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Table of Contents
LETTER TO EDITOR  
Year : 2011  |  Volume : 14  |  Issue : 3  |  Page : 243-244
Perioperative blood pressure management: Walking a tightrope


Department of Internal Medicine/Critical Care, Medwin Hospital, Nampally, Hyderabad, Andhra Pradesh, India

Click here for correspondence address and email

Date of Web Publication20-Aug-2011
 

How to cite this article:
Gude D. Perioperative blood pressure management: Walking a tightrope. Ann Card Anaesth 2011;14:243-4

How to cite this URL:
Gude D. Perioperative blood pressure management: Walking a tightrope. Ann Card Anaesth [serial online] 2011 [cited 2020 Aug 14];14:243-4. Available from: http://www.annals.in/text.asp?2011/14/3/243/84040


The Editor,

Management of perioperative hypertension could pose a considerable challenge. Blood pressure fluctuations result owing to a variety of factors like acute mechanical and physiologic perturbation related to orotracheal intubation, institution of cardiopulmonary bypass, systemic inflammatory response, use of aortic occlusive clamps, excessive release of catecholamine (surgical stress response), reperfusion injury, rapid intravascular volume shifts, peripheral vasoconstriction, altered cardiac reflexes, and inadequate anesthesia, in combination or separately. [1] These changes compromise microvascular blood flow, increase myocardial oxygen consumption, left ventricular end-diastolic pressure, and contribute to subendocardial coronary hypoperfusion. Apart from oral agents, intravenous hydralazine, labetalol, metaprolol, enalapril, and transdermal clonidine can be tried to minimize these fluctuations in BP.

In a study preinduction hypertension and the associated adverse outcomes as defined by elevated troponin or in-hospital death, independently amplified the risk for postoperative myocardial injury/infarction or in-hospital death. Increased baseline systolic BP (>200 mm Hg), intraoperative diastolic BP <85 mm Hg, increased intraoperative heart rate, blood transfusion, and anesthetic technique predicted a dismal outcome. [2] On the other hand intraoperative hypotension is also an established risk factor for perioperative cardiovascular complications most notably myocardial infarction [3] apart from arrhythmia, heart failure, and/or renal failure.

Clevidipine is a novel, rapidly acting dihydropyridine L-type calcium channel blocker with an ultrashort half-life that decreases arterial blood pressure (BP). ECLIPSE (Evaluation of CL evidipine In the Perioperative Treatment of Hypertension Assessing Safety Events) trial showed that the incidence of myocardial infarction, stroke or renal dysfunction for CLV-treated patients was similar compared to that with nitroglycerin (NTG), sodium nitroprusside (SNP), and nicardipine (NIC). There was no difference in mortality rates between the CLV, NTG or NIC groups (higher mortality with SNP). In maintaining BP within the prespecified range CLV was more effective than NTG or SNP. [4] The ECLIPSE also elucidated that increased SBP variability outside a range of 75--135 mm Hg intraoperatively and 85--145 mm Hg pre- and postoperatively is significantly associated with 30-day mortality.

Although the POISE trial showed that acute intraoperative betablockers increased stroke incidence and all-cause mortality, it also confirmed a definite reduction in myocardial infarction perioperatively. Esmolol (β1-specific, adrenergic receptor antagonist) is shown to decrease the frequency of myocardial ischemia. An increased incidence of unplanned dose related hypotension may be seen which can be curbed with titration to a safe hemodynamic end point. A low dose of landiolol (short acting beta blocker) has shown to reduce the intraoperative sevoflurane requirement during sevoflurane/N 2 O/fentanyl anesthesia.

Upon thoracoscopic surgical manipulation of a posterior mediastinal mass, which was thought to be a nonfunctioning, benign, neurogenic tumor, a rapid rise in systemic blood pressure was noted suggesting that it was a hyperfunctioning pheochromocytoma (later proved on biopsy). [5] More than one fourth of laparoscopic adrenalectomies for pheochromocytoma can support intraoperative hypertension exceeding 170 mm of Hg.

Minimizing the BP excursions perioperatively is paramount in reducing most kinds of morbidities and there is an urgent need to pay heed this underrated factor.


   Acknowledgments Top


I thank the department of Internal medicine and critical care for their perpetual support.

 
   References Top

1.Chen JC, Shernan SK, Dyke C, Aronson S. A target for perioperative blood pressure during cardiac operations. Ann Thorac Surg 2010;89:672-3.  Back to cited text no. 1
[PUBMED]  [FULLTEXT]  
2.Wax DB, Porter SB, Lin HM, Hossain S, Reich DL. Association of preanesthesia hypertension with adverse outcomes. J Cardiothorac Vasc Anesth 2010;24:927-30.  Back to cited text no. 2
[PUBMED]  [FULLTEXT]  
3.Singh A, Antognini JF. Perioperative hypotension and myocardial ischemia: Diagnostic and therapeutic approaches. Ann Card Anaesth 2011;14:127-32.  Back to cited text no. 3
[PUBMED]  Medknow Journal  
4.Aronson S, Dyke CM, Stierer KA, Levy JH, Cheung AT, Lumb PD, et al. The ECLIPSE trials: Comparative studies of clevidipine to nitroglycerin, sodium nitroprusside, and nicardipine for acute hypertension treatment in cardiac surgery patients. Anesth Analg 2008;107:1110-21.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Sakamaki Y, Yasukawa M, Kido T. Pheochromocytoma of the posterior mediastinum undiagnosed until the onset of intraoperative hypertension. Gen Thorac Cardiovasc Surg 2008;56:509-11.  Back to cited text no. 5
[PUBMED]  [FULLTEXT]  

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Correspondence Address:
Dilip Gude
AMC, 3rd Floor, Medwin Hospital, Chirag Ali lane, Nampally, Hyderabad - 500 001, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.84040

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