Preop HTN

[marr65]

68M for elective THA. Pmhx: Htn only. BP in preop 220/125. Rechecked in both arms, no change. Pt does not have any symptoms of hypertensive emergency. Not anxious at all. He did take all of his usual home medications. Per patient usual BP is 140-160’s. In Preop Clinic, BP was 130’s or so.

A: cancel case
B: give versed and recheck BP
C: proceed with case knowing that his Preop Clinic BP was normal.

Thoughts?

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[dabears505]

One of the most annoying things ever. I just cancel it.

 

[DirtDocMD]

Many times, I’ve gotten the question “Can you just give them something, and see if it comes down in 30 minutes?”.

On an elective case, I tell them “no”, and request they either get the pt an appt with their pcp to address the issue, and reschedule, or, admit the pt, and do them in 24-48 hours if they improve, after an IM/hospitalist eval and addressing the issue.

Dad went to see the ortho last year to have his knee done. Ortho said great, but sent him home from office with BP of 185/115, and said it needed to be improved (Didn’t insist on immediate pcp visit, urgent care, ER. Just “when you get around to it, before surgery”.....). Told Mom to get him to ER or appt, immediately. The next morning, the family doc told him he had a-fib and diabetes. Previously healthy, just mild htn hx....

Maybe something has changed recently, but my knowledge of the literature is that a diastolic of 110 or above was a “no go”, and I’m not going to crash somebody down in pre-op or on induction, and hope there’s not an issue with the head/heart/kidneys...

 

[bigdan]

I would delay/cancel. I can't think of any upside to proceeding to the OR, and the downsides are massive.

 

[vector2]

Definite cancel.

 

[GassYous]

Cancel culture is going wild

 

[Katheudontas parateroumen]

If the SBP >200 or DBP>110 thus far Ive seen that we give a little of labetolol or hydralazine and see if it comes down and if sustained <180s for a bit of time. A lot of times the patient didn't take their normal BP meds in the AM. I've always thought that DBP >110 is a good reason to cancel. So do you guys think giving some of their home meds or some labetalol to see it comes down a really bad idea? If so, is it the risk of further dropping the BP during induction/anesthesia the worry or of course the BP is not really controlled at all and leads to increased risk of periop MI/CVA etc?

 

[UnbentLaryngoscope]

Check the BP "by the book". That is, make sure the patient hasn't had any caffeine or nicotine in the past 30 mins (the morning cigarette will get you), send them to the bathroom and have them void (even if they don't think they have to). Then, have them sit quietly, with their feet flat on the floor, back supported, with no one bothering them for 10 mins. Then, come into the room, and do a manual BP with the patient's arm cradled at heart level. That's the BP you want.

Now, let's say that BP is still bad. Just tell the ortho that you're willing to proceed but you're going to do an A-line and strictly keep the patient's BP within 20% of baseline... then the surgeon will cancel the case because they won't want the patient to bleed all over the place

 

[marr65]

I actually gave him versed but his sbp never decreased below 220 after 30 mins and he looked sedated so I cancelled the case. Had his bp decreased to his baseline around 140’s, I would of have done the case. My thought process was that his baseline bp as noted in our Preop Clinic was essentially normal. Why was it high day of surgery? I don’t have an answer to that.

 

[coffeebythelake]

68M for elective THA. Pmhx: Htn only. BP in preop 220/125. Rechecked in both arms, no change. Pt does not have any symptoms of hypertensive emergency. Not anxious at all. He did take all of his usual home medications. Per patient usual BP is 140-160’s. In Preop Clinic, BP was 130’s or so.

A: cancel case
B: give versed and recheck BP
C: proceed with case knowing that his Preop Clinic BP was normal.

Thoughts?

Would not cancel. Yeah the diastolic is high, but you just said there is documented normal recent BP which tells me it isn't chronic poor controlled HTN. No suggestion for anything weird like pheo? The big question with canceling case is what would be done further to optimize? Unlikely to start a new bp med if pressura normally reasonable well controlled

 

[coffeebythelake]

Many times, I’ve gotten the question “Can you just give them something, and see if it comes down in 30 minutes?”.

