CONTROLLED HYPOTENSIVE

ANAESTHESIA
Dr
Hussain Almejadi
?what
is safe
AL RAZI Hospital

Definition.
History and evolution.
Physiology.
Blood pressure goal.
Contraindications.
Techniques.
Anaesthetic management.
Our experience in Al RAZI hospital.

 why should we be bothered with

hypotensive anaesthesia ?
Decrease blood loss.
Improve operative field.
Decrease duration of surgery.

Decrease in blood loss by 55 %

and shorten the operating time
by one hour .

Sum DC, Chung PC, Chen WC: Deliberate hypotensive

anesthesia with labetalol in reconstructive surgery for
scoliosis. Acta Anaesthesiol Sin 1996 Dec;34(4):203-207

Significant less blood loss and

improving of the surgical field.

Precious DS, Splinter W, Bosco D: Induced hypotensive

anesthesia for adolescent orthognathic surgery
J Oral Maxillofac Surg 1996 Jun;54(6):680-683

Intraoperative blood loss is 40%

less.

Nelson CL, Fontenot HJ: Ten strategies to reduce blood loss in

orthopedic surgery Am J Surg 1995, N6A (Suppl.), 170:64-68

Deliberate hypotension in orthopedic

surgery reduces blood loss, a meta
analysis of RCT.
CANADAIN JOURNAL OF ANESTHESIA 2007
McMaster ,Hamilton,Ontario.

17 ARTICLES.
CONCLUSION : Deliberate hypotension does
reduce blood loss.

Definition
It is a State of induced hypotension
during anaesthesia to reduce
bleeding and improve the surgical
field adjusted to the patients age
,pre-operative blood pressure and
past medical history.

Definition
Effect VS Safety .
Reduction in systolic blood pressure
to
80 -90 mmHg.
Decrease in MAP to 50-60 mmHg in
normotensive patients.
Reduction in MAP by 30% of the
baseline values.

History
1917 Harvey Cushing for neurosurgery.
1943 Kolhstaedt and Page on dogs arterial

bleeding.
1946 Gardner arteriotomy.
1948 High spinal.
1951 High epidural.
1951 Enderby ganlion blockade .
1960 Murtagh halothane.
1962 Moraca sodium nitroprusside.
1967 Dimant pacemaker.
1978 Fahmy nitroglycerin.
1981 Zimpfer verapamil.
1982 Fukunaga adenosine .

Physiology
Cerebral circulation.
Coronary circulation.
Renal circulation.

Cerebral Autoregulation

Cerebral Circulation

PaCO2 .
PaO2.
Temperature.
Volatile agents.
Vasodilators.

Coronary Circulation
Dependent on aortic diastolic blood
pressure.
Myocardium extracts most of the
oxygen delivered.
Circulation is autoregulated .

Renal Circulation
Autoregulation over the range 80180 mmHg ( Miles and Venton 1954 )
MAP less than 75 mmHg leads to
decrease in GFR ( Larson et al,
1974 )
Opioids and inhalational agents
stimulate ADH release (Stunn 1974 )

Respiratory System
Increase in blood flow to the
dependent areas.
Vasodilators inhibits hypoxic
pulmonary vasoconstriction.
PaCO2 and EtCO2 gradient increase.

Blood Pressure Goal

Reduce blood loss.
Improve the surgical field .

Contraindications
Anaethetist factors.
Patients factors.

Anaesthetist factors
Lack of understanding of the
technique.
Lack of technical experience.
Inability to monitor the patient
adequately.

Patient factors

Cardiac disease .
Diabetes .
Anemia.
Hepatic disease.
Ischaemic cerebrovascular disease.
Renal disease.
Respiratory insufficiency.
Severe systemic hypertension.
Intolerance to drugs used for hypotensive
anaesthesia.

Absolute contraindications
Known drug allergy.
Inability to monitor the patient
adequately.
Unfamiliarity with the technique.

Morbidity and Mortality

1954 little et al
mortality 1 in 291
morbidity 1 in 31.
Systolic pressure below 80 mmHg.

karol et al Anaesthes and 2008

.Anlgesia
NO DIFFERENCE.

Techniques
MAP = CO x SYSTEMIC VASCULAR
RESISTANCE

Decrease cardiac output

Reduce blood volume.

Dilate capacitance vessels.
Decrease cardiac contractility .
Decrease of heart rate.

Peripheral vascular
resistance
Blockade of alpha adrenergic
receptors.
Blockade of autonomic ganglion.
Ralaxation of vascular smooth
muscle.

