Christine Lee
January 6, 2010
Definition:
An acute transient increase in blood pressure that develops within 30-90 min following surgical procedure
and lasts 4-8 hours. SBP > 160 mmHg or DBP > 90 mm Hg or an increase of 40-50 mm Hg in systolic
blood pressure or post-operative BP greater than 15-20% above baseline.
Complications:
Uncontrolled Post-op hypertension is an independent predictor of morbidity and mortality, more
unplanned ICU admissions and greater mortality. Left untreated, will depress LV performance, increased
myocardial O2 demand, CVA, acute MI, arrhythmias, suture line disruption and bleeding.
Pathophysiology:
Unknown in 20% pts may be result of sympathetic stimulation and elevated catecholamines. In
cardiac surgery the cause is multifactoral and is characterized by an increase in total peripheral
resistance with normal cardiac output. An increase BP secondary to increase systemic vascular
resistance by reflex changes in humoral factors including catecholamines, renin, and serotonin
levels and well as alteration in baroreceptor function and cardiac reflexes. Occurs in pts with
preserved function and history of pre-op HTN.
Stimulation of carotid sinus receptors during surgery and activation of carotid sinus reflex.
Carotid sinus stimulation due to increased carotid artery pressure inhibits sympathetic activity to
decrease BP and HR. However, denervation of the receptors or dampening of the pulse pressure
produces increased BP and increase HR.
Treatment:
Patients who have chronic hypertension should resume their medications as soon as able. However in
the immediate post-op phase parental medications are appropriate.
Nitrovasodilators (Nitroglycerin, Nitroprusside, Hydralazine): mediators derived from Nitric Oxide
generating cGMP in vascular smooth muscle
o Nitroprusside arterial and venous vasodilator, rapid and short duration; vasodilation in
cerebral resistance vessels can cause increase cerebral blood volume and ICP, can
reduce coronary perfusion pressure resulting in shunting from ischemic areas further
exacerbating ischemia and can result in hypotension especially those with hypovolemia.
Toxicities include cyanide and thiocyanate accumulation.
Limitations of nitroprusside and nitroglycerin include a decrease in PaO2 and increase in venous
admixture by inhibiting hypoxic pulmonary vasoconstriction can worsen arterial oxygenation.
o Hydralazine: direct arteriolar vasodilator that produces rapid blood pressure affecting
DBP more than SBP. Reduction in peripheral vascular resistance leads to reflex
tachycardia and increased myocardial O2 consumption. 10-15 min onset. Duration 3-8
hours. Potent vasodilation of cerebral vessels which can cause increased ICP
Beta blockers:
o Labatelol: Reduces BP and only slightly reduces HR. Decreases SVR. Onset action 5
min, duration 6 hrs. Caution with patients with heart failure and avoid in pts with SSS,
heart block, asthma
o Esmolol: beta selective, short acting 1/2 life is 2 min, elimination 1/2 life is 9 min.
Exclusion criteria include cardiac index less than 2.2 L/min/m2. Caution in pts with heart
failure, avoid in patients with SSS or those with greater than 1 st degree heart block
References:
Lewis, Kelly S. Pharmacological Review of Postoperative Hypertension. Journal of Pharmacy Practice.
2002; 15;135-146.
Rose, D. Keith et al. Cardiovascular Events in the Postanesthesia Care Unit: Contribution of Risk Factors.
Anesthesiology.1996; 84:772-781.