On an elective case, I tell them “no”, and request they either get the pt an appt with their pcp to address the issue, and reschedule, or, admit the pt, and do them in 24-48 hours if they improve, after an IM/hospitalist eval and addressing the issue.

Dad went to see the ortho last year to have his knee done. Ortho said great, but sent him home from office with BP of 185/115, and said it needed to be improved (Didn’t insist on immediate pcp visit, urgent care, ER. Just “when you get around to it, before surgery”.....). Told Mom to get him to ER or appt, immediately. The next morning, the family doc told him he had a-fib and diabetes. Previously healthy, just mild htn hx....

Maybe something has changed recently, but my knowledge of the literature is that a diastolic of 110 or above was a “no go”, and I’m not going to crash somebody down in pre-op or on induction, and hope there’s not an issue with the head/heart/kidneys...

With rapidly titrable antihypertensive meds, the thought about canceling such cases is changing

 

[linkin06]

I actually gave him versed but his sbp never decreased below 220 after 30 mins and he looked sedated so I cancelled the case. Had his bp decreased to his baseline around 140’s, I would of have done the case. My thought process was that his baseline bp as noted in our Preop Clinic was essentially normal. Why was it high day of surgery? I don’t have an answer to that.

I wouldn't give versed unless it was clearly due to anxiety, but you said he was clearly not anxious.

 

[marr65]

I wouldn't give versed unless it was clearly due to anxiety, but you said he was clearly not anxious.

I thought he was being a macho man. I was wrong.

 

[epidural man]

I think giving a short acting anxiolytic is a great idea. You have a hypothesis, and you tested it. That is perfect. You have no idea what is going on in their head, and they aren't going to tell you.

 

[marr65]

Would not cancel. Yeah the diastolic is high, but you just said there is documented normal recent BP which tells me it isn't chronic HTN. No suggestion for anything weird like pheo? The big question with canceling case is what would be done further to optimize? Unlikely to start a new bp med if pressura normally reasonable well controlled

I would say that this patient does have paroxysmal elevation of bp with no other symptoms. No abd CT scan to review. Pheo was very very low on my differential. I was sure that the patient was being a macho, hence the versed. But his BP didn’t budge. I called his PCP to schedule a visit that same day since by definition this is hypertensive urgency.

I am not sure what the PCP will do differently since per pt his BP is normal at home. I did ask the pt to bring progress note from his visit with PCP to look at the vital signs especially his BP.

 

[thinkorswim]

Propofol and general anesthesia will fix that BP in no time. I wouldn’t give him any antihypertensives beforehand and risk dropping his BP too low, especially after induction. If he’s asymptomatic, why cancel the case?

 

[nimbus]

Would not cancel. Yeah the diastolic is high, but you just said there is documented normal recent BP which tells me it isn't chronic HTN. No suggestion for anything weird like pheo? The big question with canceling case is what would be done further to optimize? Unlikely to start a new bp med if pressura normally reasonable well controlled

Agree. His BP is acceptable in clinic. Why would they change his meds? He’s already optimized. When he shows up for surgery next week and his BP is high again, will he be cancelled again?

 

[epidural man]

You must not read the literature very closely because the obvious answer was to let the patient sing religious songs.

 

[coffeebythelake]

Cancel culture is going wild

I would actually say the opposite. In the past most people would agree that such case should be cancelled. The "book answer" is to cancel, and that was what I was taught as a resident (which wasn't that long ago). I have a much higher index needed to cancel for BP nowadays.

 

[turkeyjerky]

EM here, and I apologize for hijacking this a little bit. But but sometimes we get patients sent down from pre-op for severe asymptomatic hypertension, and I'm honestly curious what the thought process behind this is?

For background, our typical practice for this type of patient is immediate discharge w/o any testing or treatment (guideline supported and pretty standard for anyone who's trained in the past 20 years).

 

[coffeebythelake]

EM here, and I apologize for hijacking this a little bit. But but sometimes we get patients sent down from pre-op for severe asymptomatic hypertension, and I'm honestly curious what the thought process behind this is?

For background, our typical practice for this type of patient is immediate discharge w/o any testing or treatment (guideline supported and pretty standard for anyone who's trained in the past 20 years).

