ANESTHESIA IN HYPERTENSIVE PATIENTS

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ANESTHESIA IN HYPERTENSIVE PATIENTS

• DR MOHAMMED EID ALI

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OBJECTIVE OF THIS REVIEW

• which is who hypertensive patient
• When I make the operation or cancel
• Whats perioperative care in hypertension
  patients

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Introduction

• Hypertension prevalence in surgical patient is
  about 20 25 .
• Hypertension is a major risk factor for cardiac,
  cerebral ,renal and vascular disease.
• The presence of left ventricular hypertrophy
  (LVH) in hypertensive patients may be an
  important predictor of cardiac mortality.
• Cardiovascular complication account for 25 50
  of death following noncardiac surgery.

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Excess deaths Relative risk
6 5 4 3 2 1 0
800 600 400 200 0
lt110 110 -119 120 -129 130 -139 140
-149 150 159 160 -169 170 -179 gt180
Excess deaths
Relative risk
systolic blood pressure (mm Hg)
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Physical examinationlaboratory and evaluation

• Measure of blood pressure
• S4 sounds LVH
• S3 sound congestive heart failure
• ECG
• Echocardiography
• Serum creatnine and blood vear
• Serum electrolyte level

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Subjects visited by a doctor Subjects
visited by a nurse
Deviation of systolic blood pressure from
baseline (mm Hg)
Peak time (min)
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(No Transcript)
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Initial blood pressure (mm Hg)
gt200/110
140-159 90-99
135-139 85-89
lt135 /85
160-199 100-109



gt160/100
14-159 90-99
lt140/90
No target organ damage or Cardiovascular Complica
tion Or No diabetes Or 10 year CHD risk lt 15
Target organ damage or Cardiovascular
Complication Or diabetes Or 10 year CHD risk lt
15
Reassess yearly
Observe Reassess CHD Risk yearly
Reassess In 5 Years
Treat
Treat
Treat
if cardiovascular complications, Target
organ damage, or diabetes is Present confirm
over 3-4 weeks, then Treat if blood pressure
persists at Theses if leave over 4-12 weeks
Un malignant phase, or Hypertensive emergency.
Confirm Over 1-2 weeks, then treat
if cardiovascular complications, Target
organ damage, or diabetes is Present confirm
over 12 weeks, then Treat if levels are
maintained and if estimated 10 years CHD risk
is gt 15
Assessed with Cardiac Risk Assessor computer
program or heart disease risk chart
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Cardiac Risk Index (Goldman)

• Third heart sound (S3)
  11
• Elevated jugulovenous pressure 11
• Myocardial infarction in past 6 months 10
• EKG premature arterial contractions or any
  rhythm other than sinus 7
• EKG shows gt5 premature ventricular contractions
  per minute 7
• Age gt70 yrs
  5
• Emergency procedure 4
• Intra-
• Thoracic, intra-abdominal, or aortic surgery
  3
• Poor general status, metabolic or bedridden
  3

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The total number of points scored is then used to
classify patients into 4 categories of surgical
risk as follows
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250 200 150 100 50
arterial pressure (mm Hg)
Cases Systolic pressure
Control Systolic pressure
Cases Diastolic pressure
Control Diastolic pressure
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• Clinical Predictors of Increased Preoperative
• Cardiovascular Risk (Myocardial Infarction, Heart
  Failure, Death)
• Major
• Unstable coronary syndromes
• Acute or recent myocardial infarction with
  evidence of important ischemic risk by clinical
  symptoms or noninvasive study
• Unstable or severe angina (Canadian class III
  or IV) Decompensated heart failure Significant
  arrhythmias
• High-grade atrioventricular block
• Symptomatic ventricular arrhythmias in the
  presence of underlying heart disease
• Supraventricular arrhythmias with uncontrolled
  ventricular rate Severe valvular disease
• Intermediate
• Mild angina pectoris (Canadian class I or II)
• Previous myocardial infarction by history or
  pathological Q waves
• Compensated or prior heart failure
• Diabetes mellitus (particularly
  insulin-dependent)

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• Minor
• Advanced age
• Abnormal ECG (left ventricular hypertrophy, left
  bundle-branch block, ST-T abnormalities)
• Rhythm other than sinus (e.g., atrial
  fibrillation)
• Low functional capacity (e.g., inability to climb
  one flight of stairs with a bag of groceries)
• History of stroke
• Uncontrolled systemic hypertension
• ECG indicates electrocardiogram.
• The American College of Cardiology National
  Database Library defines recent
• MI as greater than 7 days but less than or equal
  to 1 month (30 days) acute MI is
• within 7 days.
• May include stable angina in patients who are
  unusually sedentary.
• Campeau L. Grading of angina pectoris.
  Circulation. 197654522523.

