Anda di halaman 1dari 44

| | 


 
| | 


| |

By
Dr Ritu Pradhan
MD anaesthesiology 2nd year resident
NAMS ,BIR HOSPITAL
Moderator :Prof Dr G R Bajracharya

  
4 Systolic and diastolic blood
pressure 140/90 mmHg or more on
at least two occasions measured at
least 1 to 2 weeks apart in adult
(>18yr)
a 
 
 
  
  
pategory Systolic Diastolic
BPmmHg BPmmHg
Optimal <120 <80
Normal <130 <85
High Normal 130-139 85-89
Systemic HTN

Stage I(mild) 140-159 90-99


StageII(mode 160-179 100-109
rate)

Stage3 •180 ”110



  

4 Significant risk factor for IHD
and major cause for
pHF,p A, arterial aneurysm
and end stage renal diseae.
4 Risk for perioperative mobidity
through the extent of end
organ damage and not the
manifestation of disease itself.
 !
4 3arma suri Gharti 53yr
female,admitted for elective open
cholecystectomy with diagnosis of
cholelithiasis on 2066/4/30.Her
chief complain was pain abdomen
for 4-5 months on and off. She had
history of hypertension for 10
months and diabetes mellitus for
last 5 years.
4 Medications:Metformin 500mg BD
for 10yrs,
4 Tab glicazide 40mg BD for
2years
4 Tab ramipril 7.5mg HS for
10months
4 No history of chest pain,dyspnea,
shortness of breath, PND
,orthopnea,syncope.
4 No h/o asthma, PTB,pOPD
4 H/o operation for uterine tumor 10
years ago under GA
4 LMP 2066/4/14
4 No other significant medical history
4 No h/o smoking and alcohol
 "
4 Gp : fair
4 J(-)A(-)py(-)pl(-)O(-)D(-)

Weight:57kg
Pulse: 86/min
BP :130/90mmhg
RR :16/min
Peripheral veins : accessable
| #| $|%&|

4 Mouth opening :3fingers(approx)
4 Thyromental distance :3
fingers(approx)
4 TMJ :free
4 Teeth :intact
4 Neck mobility : no restriction
4 NO neck swelling
4 Mallampati grade III
 "
4 pardiovascular:NAD
4 Respiratory:B/L air entry ,no added
sounds
4 P/A :soft
4 pNS/spine :NAD
4 Hb :11.7gm%,Tp: 4700cells/cumm
4 Platelets:242,000cells/cumm
4 Fasting blood glucose: 105mg%
4 R blood glucose:128mg%
4 Urea: 31mg%
4 preatinine:0.8mg%
4 Na+ :144mg%
4 3+:4.5mg%
4 PT:11.7sec, control :12sec,INR :1
4 HBA1p: 4.6%
4 pR : NAD
4 EpG : HR 85bpm,sinus rhythm
4 EpHO: L ejection fraction:60%
L diastolic dysfunction
normal L systolic function
' 
4 Etiology of HTN
4 Severity
4 Medications/compliance
4 Sequelae of HTN/end organ
damage
(

4 Primary/essential HTN
- accounts for >95%of all causes
- cause for increased BP cannot de
identified
- Strong family history of HTN
 

4 Renal
4 Endocrine

4 Pregnancy induced

4 Neurological dysfunction

4 Drugs

-glucocorticoids
Mineralocorticoids
Sympathomimetics
-tyramine/MAO inhibitors
-nasal decongestant
-sudden withdrawl of antiHTNsive
drugs(centrally acting and ß
adrenergic antagonist)
4 Isolated systolic HTN /pulse
pressure HTN
-age associated rigidity
-increased pO ±
thyrotoxicosis,anemia,AR
') 
4 Ideally should be normotensive
before any elective surgery
4 End organ damage is associated
with severity and duration
4 There are evidences of incidence
of perioperative hypertensive
episodes and post operative
cardiac complication depending
upon pre operative systemic BP
status
4 Optimal BP <170/95mmHg for
elective surgery
4 Ref;critical analysis of data od
Asidda and collegaes study ±
patients who have high BP before
durgery are likely to have high BP
after surgery.
4 In moderate hypertensive patient
with end organ damage
preoperative blood pressure
should be normalised as much as
possible.
4 Goldman et al found that patients
with mild to moderate HTN(diastlic
BP<110mmHg) were not at risk of
vascular complication unless they
have other risk factor like pAD
4 Elective surgery should be
postponded for patients with
severe hypertension (diastolic
BP>110mmhg) or with severe
isolated hypertension(systolic
BP>200mmHg)until Bp is below
180/110mmHg
4 Reduction of blood pressure within 4 to 6
weeks is advisable.
4 Acute reduction is not advised because
auto regulation curve of cerebral blood
flow is shifted toward left and so more
pressure dependent.
4 Ref:Yao and Artusio¶s Anesthesiology
problem oriented pateint management
.6thedition,page no:311.

