1 / 21

Perioperative Hypertension: Evaluation and Management

Perioperative Hypertension: Evaluation and Management. R3 이재우. I. Definition. Systemic Hypertension systolic BP ≥160 mmHg diastolic BP ≥90 mmHg Kaplan

gefen
Download Presentation

Perioperative Hypertension: Evaluation and Management

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Perioperative Hypertension:Evaluation and Management R3 이재우

  2. I. Definition • Systemic Hypertension • systolic BP ≥160 mmHg diastolic BP ≥90 mmHg • Kaplan • " that level of BP at which the benefits minus the risks and costs (of action) exceed the risks and costs minus the benefits of inaction." • periop. period에는 end-organ damage의 예방에 BP control의 중점을 둬야 한다.

  3. II. Incidence(1) • periop. hypertension • depends on the type of the patients studied and the operative procedure • HTN 병력이 꼭 periop. HTN이 risk factor는 아니다. • Risk factors of periop. HTN • Patients : • with poor BP control • recent development of moderate to severe HTN • treated with antiHTN drugs or other drugs(i.e. sedatives) • with certain problems(high spinal cord injury or thyrotoxicosis

  4. II. Incidence(2) • OP procedure : • intracranial and spinal op • head and neck op. • major cardiovascular op • etc. • manipulation of trachea(i.e. endotracheal intubation) • inadequate or light anesthesia • hypoxia or hypercapina

  5. III. Causes • idiopathic or essential HTN • 90-95% of HTN patients • secondary HTN • usually related to renal or endocrine abnormalities

  6. IV. Clinical Implications (1) • Slogoff and Keats  • Pt. with a Hx. of HTN  → increased risk for myocardial events, stroke, and renal failure  • Goldman and Caldera  • the risk for hypertensive pts. who undergo anesthesia and surgical procedures.(of 431 pts.)  • normotensive preop. and not receiving any therapy   → 8% develop periop. HTN.  • no Hx. of HTN but receiving diuretics → 6%  • normotensive when taking antiHTN therapy → 27%  • hypertensive despite therapy → 25%  • untreated HTN → 20%

  7. IV. Clinical Implications (2) • Charlson et al.  • mean arterial pr.가 preop. level에 비해 20% 혹은 20mmHg 이상 변화한채 지속되는 경우 complication(cardiac or renal)과 유의하게 관련이 있다.  • HTN의 병력을 가진 환자의 경우 preexisting end-organ disease를 가지고 있을 가능성이 높다.(LVH, athrosclerosis, ischemic cardiac and cerebral events, congestive heart failure, and pph. vascular insufficiency)

  8. V. Monitoring Blood Pressure (1) • Noninvasive  • BP의 정확한 측정을 위해 cuff size가 적절해야 한다.  → 20% larger than limb diameter • manual measurement • using a blood pr. cuff, auscultating Korotkoff's sound.  • m/c outside the op. room • automatic measurement • oscillometric technique(the Dinamap)  • Doppler principle technique  • Finapres - infrared photoplethysmograph vol. transducer containing small finger cuff.  • risks • electric shock  • cuff deflation이 안될 경우 ischemia and nerve damage

  9. V. Monitoring Blood Pressure (2) • Invasive measures  • in Pt. with cardiovascular, thoracic, neurologic, and traumatic disorders.  • labile BP or large vol. shift가 예상되는 수술의 경우.  • Cx. : hemorrhage, infection, thrombosis  • Allen's test : to confirm collateral circulation  • sites : radial and femoral (preferred)  * closer to the central circulation, the more real the BP is. 

  10. VI. Therapy (1)  • General Principles  • anesthesiologist must first determine,   •  the desired level of BP  •  the urgency of Tx.  •  the presence and severity of preexisting end-organ damage  • in the preop. evaluation,   •  HTN emergency     → parenteral drug therapy와 reversible causes의 Mx.를 동시에 시행.  •  HTN urgency     → identify and treat reversible causes first. 

  11. VI. Therapy (2) • essential HTN   • 대부분의 경우 diuretics와 β-blocker로 manage.    •  diuretics 사용시에는 K+store assessment monitoring 필요.  •  β-blocker   •   preop. period에 사용했던 환자의 경우 periop. period에도 지속.  •   → 중단시 periop. myocardial event risk↑  •   labetalol : excellent parenteral drug for periop. use.   * all β-blockers should be used with caution in pts. with any evidence of reactive airway disease.(d/t rare case of bronchospasm) 

  12. VI. Therapy (3) • α2-agonist(clonidine)    •  monoamine oxidase inhibitors    •  calcium antagonists  • parenteral calcium antagonists(diltiazem, nicardipine) : good for periop. BP control.  •  ACE(angiotensin converting enzyme) inhibitors  •  adjuvants to control BP  •   regional anesthesia  •   analgesics  * NSAIDs  • preemptive analgesia 위해 많이 사용.  • but, ass. with intravascular pr.↑ and renal function↓

  13. VI. Therapy (4) • Intraop. managements  • a calm, reassuring environment  • induction of anesthesia  • intratracheal lidocaine, nitroprusside, esmolol to attenuate the HTN response to laryngoscopy  • significant underlying diseases  • ineffective alv. ventilation, hypercarbia, triggering of malig. hyperthermia, pheochromocytoma crisis, hyperthyroid storm, hyperparathyroidism  • HTN during op.  • effective pain control이 중요.(esp. low-conc. inhalation or IV anesthesia)  • 일부 inhalation anesthetics(i.e. isoflurane, desflurane)의 경우 high conc.에서 BP↑. 

  14. VII. Postoperative Concerns (1) • postop. HTN의 경우, 우선 comorbid factor를 manage한 후 안될 경우 pharmacologic Mx.   • preop. period에 사용하던 medication을 postop.에 restart.  • if NPO, control with parenteral drugs according to the level of BP.   

  15. VII. Postoperative Concerns (2)

  16. VIII. Conclusions (1)  • systemic HTN  • common morbid factor (present in one of five pts. coming to op. room) • HTN pt.의 경우 preop.에 end-organ dysfunction(cardiovascular, neurologic, renal)에 대한 evaluation이 꼭 필요.  • intraop. HTN 발생시 우선 hypoxia, hypercarbia, light anesthesia, comorbid factor들이 원인인지 R/O한 후 pharmacologic therapy를 고려한다. 

  17. VIII. Conclusions (2) • intraop. HTN시 sodium nitroprusside, nitroglycerine, hydralazine등이 가장 많이 사용되며, β-blocker는 op.후에도 지속해서 사용 가능한 first-line drug이다.  • perianesthetic period동안 돌보는 환자들의 short-term and long-term outcome을 향상시키기 위해 마취의는 periop. HTN을 manage하기 위한 모든 Tx. modality들을 숙지하고 있어야 한다.

More Related