Yeah asymptomatic cases shouldn't go to the ER. Not sure what you can do in the ER that we can't do with antihypertensives and other things in preop holding. Unfortunately this is one of those nebulous situations where surgical cancellation occurs because of BP and whoever cancelled it didn't feel the patient is safe to go home directly.

Any literature regarding the specific ER recommendations for this. I'll bust it out next time someone I work w thinks about doing this..

 

[epidural man]

EM here, and I apologize for hijacking this a little bit. But but sometimes we get patients sent down from pre-op for severe asymptomatic hypertension, and I'm honestly curious what the thought process behind this is?

For background, our typical practice for this type of patient is immediate discharge w/o any testing or treatment (guideline supported and pretty standard for anyone who's trained in the past 20 years).

Historically, literature has stated that perioperative morbidity is increased with oreoperative diastolic >110.

Here is a question for you. You see someone sent with a BP of 220/125 and you don’t do anything and send them home? If that isn’t a concern, what BP WOULD concern you? At what point would you say, hey we better get an EKG, some urine, treat with labetol, etc?

 

[epidural man]

Would not cancel. Yeah the diastolic is high, but you just said there is documented normal recent BP which tells me it isn't chronic poor controlled HTN. No suggestion for anything weird like pheo? The big question with canceling case is what would be done further to optimize? Unlikely to start a new bp med if pressura normally reasonable well controlled

Same question for you. If a diastolic of 125 isn't high enough for you to cancel, what number WOULD be high enough? Have you seen diastolics higher than this? I have twice, and both involved epinephrine administration. What about a systolic of 220? What number would be too high for you?

And also, not trying to be difficult, but what do symptoms have to do with it?

 

[coffeebythelake]

Same question for you. If a diastolic of 125 isn't high enough for you to cancel, what number WOULD be high enough? Have you seen diastolics higher than this? I have twice, and both involved epinephrine administration. What about a systolic of 220? What number would be too high for you?

Recognizing that (a) patient normally has controlled HTN and is taking their meds and (b) patient does not have red flags to suggest something unusual going on, then I would give some versed, maybe short acting antihypertensives, and proceed with case. Put in an a-line if so worried. A ridiculous high BP would lead me to think more about (b) and perhaps investigate further. But generally, the closer the interval of time from last known normal BP and DOS, the less worried I am. If this is a patient with no known history of HTN coming in, that's a different story.

My question for you is this-- If you cancel the case today, and his BP at home is normal, what are you going to do to make sure the same situation doesn't happen again when the patient comes back next week? (Except that someone else does the anesthesia for the pt instead of you)

 

[marr65]

Propofol and general anesthesia will fix that BP in no time. I wouldn’t give him any antihypertensives beforehand and risk dropping his BP too low, especially after induction. If he’s asymptomatic, why cancel the case?

To be honest, that sbp and dbp were really high in my opinion. I was there for the recheck and even after versed it was still high. Maybe my spidey sense was going off but could this be an early stroke, early thyroid storm or illicit drugs. I didn’t have a clue why his bp was high since he admitted that he took his home med. But the differentials scared me to cancel the case. If his vitals were normal at his PCP visit, I would be less worry about a stroke, thyroid issues or illicit drug use.

 

[epidural man]

Recognizing that (a) patient normally has controlled HTN and is taking their meds and (b) patient does not have red flags to suggest something unusual going on, then I would give some versed, maybe short acting antihypertensives, and proceed with case. Put in an a-line if so worried. A ridiculous high BP would lead me to think more about (b) and perhaps investigate further. If this is a patient with no known history of HTN coming in, that's a different story.

My question for you is this-- If you cancel the case today, and his BP at home is normal, what are you going to make sure the same situation doesn't happen again when the patient comes back next week? (Except that someone else does the anesthesia for the pt instead of you)

Good question.

First off - I don't think he is managed well. I wouldn't think a well managed patient, who took his BP meds the night before (it seems most do) should have a BP like this. So it makes me think he isn't managed well at all. I would need better evidence than a note from a PCM, and a single BP at the preop clinic.

BUT, for the next time, I would tell him that the patient needs to take all his BP meds (either the night before or morning of) and just let them know that this is likely to happen again if the BP isn't better controlled. I would suggest he work out a plan with his PCM to make sure his BP is stable.