4 Drugs ±which drug to continue
-which drug to stop
Adverse effects of drugs-electrolyte
imbalance
Drugs affecting anaesthetic agents
-ca channel blockers, drug having
sedative and anxiolytic property
like beta blocker,clonidine
4 Drug affecting autonomic nervous
system
4 Alpha1 antagonist;prazosin
4 Alpha and beta antagonist;labetolol
4 ApE inhibitors and Angiotensin II
Antagonist are usually stopped
4 pause the increase in the potential
hypotensive effect of induction of
anaesthesia
*   

4 pardiac:IHD,Angina,ppF
4 D :pR ±
cardiomegaly,pulmonary vascular
congestion, EpG-L H,ischaemic
conduction abnormalities,old
infarction,strain
4 pNS;TIA,p A,
4 Renal: glomerulosclerosis
,decrease GFR,renal insufficiency
4 Peripheral vascular disease
4 retinopathy
' 
4 Premedication was done with
diazepam 10mg po Hs
4 Ramipril was stopped
4 Metformin and glicazide was
stopped
4 Blood glucose fasting,electrolyte
was sent at 6am on the day of
surgery
 '  
4 itals: BP 120/80mmHg
4 pulse :80/min
4 Spo2:100%
4 Investigations:
4 Fasting blood glucose 106mg%
4 Na+:140meq/l
4 3+ :3.6meq/l
  

4 Iv cannulation
4 Preloading with NS
4 Monitors: NIBP,EpG,SPO2
4 Premedication :Inj Mida 2mg iv,
4 Inj pethidine 50mg
inj xylocard 60mg
4 Induction :propofol 100mg
4 Muscle relaxant:100mg sux
4 ETpT 7mmid
4 Muscle relaxant maintenance:Nor
6mg +1mg+1mg+1mg+1mg
4 Maintenance with o2+halo+IPP
4 Intra operative vitals were almost
stable
4 Reversal :inj atropine 1.2mg +inj
neostigmine 2.5mg iv
4 Extubation
4 Post extubation vitals stable
4 Patient awake
4 Patient was transferred to PApU
4 O2 supplementation with
mask@5L/min
&

4 Depletion of intravascular volume
especially in diastolic hypertension
4 Induction
Agents;propofol,sodiumthiopentone,(NO
3ETAMINE)
4 Exaggerated stress response to
laryngoscopy and tracheal intubation
4 Duration of laryngoscopy ;
<15secs
4 Blunting of reflexes :
4 Lidiocaine: 1mg/kg I v 1min before
induction
4 Beta blocker :esmolol 100-
200mcgabout 15 secs before
induction
4 Topical lignocaine spray 4%
4 Opiods :fentanyl 50-150mcg/kg iv
3min before induction
4 Ramifentanyl 1mcg/kg iv before
induction
4 Alfentanyl 15 to 30mcg
|
 | 
4 2 
   
   


   


4 inhalational agents(halothane ,
isoflurane, sevoflurane,desflurane)
4 Opiods+N2O+inhalational agent
(
4 Noninvasive
-EpG
-NIBP
-SPO2
-temp
-ETpO2
4 Invasive
4 p P
4 PAp
4 Intra arterial line
4 TEE

 |
$
4 u      
       
  
     
      
 !
|&
4 PAIN
4 HYPOIA
4 HYPERpARBIA
4 EMERGENpE EpITEMENT
4 URINARY RETENSION
4 SHARP INSTRUMENTS
  



4 Inj nitroprusside 0.5 to 10
mcg/kg/min in titrated dose to
produce desired SBP with the help
of continous intra arterial BP
monitoring
4 Or
4 Inj labetolol 0.1 to 0.5mg /kg iv
every 10 min with monitoring

4 Robert 3 stoelting ,S F Dierdorf
.Anesthesia and coexisting disease ,4th
edition:churchhill living stone 2007.
4 Yao and Artusio¶sAnesthesiology
promblem oriented patient
management,6th edition:lippincott willim
and wilkins 2008
4 G E morgan,M s Mikhail,M J
murray.plinical Anesthesiology,4th
edition:Mc GrawHill ,2008
4 Millers anesthesia 6th edition
Thank
4
you