case and manipulate BP as you need after induction. Chances are they will be very labile. No need to change BP preop.

 

[Hoya11]

Had some intraoperative pimping by an attending regarding this topic and felt I'd see what other's approaches are.

I'll give the scenario I encountered, but please feel free to comment broadly as well.

75 yo M, ASA 3 d/t BMI 37, DM2, and uncontrolled HTN for a low-risk non-cardiac case. Can't recall his anti-HTN regimen but IIRC it included Toprol, Lisinopril, and HCTZ. Clinic SBPs were 130-160s, doesn't check BP at home. Day of surgery he had taken Toprol only and BP was 170-200 SBP in pre-op (multiple cuff sizes and locations) with no evidence of new/worsening/changing end organ effects.

What would your approach be? When do you consider cancellation of case?

a few things go into the decision making process.. how high is it? diastolic 110? 115? 120? how otherwise sick is the person besides the htn? how elective is the surgery? if you do decide to do the case and you have to induce the person and you are staring at a BP of 180+ prior to induction, i would give a touch of BP agent like labetalol or hydralazine to reduce the chances of even higher pressures if induction/intubation will be stimulating

 

[propadope]

On an ACEI. Chances are you will be dealing with low(er)pressures post induction. I would be more concerned about hypotension and have vasopressin ready. Also how much anxiety does the pt have?

 

[Noyac]

You could also give him some versed in preop and recheck the BP. Nine times out of ten this does the trick.
Either way, proceed with the case.

 

[Mman]

I give versed and then recheck it. Then I review records from clinic to see what BP was there. I'm mostly just trying to figure out a baseline number to use during the case. If it's 175/100 today because he skipped some meds and is nervous but is always 130/85 in clinic, I'll be far more tolerant of some hypotension during the case than if it's always 175/100 in clinic.

 

[d9sccr]

On an ACEI. Chances are you will be dealing with low(er)pressures post induction. I would be more concerned about hypotension and have vasopressin ready. Also how much anxiety does the pt have?

How much vaso do you typically give during this? I had a patient w/ profound hypotension for a nothing CT-RF case that ha to be d/t ACEi. I ended up using 8 units for a case that last 40 minutes. I was about to give some norepinephrine (currently the first line treatment for ACEi induced hypotension) but was waiting for it to come from pharmacy.

 

[anbuitachi]

I think its a hassel to give versed in pre op. we can only do it after everybodys talked to the patient (surgical team, nursing team, us), so by that point it's pretty much right before we enter the OR. Might as well just go to the OR and slam the propofol. And if it's still high after versed, will you cancel the case? Cause if you do, and the patient already has versed, and it becomes cancellation after anesthetics were given

How much vaso do you typically give during this? I had a patient w/ profound hypotension for a nothing CT-RF case that ha to be d/t ACEi. I ended up using 8 units for a case that last 40 minutes. I was about to give some norepinephrine (currently the first line treatment for ACEi induced hypotension) but was waiting for it to come from pharmacy.

that is insane. how do you not have NE? you have to get it from pharmacy? Do you have to get succinylcholine from pharmacy too when you need it

 

[drmwvr]

While you're waiting for your NE (?) be sure you're raising the HR and getting a liter of fluid in...

 

[pgg]

Proceed. I wouldn't give midazolam to a 75 yo just to convince myself the hypertension is the result of skipping his BP meds for the day. Of course it is. You have documented controlled BPs from clinic visits. Old people don't need benzos 98% of the time.

The board answer is that the patient's hypertension in preop is not a reflection of his normal disease state and therefore doesn't elevate his perioperative risk the way chronic uncontrolled hypertension does. You will control his blood pressure with relatively short acting drugs, while being cognizant of the likelihood that his autoregulation curve is shifted to the right, that he may need a higher BP to ensure appropriate perfusion, and that hypotension may be the more immediate problem under general anesthesia. Depending on the surgical procedure and other comorbidities, you may place an arterial line. That's all.