I suspect that someone isn't telling the whole story in this patient - and the patient needs to understand that and it should be easily correctable.

I read once that the reason people are often on multiple BP meds, is because they rarely take the ones already given to them. These meds are super powerful and when used correctly, seem to fix the problem.

BUT, I am no IM doc. I could be wrong.

 

[coffeebythelake]

To be honest, that sbp and dbp were really high in my opinion. I was there for the recheck and even after versed it was still high. Maybe my spidey sense was going off but could this be an early stroke, early thyroid storm or illicit drugs. I didn’t have a clue why his bp was high since he admitted that he took his home med. But the differentials scared me to cancel the case. If his vitals were normal at his PCP visit, I would be less worry about a stroke, thyroid issues or illicit drug use.

Any symptoms to suggest stroke? Focal deficits? If you cancel would you go to ER and have them do a CT scan and neuro workup? Consult neuro?
Thyroid storm? You can always check a TSH/T4? If that's the case you are also going to sent them to ER? Tank them up with some fluids, steroids, BB?
Illicit drugs? I guess that's possible if you don't trust your patient. You can do a urine tox screen, comes back quickly..

 

[marr65]

Agree. His BP is acceptable in clinic. Why would they change his meds? He’s already optimized. When he shows up for surgery next week and his BP is high again, will he be cancelled again?

If his bp were normal at the PCP visit and his bp is sky high again, I would proceed with the case. I’m comforted knowing that his bp isn’t acutely elevated due to stroke, thyroid and such.

 

[DirtDocMD]

Everyone’s free to do what they want, but RIGHT NOW the literature says diastolic of >110 is a “cancel”.

The American Heart Assn says over 180/120 (which calculates to a mean of 140) is worthy of a call to 911 and an ambulance ride:

Hypertensive Crisis: When You Should Call 911 for High Blood Pressure

What is hypertensive crisis? The American Heart Association explains if your systolic blood pressure is over 180 or your diastolic blood pressure is over 110, you could be having an hypertensive crisis and should seek medical attention immediately.

www.heart.org

Do what you will, but you’re fighting the ASA, maybe the AHA (if high enough), and elective means “it can wait”.

Their grandkids (and your malpractice carrier) will thank you....

 

[marr65]

Any symptoms to suggest stroke? Focal deficits? If you cancel would you go to ER and have them do a CT scan and neuro workup?
Thyroid storm? You can always check a TSH/T4? If that's the case you are also going to sent them to ER?
Illicit drugs? I guess that's possible if you don't trust your patient. You can do a urine tox screen, comes back quickly..

Per pt, no symptoms at all! But those were my differentials. I have no other symptoms except for the severely elevated bp. Hence, I decided to send him to his PCP instead.

 

[coffeebythelake]

Good question.

First off - I don't think he is managed well. I wouldn't think a well managed patient, who took his BP meds the night before (it seems most do) should have a BP like this. So it makes me think he isn't managed well at all. I would need better evidence than a note from a PCM, and a single BP at the preop clinic.

BUT, for the next time, I would tell him that the patient needs to take all his BP meds (either the night before or morning of) and just let them know that this is likely to happen again if the BP isn't better controlled. I would suggest he work out a plan with his PCM to make sure his BP is stable.

I suspect that someone isn't telling the whole story in this patient - and the patient needs to understand that and it should be easily correctable.

I read once that the reason people are often on multiple BP meds, is because they rarely take the ones already given to them. These meds are super powerful and when used correctly, seem to fix the problem.

BUT, I am no IM doc. I could be wrong.

If you cancel the case, you're basically saying they need to be seen by PCP for medical management optimization. I don't think you have quite enough evidence to say that based on your DOS BP measurements. No only is hypotension a possibility from overzealous prescription, it should also be recognized that anxiety is generally not so well controlled with antihypertensives. Maybe have pt buy a BP cuff and check frequently at home? Keep a log?

 

[coffeebythelake]

Everyone’s free to do what they want, but RIGHT NOW the literature says diastolic of >110 is a “cancel”.