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. Estimated Energy Requirements for Activities

• 4METs
• Climb a flight of stairs or walk up a hill ?
• Walk on level ground at 4 mph or 6.4.km per h?
• Run a short distance?
• Do heavy work around the house like scrubbing
  floors or lifting or moving heavy furniture?
• Participate in moderate recreational activates
  like golf, bowling, dancing, doubles tennis, or
  throwing a baseball or football?
• Greater than participate in strenuos sport like
  swimming, singles tennis, football, basketball,
  or skiing?
• 10 METs singles tennis, football,basketball,or
  skiing

• 1 MET
• Can you take care of yourself?
• Eat, dress, or use the tolet?
• Walk a blaock or two on level ground at 2 to 3
  mph or 3.2 to 4.8 km per h?
• Do light work around the house
• 4 METs
• like dusting or washing dishes?

MET indicates metabolic equivalent. Adapted
from the Duke Activity Status Index (20) and AHA
Exercise Standards (96)
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Cardiac Risk Stratification for Noncardiac
Surgical Procedures High (Reported cardiac risk
often greater than 5) Emergent major
operations, particularly in the elderly Aortic
and other major vascular surgery Peripheral
vascular surgery Anticipated prolonged surgical
procedures associated with large fluid shifts
and/or blood loss Intermediate (Reported cardiac
risk generally less than 5) Carotid
endarterectomy Head and neck surgery
Intraperitoneal and intrathoracic surgery
Orthopedic surgery Prostate surgery Low
(Reported cardiac risk generally less than 1)
Endoscopic procedures Superficial procedure
Cataract surgery Breast surgery Combined
incidence of cardiac death and nonfatal
myocardial infarction. Do not generally require
further preoperative cardiac testing.
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Need for noncardiac surgery
Operating room
Postoperative risk Stratification and Risk factor
management
Step 1
Emergency surgery
Urgent or elective surgery
No
Step 2
Recurrent Symptoms Or signs?
Coronary revascularization Within 5yr ?
Yes
Yes
No
Step 3
Recent coronary Evaluation
Recent coronary angiogram Or stress test?
Operating room
Favorable result and No change in symptoms
Yes
Favorable result or No change in symptoms
No
Clinical Predictors
Step 5
Intermediacy clinical predicators
Minor or no Clinical predicators
Step 4
Major clinical Predicators
Go to Step 6
Go to Step 7
Consider delay Or cancel noncardiac surgery
Consider coronary angiography

• Major Clinical Predicators
• Unstable coronary syndromes
• Decompensated CHF
• Significant arrhythmias
• Sever valvular disease

Medical management And risk factor modification
Subsequent care Dictated by finding and
treatment results
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Intermediate Clinical predictors
Clinical predictors
Step 6
Moderate Or Excellent(gt4 METs)
Poor(lt4 METs)
Functional Capacity
HighSurgical riskprocedure
IntermediateSurgical Riskprocedure
LowSurgical riskprocedure
Surgical risk
Postoperative riskStratification and riskFactor
Reduction
Operating Room
NoninvasiveTesting
Step 8
Low risk
Noninvasive Testing
High risk
ConsiderCoronaryAngiography

• Intermediate Clinical predictors
• Mild angina Pectoris
• Prior MI
• Compensated Or Prior CHF
• Diabetes Mellitus
• Renal Insufficiency

Invasive Testing
Subsequent Care Dictated by FindingsAnd
Treatment Results
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Step 7
Minor or no clinical predictors
Clinical predictors

• Minor Clinical predictors
• Advanced age
• Abnormal ECG
• Rhythm other than sinus
• Low functional capacity
• History of stroke
• Uncontrolled systemic hypertension

Poor(lt4 METs)
ModerateOr Excellent(gt4 METs)
Functional Capacity
High Surgicalriskprocedure
IntermediateSurgical Riskprocedure
Surgical risk
Postoperative riskStratification and riskFactor
Reduction
Step 8
Low risk
Noninvasive Testing
Operating Room
NoninvasiveTesting
High risk
ConsiderCoronaryAngiography
Invasive Testing
Subsequent CareDictated by FindingsAnd
Treatment Results
Figer1. Stepwise approach to preoperative cardiac
assessment. Steps are discussed in text.
Subsequent care may include cancellation or
delay of surgery, coronary revascularization
followed by noncardiac surgery, or intensified
care.
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Intraoperative management

• The aim of anesthesia plan to maintain patients
  hypertension within 10 20 of preoperative
  levels.
• Arterial blood pressure should be maintained
  below 180/110 mm Hg.
• Take attention to intubations procedure.
• .Make best control of pain postoperative period

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MYOCARDIAL BLANCE

• DECREASED MYOCARDIAL OXYGEN SUPPLY
• 1-Decreased coronary blood flow.
• A .Tachycardia
• B .Diasstolic hypotension
• C .Increased preload
• D .Hypocapnia
• E .Coronary spasm
• d oxy2-Decreasegen delivery
• A . Anemia
• B . Hypoxia
• C . Decreased 2.3DPG

• INCREASED MYOCARDIAL OXYGEN DEMAND
• 1-Tachycardia
• 2-Increased wall tension
• A . Increased preload
• B . Increased afterload
• 3- Increased contractility