Mechanical manoeuvers

Positioning .
Positive airway pressure.
Spinal anesthesia.
Epidural anesthesia.

Pharmacologic technique
Ideal agent

- Ease of administration

- Predictable & dose-dependent effect

- Rapid onset/offset
- Quick elimination without the
production of toxic metabolites
- Minimal effects on blood flow to vital
organs

Inhalational anesthetics
negative inotropic effect
vasodilation

Advantage

Disadvantage

Provides surgical

Decreases CO
Cerebral

anesthesia
Rapid onset/offset
Easy to titrate
Cerebral protection

vasodilation

Sodium nitroprusside
Direct vasodilator (nitric oxide
release)
Disadvantage
Advantage

Rapid onset/offset
East to titrate
Increases CO

Cyanide/thiocyanate

toxicity
Increased ICP
Increased pulm. shunt
Sympathetic
stimulation
Rebound
hypertension
Coronary steal
Tachycardia

Nitroglycerin
Direct vasodilator

(nitric oxide release)

Advantage

Rapid onset/offset
East to titrate
Limited increase

in heart rate
No coronary steal

Disadvantage

Lack of efficacy-

depending on
anesthetic
technique
Increased ICP
Increased pulm.
shunt
Methemoglobinemia
Inhibition of plt.
aggregation

Beta adrenergic antagonist

Beta adrenergic blockade
myocardial contractility)

(decreased

Advantage

Rapid onset/offset
Decreased

myocardial O2
consumption
No increase in ICP
No increase in pulm.
shunt

Disadvantage

Decreased CO
Heart block
Bronchospasm
Limited efficacy
when used alone

Calcium channel blocker

- vasodilation
Advantage

Rapid onset
Limited increase in HR
Increase CO
No effect on airway
reactivity
Increased GFR/urine
output

Disadvantage

Prolonged duration of

action
Increased ICP
Increased pulm. shunt

Remifentanil

Remifentanil is an OPIOID
Pure agonist

little binding at and receptors

Rapid onset/offset
Decreases blood pressure & heart

rate
No need for additional use of a
potent
hypotensive or adjunct agents

Remifentanil Key Concepts

Remifentanil is an ESTER
. Metabolized by nonspecific esterases in
blood and tissue

Anesthesia maintained with high-

dose remifentanil will be associated

with rapid recovery.
Within 5-10 minutes of turning off an infusion
there is virtually no residual remifentanil drug
effect

Dosing and Administration

Dex. should be administered using a

controlled infusion device.

Dex. dosing should be individualized and
titrated to the desired clinical effect
For adult patients Dex. is generally
initiated with a infusion of 1mcg/kg over
10 minutes, followed by a maintenance
infusion of 0.2 to 0.7 mcg/kg/hr
It is not necessary to discontinue Dex.
prior to extubation

 Comparison between dexmedetomidine and

remifentanil for controlled hypotension during

tympanoplasty.

CONCLUSIONS: Infusion of dexmedetomidine, at

the doses used in this study, was less effective
than remifentanil in achieving controlled
hypotension, good surgical field exposure
condition and surgeons' satisfaction during
tympanoplasty.
Feb 25.

2008-05, Eur J Anaesthesiol., 25(5):369-74. Epub 2008

Preoperative management
Thorough knowledge by the

anaesthetist.
Proper patient evaluation and
selection.
HB of 10 g/dl.
Arterial blood gas analysis sampling.
Good level of anxiolytics ,analgesics .
Vagolytic drugs should be avoided.

Intraoperative management

Stress free induction.

Nasal intubation ?.
Enough peripheral venous access.
Pressure points.

Monitoring
Invasive blood pressure .
Invasive blood pressure.
ECG V5 lead with ST segment

analysis.
Central venous pressure.
Urine output.
Temperature.
Blood loss.

Fluid therapy
Deficit replacement.
Maintenance.
Blood loss.

 Induced hypotension should start at

the time of mucosal incision .
Only to the level needed to reduce
bleeding.
Only during specific surgical phase.

Postoperative management
Rebound hypertension.
Reactionary hemorrhage.

Our experience in AL RAZI

hospital
Strong points.
Area of improvement.

Strong points
One OT is allocated for hypotensive
anaesthesia/TIVA.
Propofol remifentenyl.
Invasive monitoring is a must.

Area of improvement
Patients selection.
Reduction in blood transfusion.

Future studies

Prospective.
Control of age and physical status.
Bigger sample size.
Type of surgery.
Controlled studies.
Same technique.
Doppler technique.

THANK YOU
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