The American Heart Assn says over 180/120 (which calculates to a mean of 140) is worthy of a call to 911 and an ambulance ride:

Hypertensive Crisis: When You Should Call 911 for High Blood Pressure

What is hypertensive crisis? The American Heart Association explains if your systolic blood pressure is over 180 or your diastolic blood pressure is over 110, you could be having an hypertensive crisis and should seek medical attention immediately.

www.heart.org

Do what you will, but you’re fighting the ASA, maybe the AHA (if high enough), and elective means “it can wait”.

Their grandkids (and your malpractice carrier) will thank you....

I think the situation matters. What you have posted is generally true, but can it be extrapolated to the OPs specific scenario? If you stub your toe your BP might be over 180/120. If it hurts a while, your BP might be elevated a while. I don't think that warrants 911 and ambulance ride for the ER doc to give you some antihypertensives.

(BTW it is defined as systolics greater than 180 and/or diastolics greater than 120. Does not need to have both to fall within definition)

 

[turkeyjerky]

Historically, literature has stated that perioperative morbidity is increased with oreoperative diastolic >110.

Here is a question for you. You see someone sent with a BP of 220/125 and you don’t do anything and send them home? If that isn’t a concern, what BP WOULD concern you? At what point would you say, hey we better get an EKG, some urine, treat with labetol, etc?

Don't get me wrong--I totally understand cancelling the case for optimization. As an outsider, I would think the reasoning behind this is:

a) risk of stroke (watershed infarct) from intra-op (relative) hypotension
b) peri-operative CV events from general poor health and chronic cardiac strain

From an an acute medical perspective, there's really no strict numeric cut-off where emergent BP lowering is indicted. What matters far more is symptomatology (or other BP dependent acute medical conditions, such as a dissection, stroke, etc). Checking labs or UA typically isn't all that helpful and doesn't change acute management (an elevated Cr is more likely CKD than AKI in an asymptomatic patient, for instance).

That said, generally a MAP>180 is outside the auto-regulatory zone, so that's as close a number as I could give you. Still doesn't make it an emergency though. Absolutely comfortable with sending home 225/125 w/o anything other than a pat on the back and directions to call PCP in the morning.

(None of this is to say that this stuff isn't done sometimes in practice. But that's typically because a patient, family or nursing staff are overly anxious or to head off a patient or pcp complaint. But we do a lot of things for reasons other than medical benefit. Also, community-oriented handouts made by the AHA do not constitute medical consensus or standard of care...)

Asymptomatic Elevated Blood Pressure

Critical Issues in the Evaluation and Management of Adult Patients in the Emergency Department With Asymptomatic Elevated Blood Pressure (Hypertension)

www.acep.org

 

[coffeebythelake]

Don't get me wrong--I totally understand cancelling the case for optimization. As an outsider, I would think the reasoning behind this is:

a) risk of stroke (watershed infarct) from intra-op (relative) hypotension
b) peri-operative CV events from general poor health and chronic cardiac strain

And both of these things are relative non-issues if the BP is high on DOS but under normal circumstances is well controlled

 

[MirrorTodd]

Do we really expect anxiety to generate such a high blood pressure? I get that every individual experience will be different, but 220/125 is pretty fookin high. Personally, I wouldn't expect that high of a blood pressure from anxiety before surgery.

 

[dabears505]

Legally with those AHA guidelines out there, what kind of legal defense do you have if you proceed and patient does have a bad outcome?

 

[Arch Guillotti]

If his bp were normal at the PCP visit and his bp is sky high again, I would proceed with the case. I’m comforted knowing that his bp isn’t acutely elevated due to stroke, thyroid and such.

Same here.

 

[coffeebythelake]

Do we really expect anxiety to generate such a high blood pressure? I get that every individual experience will be different, but 220/125 is pretty fookin high. Personally, I wouldn't expect that high of a blood pressure from anxiety before surgery.

That's true. But if you believe the patient when he/she says they are compliant with their BP meds, and if you have records from their preop clinic or PCP that notes reasonable normal-ish BP measurements, and you don't think there is some undiagnosed weirdness going on, what else are you thinking about? And yes, I've seen patients with sky high BP related to anxiety/white coat HTN. Sometimes I let them sit and relax by themselves in preop holding for a bit. Don't even need to give them any benzos. And when you recheck their BP after a while it goes from 210/110 to 140/90.

