Hypertension 

 

 

Differential Diagnosis

 

  • Hypoxemia, hypercarbia

  • Drugs:

    • Vasopressors, cocaine, MAOIs, stimulants

    • Drug errors

    • Acute withdrawal: EtOH, benzodiazepines, opioids, clonidine, beta-blockers

  • Pain, inadequate anesthesia:

    • Laryngoscopy/intubation

    • Surgical stimulation, laparoscopy

    • Remote (distended bladder)

    • Awareness

  • Patient factors:

    • Pre-existing hypertension

    • Pre-eclampsia

    • High ICP (Cushing reflex) 

    • Autonomic dysreflexia

  • Endocrine:

    • Hyperthyroidism

    • Pheochromocytoma

    • Carcinoid

    • Malignant hyperthermia

    • Serotonin syndrome

    • Hyperaldosteronism 

    • Cushing syndrome 

  • Equipment error (falsely high reading)

 

 

Management

 

  • Inform surgeon, request cessation of surgical stimulation

  • Cycle BP, scan monitors for HR, ECG rhythm, EtCO2, temperature

  • Provided the patient is adequately oxygenated & ventilated, deepen anesthetic

  • Examine patient:

    • Pupils (high ICP)

    • Diaphoresis & flushing (carcinoid, pheochromocytoma, hyperthyroidism)

    • Rigidity (malignant hyperthermia, serotonin syndrome)

    • Bladder distension

    • Hot (thyroid storm, malignant hyperthermia, serotonin syndrome)

  • Examine drugs & equipment:

    • Potential drug error

    • Possible TIVA or circuit disconnect (awareness)

    • Tourniquet (pain)

    • Equipment error (falsely high reading)

  • Temporize​:

    • Labetalol 5-20mg IV q10 min (max total 300mg)

    • Esmolol 0.5mg/kg IV over 1 minute; start infusion at 50mcg/kg/min

    • Hydralazine 5-20mg IV (max 30mg) slow IV push every 20 minutes

    • Nitroglycerin 50-100mcg IV; start infusion at 10mcg/min 

  • Treat underlying cause

 

 

Complications

 

  • CVS: MI, arrhythmia, CHF/pulmonary edema, dissection

  • CNS: intracranial hemorrhage 

  • ↑ surgical bleeding

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