 

[d9sccr]

I think its a hassel to give versed in pre op. we can only do it after everybodys talked to the patient (surgical team, nursing team, us), so by that point it's pretty much right before we enter the OR. Might as well just go to the OR and slam the propofol. And if it's still high after versed, will you cancel the case? Cause if you do, and the patient already has versed, and it becomes cancellation after anesthetics were given



that is insane. how do you not have NE? you have to get it from pharmacy? Do you have to get succinylcholine from pharmacy too when you need it

No clue. I didn't make the decision. We have it in our vascular rooms but not in any of the general, ortho, ent, etc rooms. No vaso either. I saw he was on an ACEi and had taken it so I grabbed vaso from the core prior to the case

 

[Twiggidy]

Had some intraoperative pimping by an attending regarding this topic and felt I'd see what other's approaches are.

I'll give the scenario I encountered, but please feel free to comment broadly as well.

75 yo M, ASA 3 d/t BMI 37, DM2, and uncontrolled HTN for a low-risk non-cardiac case. Can't recall his anti-HTN regimen but IIRC it included Toprol, Lisinopril, and HCTZ. Clinic SBPs were 130-160s, doesn't check BP at home. Day of surgery he had taken Toprol only and BP was 170-200 SBP in pre-op (multiple cuff sizes and locations) with no evidence of new/worsening/changing end organ effects.

What would your approach be? When do you consider cancellation of case?

I treat his HTN with an anesthetic

 

[Twiggidy]

I think its a hassel to give versed in pre op. we can only do it after everybodys talked to the patient (surgical team, nursing team, us), so by that point it's pretty much right before we enter the OR. Might as well just go to the OR and slam the propofol. And if it's still high after versed, will you cancel the case? Cause if you do, and the patient already has versed, and it becomes cancellation after anesthetics were given



that is insane. how do you not have NE? you have to get it from pharmacy? Do you have to get succinylcholine from pharmacy too when you need it

Not unusual. Our drawer only doesn’t have norepinephrine and we do hearts, but we also have an Omni in the OR area that has our less often used drips (milrinone, norepinephrine, etc)

 

[Urzuz]

I can't tell if people are being serious by saying they would give him Versed and recheck it? What a royal waste of everyone's time. Take him back to the OR and start the damn case. He didn't take all of his anti-hypertensives and he is coming in for a surgical procedure. Why do you think his BP is slightly higher than it usually is?! If you delayed a case to mentally stroke yourself off as to the possible causes of his slight hypertension I'm sure most PP groups would kindly show you the nearest exit.

 

[Twiggidy]

How about this one? This stem is a bit from the hip but we had a similar situation here

75 yo, HTN, PVD, comes down to the OR for a carotid. Patient had syncope and duplex revealed say a 95% left occlusion. Didn’t take usual BP meds per surgeons instructions. BP in holding area is 170/100. You get him in the OR and give midazolam 1mg and place his arterial line (doesn’t seem painful to the patient) and the BP reads 205/105. Surgeon cancels.

 

[Shimmy8]

If my vascular surgeons did that routinely...they’d be out of business.

 

[Twiggidy]

If my vascular surgeons did that routinely...they’d be out of business.

I think we were even shocked. I can't remember all the details but I think he recently had a complication from another carotid and enter a brief conservative period. I think the guy was done a couple days later

 

[pgg]

How about this one? This stem is a bit from the hip but we had a similar situation here

75 yo, HTN, PVD, comes down to the OR for a carotid. Patient had syncope and duplex revealed say a 95% left occlusion. Didn’t take usual BP meds per surgeons instructions. BP in holding area is 170/100. You get him in the OR and give midazolam 1mg and place his arterial line (doesn’t seem painful to the patient) and the BP reads 205/105. Surgeon cancels.

Must have been a critical intersection between a Medicare patient and a sunny day on the golf course.

 

[psychbender]

How about this one? This stem is a bit from the hip but we had a similar situation here

75 yo, HTN, PVD, comes down to the OR for a carotid. Patient had syncope and duplex revealed say a 95% left occlusion. Didn’t take usual BP meds per surgeons instructions. BP in holding area is 170/100. You get him in the OR and give midazolam 1mg and place his arterial line (doesn’t seem painful to the patient) and the BP reads 205/105. Surgeon cancels.

Nearly the same situation for the carotid I'm doing Monday. Surgeon cancelled after art-line in the OR showed pressures of around 220/110. I've had it happen several other times, and I've told the surgeons before not to instruct their patients to hold every single one of their antihypertensives, particularly for the those that take three or four different ones. No need to hold BB, CCB, and clonidine.

Sent from my SM-G930V using SDN mobile

 

[dhb]

If i had to cancel all the 170-200 SBP pre-op my days would be very short.