Legally with those AHA guidelines out there, what kind of legal defense do you have if you proceed and patient does have a bad outcome?

Are you talking about specifically the OPs scenario? Or in general?

 

[sleepallday]

Cant really get a more elective case then a THA. Not only is this BP to high for a purely elective case, I'm also worried about intraop hypotension. Their pressure may tank on induction. Also, those of you that feel comfortable proceeding, how low of a intraop pressure are you going to be comfortable with? Most orthopods I work with will ask for a low BP for their THA's.

If this was another type of elective case like say a mastectomy for breast CA where the surgery is timed after the chemo, I would probably proceed. But a THA, nah. Not worth the liability.

 

[DirtDocMD]

I think some people like to argue just to argue. I can’t tell you a 220/125 will definitely/likely hurt you, but the CURRENT literature says it’s not safe. If the pt isn’t obviously anxious, and
BP’s in multiple sites in pre-op holding are confirming it, well.....

I’m not there, 30 minutes before surgery, to diagnose or rule out adrenals/thyroid/pending stroke, immediately pre-op. I AM there to determine if this pt is safe for surgery/anesthesia at this time, and BP 220/125 doesn’t pass the “smell test”.

Things change. Maybe he WAS ok during his preop clinic visit, three days previous This is another day.

 

[chocomorsel]

I actually gave him versed but his sbp never decreased below 220 after 30 mins and he looked sedated so I cancelled the case. Had his bp decreased to his baseline around 140’s, I would of have done the case. My thought process was that his baseline bp as noted in our Preop Clinic was essentially normal. Why was it high day of surgery? I don’t have an answer to that.

How many BP meds is he on and how many of them did he take that morning?
I see now. But with a BP of 140s to 160s doesn’t seem to be that well controlled to begin with.
I would try a little labetalol to start. And then proceed once I got it below 200/110. The rest would be taken care of by the anesthesia.
I am getting older and less anxious about certain things.

 

[epidural man]

I am getting older and less anxious about certain things.

This is interesting. As I get older, I get more concerned.

Mostly this happens in the pain clinic. I used to want to stick a needle everywhere. Now I just want to do trigger points and caudal epidurals. Let someone else have the fun with the “exciting gassarian Ganglion” block.

 

[chocomorsel]

This is interesting. As I get older, I get more concerned.

Mostly this happens in the pain clinic. I used to want to stick a needle everywhere. Now I just want to do trigger points and caudal epidurals. Let someone else have the fun with the “exciting gassarian Ganglion” block.

I posed a very similar case scenario about five years ago where I went ahead and did the versed and 10-15 of Hydralazine before induction but then ended up getting hypotensive during case or towards the end.
Most everyone said I gave too much Hydralazine and should have just waited till Intraop to load him up.
I learned something that day and now I just go ahead and give anesthesia unless patient is symptomatic.
In this case I would do a touch of labetalol to start and proceed but let them know that they need to see their PCP ASAP after discharge.
And if now you aren’t interested in sticking people as much as before, then I would say you are also less anxious about something bad happening if you don’t stick.

 

[GassYous]

10-15 is a large dose. I've gotten burned bad before by hydralazine so I stick with labetalol as much as possible and then if I need it, I give 2.5-5 of hydralazine.

 

[chocomorsel]

10-15 is a large dose. I've gotten burned bad before by hydralazine so I stick with labetalol as much as possible and then if I need it, I give 2.5-5 of hydralazine.

Already learned that lesson I said. It was in divided doses but yeah. Too much.

 

[GassYous]

It wasn't for you as I think you've been out for longer than I have. It was for the trainees.

 

[abolt18]

It wasn't for you as I think you've been out for longer than I have. It was for the trainees.

As a trainee, I've never given less than 10mg in a dose. Never seen it drop pressure significantly.

 

[deleted162650]

I give hydralazine 5mg at a time, usually after labetalol has proven ineffective or if the HR is already on the low side. The sneaky thing with it is that it takes a while for it to really soak in and do its thing. You gotta give it a minimum of 15 mins before deciding you need more.

 

[fakin' the funk]

I think some people like to argue just to argue. I can’t tell you a 220/125 will definitely/likely hurt you,

I can.

Spoiler alert: it will.