 

[anbuitachi]

Proceed. I wouldn't give midazolam to a 75 yo just to convince myself the hypertension is the result of skipping his BP meds for the day. Of course it is. You have documented controlled BPs from clinic visits. Old people don't need benzos 98% of the time.

The board answer is that the patient's hypertension in preop is not a reflection of his normal disease state and therefore doesn't elevate his perioperative risk the way chronic uncontrolled hypertension does. You will control his blood pressure with relatively short acting drugs, while being cognizant of the likelihood that his autoregulation curve is shifted to the right, that he may need a higher BP to ensure appropriate perfusion, and that hypotension may be the more immediate problem under general anesthesia. Depending on the surgical procedure and other comorbidities, you may place an arterial line. That's all.

What if the patient took all his BP medication, we have no prior pressure to compare with, comes into pre op with BP of 190/100. on oral boards, would you cancel or proceed? Where would you draw the line/how high is too high?

 

[pgg]

What if the patient took all his BP medication, we have no prior pressure to compare with, comes into pre op with BP of 190/100. on oral boards, would you cancel or proceed? Where would you draw the line/how high is too high?

For the elective non-cardiac case in the OP, for the oral boards, you need to pick a number and defend it. It would be reasonable to pick the cutoffs for stage 3 hypertension (180/110). This is the textbook answer, based on the 2004 study by Howell, and I think it's where you should draw the line during the exam.

In real life that line is sort of fuzzy, based on your overall assessment of the patient and the surgical procedure. I wouldn't cast stones at anyone who canceled an otherwise healthy 190/100 patient getting a knee scope but I'd probably do it, and slip in a touch of some hydralazine or labetalol to head off PACU calls.


Edit - Just did some reading and it looks like JNC got rid of the stage 3 & 4 definitions a while ago, and I never got around to updating my notes. I guess the preferred nomenclature for >180/110 now is hypertensive urgency, or crisis if there's evidence of end organ damage. Which then raises the question if you're postponing surgeries for patients >180/110, should you be referring them to IM for admission?

 

[narcusprince]

Do the case. Depending on hospital system I would treat bp with nominal doses of labetalol to keep systolics below 180 prior to inducation. Great system nurses can administer 5-10mg x 1 dose. Poor system I treat the bp while wheeling to the OR. Either way do the case. Have pressors drawn up and ensure euvolemia with a fluid bolus. Be prepared to doce do on induction. +_ aline depending on procedure. Do not waste time.

 

[Mman]

I can't tell if people are being serious by saying they would give him Versed and recheck it? What a royal waste of everyone's time. Take him back to the OR and start the damn case. He didn't take all of his anti-hypertensives and he is coming in for a surgical procedure. Why do you think his BP is slightly higher than it usually is?! If you delayed a case to mentally stroke yourself off as to the possible causes of his slight hypertension I'm sure most PP groups would kindly show you the nearest exit.

I'm serious because I'm ordering versed anyway and I will tell the nurse to recheck the BP afterwards anyway. It adds literally zero time to anything and it helps me establish a baseline for the case. Besides, at our place the BP is taken by a nursing assistant and might not even be done correctly for all I know. I'd at least like another reading. Doesn't delay the case in any way and never hurts to document another reading. Not everywhere does the patient get versed 1 second before rolling to the OR. Our patients generally start getting medicated 20-30 minutes before rolling back.

 

[Noyac]

Maybe someone has said this already, I haven’t r ad all the responses. But if you do decide to cancel a case for hypertension, whatever the numbers are. What do you do with the pt? Do you send them home to take their meds and make a follow up appt for them to see PCP? Do you send to the ER? What’s the plan?

 

[Mman]

Maybe someone has said this already, I haven’t r ad all the responses. But if you do decide to cancel a case for hypertension, whatever the numbers are. What do you do with the pt? Do you send them home to take their meds and make a follow up appt for them to see PCP? Do you send to the ER? What’s the plan?

I've cancelled a few cases for hypertension in the past. At outpatient center, I've called their PCP and gotten them to see them same day after we had administered some IV meds to take the diastolic down below 120. At the hospital we've either sent to ER or admitted them depending on the surgeon's preference. It's rare the I'm cancelling a case for hypertension, usually in the 240/120 range or something where I'm actually kinda worried they might have a stroke and if they do it's kinda indefensible to have done an elective case. I feel like my average patient has a BP of like 160/95 in preop holding and we see plenty in the 180s to 200 SBP.

 

[psychbender]

Last time that I (as opposed to the surgeon) cancelled a case for to hypertension, it was for a nephrectomy. 60s AA male, on every class of antihypertensive. His pressure was 270/140 when the preinduction a-line went in (cuff pressure in pre-op only 180s/90s), and I cancelled and sent him to the unit. Turned out, he had a pheo.

Sent from my SM-G930V using SDN mobile

 

[sethco]

Nearly the same situation for the carotid I'm doing Monday. Surgeon cancelled after art-line in the OR showed pressures of around 220/110. I've had it happen several other times, and I've told the surgeons before not to instruct their patients to hold every single one of their antihypertensives, particularly for the those that take three or four different ones. No need to hold BB, CCB, and clonidine.

Sent from my SM-G930V using SDN mobile

This is another situation where I have moved to post induction arterial lines for the majority of my "healthy" carotids. There is very little difference in putting the arterial line in two minutes later. We're not talking about VAD patients, after all 🙂

 

[pgg]

Last time that I (as opposed to the surgeon) cancelled a case for to hypertension, it was for a nephrectomy. 60s AA male, on every class of antihypertensive. His pressure was 270/140 when the preinduction a-line went in (cuff pressure in pre-op only 180s/90s), and I cancelled and sent him to the unit. Turned out, he had a pheo.

You're such an obstructionist. I bet you wanted to wait WEEKS to reschedule him, too.

 

[sethco]

The only case I ever canceled for HTN was an AFib Ablation with TEE. Starting BP 270/140 by NIBP. Checked both sides, even placed an arterial line (Looking back, I wound not have done this but the BP was even higher). Took all of his AM BP medications, just so poorly controlled. Couldn't justify doing this completely elective case. EP guy agreed and I think we admitted him.

 

[chocomorsel]

Last time that I (as opposed to the surgeon) cancelled a case for to hypertension, it was for a nephrectomy. 60s AA male, on every class of antihypertensive. His pressure was 270/140 when the preinduction a-line went in (cuff pressure in pre-op only 180s/90s), and I cancelled and sent him to the unit. Turned out, he had a pheo.

Sent from my SM-G930V using SDN mobile

Well, that was the first thing that sprung to my mind after reading the first sentence. Especially with the giveaway of a nephrectomy.

 

[Noyac]

The only case I ever canceled for HTN was an AFib Ablation with TEE. Starting BP 270/140 by NIBP. Checked both sides, even placed an arterial line (Looking back, I wound not have done this but the BP was even higher). Took all of his AM BP medications, just so poorly controlled. Couldn't justify doing this completely elective case. EP guy agreed and I think we admitted him.

That seems impossible. That kind of BP with no atrial contribution is hard to believe. But I wasn’t there.

 

[sethco]

That seems impossible. That kind of BP with no atrial contribution is hard to believe. But I wasn’t there.

Paroxysmal AFib

 

[fakin' the funk]

Aside from the obvious "how elective is this case?" question, also worth thinking about how critical certain BP or pressors are to the case, e.g., free flap case, head & neck, total shoulder. If your ortho is gonna bitch because you need to keep the beach chair BP 180/95, cancel.

 

[narcusprince]

Aside from the obvious "how elective is this case?" question, also worth thinking about how critical certain BP or pressors are to the case, e.g., free flap case, head & neck, total shoulder. If your ortho is gonna bitch because you need to keep the beach chair BP 180/95, cancel.

I was listening to a podcast and shoulder surgery in the beach chair position is the highest malpractice generating link in our field. Its definitely worth evaluating DOS. Beach chair, uncontrolled htn, + major comorbidity. Definitely higher risk surgery. Its probably best to postpone until the patient is more stable.

 

[propadope]

How much vaso do you typically give during this? I had a patient w/ profound hypotension for a nothing CT-RF case that ha to be d/t ACEi. I ended up using 8 units for a case that last 40 minutes. I was about to give some norepinephrine (currently the first line treatment for ACEi induced hypotension) but was waiting for it to come from pharmacy.

Really depends on the patient. I give 0.5-1u at a time. I often have to run a phenylephrine infusion at the same time

 

[Mman]

I was listening to a podcast and shoulder surgery in the beach chair position is the highest malpractice generating link in our field. Its definitely worth evaluating DOS. Beach chair, uncontrolled htn, + major comorbidity. Definitely higher risk surgery. Its probably best to postpone until the patient is more stable.

I give those patients an art line and make sure the surgeon understands that the patient will have an elevated BP during the case no matter how much it bleeds. I'm not lowering it to 100/60 just because it's oozing in your field. And yes we do occasionally reschedule those cases when it's high enough preop.

 

[BobLoblaw78]

Had a patient yesterday in Preop with 230/130 that I delayed to have better control of BP. Case (elective) was the next day and the cardiology clinic recommended push IV hydralazine to fix the BP and do the case the next day😵. If only I could have thought of that! LOL

To answer the question. Baseline is all that matters unless there is a good reason it has changed. Uncontrolled 200/100 is too much for me when I have a chance prior to the holding area. Sometimes it does get treated in HA with expected big drop after induction/volatile and I try to keep them within 20% baseline. I would specifically make sure to chart HR control and specific goals for intraoperative period and try to maintain those. You could be overachiever and explain some of the risk to patient and low-likelihood and offer delay (knowing that the patient will want to get it done that day). It is not a get out of jail free card but does help if there was bad outcome.

 

[Snoozemd77]

I think diastolic >110 and end organ dysfunction is an indication for postponement.
Any elderly patient who receives versed in holding area should be monitored with supplemental oxygen via nasal canula
If plan to proceed don’t use high dose propofol,etomidate /Fentanyl and lidocaine are better choices.

 

[fakin' the funk]

I think diastolic >110 and end organ dysfunction is an indication for postponement.
Any elderly patient who receives versed in holding area should be monitored with supplemental oxygen via nasal canula
If plan to proceed don’t use high dose propofol,etomidate /Fentanyl and lidocaine are better choices.

You have precisely two (2) organs that you can monitor in real time, based on symptoms.

And I've never seen anyone who's 200/110 have chest pain or headache.

"End organ dysfunction" is wankery in this context; pick a number above which you postpone, and then apply it.

And IF you postpone, have a plan to optimize antiHTN rx, see PCP, get admitted, etc.

Usually an area where I apply the axiom "Can't make $h!t shine"

 

[Robotic Wis-Hipple]

I think diastolic >110 and end organ dysfunction is an indication for postponement.
Any elderly patient who receives versed in holding area should be monitored with supplemental oxygen via nasal canula
If plan to proceed don’t use high dose propofol,etomidate /Fentanyl and lidocaine are better choices.

Wait... I’m supposed to use Etomidate for our low EF, hypotensive patients for its “stability” and in patients with BP you’re on the edge of considering too high for its.....”stability”?

I’ve used Etomidate exactly zero times since fellowship, and if I followed this line of thinking I’d be using it more like 60% of the time. No thanks.

 

[HLxDrummer]

Genuine question from an ED resident. Do you guys have literature showing poor outcomes from patients with elevated pressures? What kind of things do you worry about when you consider cancelling the case for hypertension? Obviously I'm not an anesthesiologist but seems a touch of elevated BPs would work in your favor given anesthetics seem to drop your BP.

In our literature it basically shows that acute BP control in the ED is more harmful than beneficial when asymptomatic. I have had patients sent from out patient procedures for asymptomatic hypertension and we just DC them to FU with their PCP for med adjustments as needed.

 

[thegenius]

Genuine question from an ED resident. Do you guys have literature showing poor outcomes from patients with elevated pressures? What kind of things do you worry about when you consider cancelling the case for hypertension? Obviously I'm not an anesthesiologist but seems a touch of elevated BPs would work in your favor given anesthetics seem to drop your BP.

In our literature it basically shows that acute BP control in the ED is more harmful than beneficial when asymptomatic. I have had patients sent from out patient procedures for asymptomatic hypertension and we just DC them to FU with their PCP for med adjustments as needed.

Moreover, the national ED guidelines (ACEP) recommends against treating asymptomatic hypertension in the ED, recommendation is no labs and d/c so PMD can slowly lower BP.

I routinely get some old person with 210/80 or like 190/110, etc and I just send home. Now.....if I had 270/140.....I dunno what I would do, would actually probably just admit the patient.

Coming from a friendly ER doc snoopin’ on your topics.

 

[pgg]

Genuine question from an ED resident. Do you guys have literature showing poor outcomes from patients with elevated pressures? What kind of things do you worry about when you consider cancelling the case for hypertension? Obviously I'm not an anesthesiologist but seems a touch of elevated BPs would work in your favor given anesthetics seem to drop your BP.

In our literature it basically shows that acute BP control in the ED is more harmful than beneficial when asymptomatic. I have had patients sent from out patient procedures for asymptomatic hypertension and we just DC them to FU with their PCP for med adjustments as needed.

Moreover, the national ED guidelines (ACEP) recommends against treating asymptomatic hypertension in the ED, recommendation is no labs and d/c so PMD can slowly lower BP.

I routinely get some old person with 210/80 or like 190/110, etc and I just send home. Now.....if I had 270/140.....I dunno what I would do, would actually probably just admit the patient.

Coming from a friendly ER doc snoopin’ on your topics.

Couple comments here -

Yes there is data showing elevated perioperative risk for patients with uncontrolled hypertension. The issue we commonly face is that a patient who is at 195/120 the day of surgery because he held all his meds that morning isn't really uncontrolled. Medicating him down to his treated baseline with some esmolol or labetalol or hydralazine or whatever doesn't carry the same risks as acutely fixing chronically uncontrolled hypertension.

The difference I'm highlighting here is the chronic uncontrolled hypertensive who you do NOT want to abruptly normalize or take into elective surgery, vs the chronically controlled hypertensive who simply missed a dose of his meds and is safe to abruptly normalize and take to elective surgery.

To the point of their hypertension being a benefit for us to offset our hypotension-causing anesthetic drugs, not really. Even well treated and controlled, these patients usually have a good bit of autonomic instability (especially if they're diabetic, which they all are). They tend to be very labile, so if anything their hypotension under anesthesia is often worse. If they have recently taken an ARB or ACE it can be profound. With their shifted autoregulation curves, we usually run their pressures higher than we might otherwise. A lot of these patients need frequent small vasopressor boluses if not infusions during surgery.

 

[Mman]

With their shifted autoregulation curves, we usually run their pressures higher than we might otherwise. A lot of these patients need frequent small vasopressor boluses if not infusions during surgery.

The problem for us in the OR is we have no way of knowing if they are tolerating a lower (or more normal BP). In the ED or clinic, the patient can tell you if they feel lightheaded with a lower BP. In the OR they might be stroking out under GA from relative hypotension and we can't tell so we have to keep them high.

 

[vector2]

Moreover, the national ED guidelines (ACEP) recommends against treating asymptomatic hypertension in the ED, recommendation is no labs and d/c so PMD can slowly lower BP.

I routinely get some old person with 210/80 or like 190/110, etc and I just send home. Now.....if I had 270/140.....I dunno what I would do, would actually probably just admit the patient.

Coming from a friendly ER doc snoopin’ on your topics.

Pgg nailed it in terms of the things we're worried about, namely autonomic instability and shifted auto regulation curves. With cerebral hypoperfusion, at least we can likely pick up neurological dysfunction after emergence from anesthesia. One of the more insidious organs are the kidneys, as there may be some evidence that autoregulation might only work down to a map of 80 in chronic hypertension.

As anesthesiologists, we might never learn of the POD1 pt whose Cr bumped 0.3 due to the intraop MAP being 60-65 because intraop UOP is an unreliable marker, but it's actually a very significant finding as we have now increased the pt's 30 day mortality, lifetime mortality, and lifetime risk of needing RRT.

 

[Ronin786]

Genuine question from an ED resident. Do you guys have literature showing poor outcomes from patients with elevated pressures? What kind of things do you worry about when you consider cancelling the case for hypertension? Obviously I'm not an anesthesiologist but seems a touch of elevated BPs would work in your favor given anesthetics seem to drop your BP.

In our literature it basically shows that acute BP control in the ED is more harmful than beneficial when asymptomatic. I have had patients sent from out patient procedures for asymptomatic hypertension and we just DC them to FU with their PCP for med adjustments as needed.

Induction of general anesthesia would fall under the realm of acute BP control and its harmful effects.

 

[MirrorTodd]

Thanks to this thread I was able to answer a question "relatively" correctly during our morning board prep academics. Cheers.