What is the perioperative medication management of hypertension?

Updated: Jan 09, 2018
  • Author: Nafisa K Kuwajerwala, MD; Chief Editor: William A Schwer, MD  more...
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Answer

Answer

Hypertension is a risk factor for coronary artery disease. Patients with elevated blood pressure seem more likely to experience significant fluctuations in intraoperative blood pressure and associated MI. Adequate blood pressure control is essential prior to elective surgeries because this reduces perioperative ischemia and subsequent cardiac morbidity. [3]

Continue antihypertensive medications throughout the perioperative period, with a change of formulation or substitution if needed. Abrupt withdrawal of beta-blocking agents may adversely affect the heart rate and blood pressure and may precipitate MI.

Administer all antihypertensive medications (with a sip of water) except diuretics and ACE inhibitors until the day of surgery. Diuretics should not be administered on the day of surgery because of the potential adverse interaction of diuretic-induced volume depletion, potassium derangement, and the use of anesthetic agents. The renin-angiotensin-aldosterone system (RAAS) is involved in maintaining normal blood pressure during anesthesia. Hemodynamic instability, including refractory hypotension, has been described in RAAS-blocked patients. Therefore, ACE inhibitors should be discontinued the day before surgery. [4, 5, 6]

Appropriate perioperative management of pain, anxiety, hypoxia, and hypothermia with rewarming are key to maintaining normotension. Patients with a history of preoperative hypertension are predisposed to postoperative hypertension and to intraoperative blood pressure lability. Restarting the patient's oral medications and minimizing oral and intravenous sodium when possible are important therapies.

For those patients unable to take oral medications who require treatment, parenteral alternatives must be used. Intravenous beta-blockers, including propranolol, atenolol, and metoprolol, are particularly attractive because of their previously discussed antiischemic benefits in the perioperative period. Other alternatives are intravenous enalapril, verapamil, or diltiazem and the transdermal clonidine patch. For more serious hypertension, labetalol, nitroglycerin, and nitroprusside are appropriate. In general, avoidance of parenteral hydralazine is warranted in patients with ischemic heart disease because the reflex tachycardia produced may lead to ischemia. Use of sublingual nifedipine is associated with strokes, MI, and death. Also, keep in mind that the clonidine patch is not fully active until 48 hours after placement.

For many patients with only mild postoperative elevations of blood pressure, withholding parenteral antihypertensives until they can take oral medications, while limiting sodium and aggressively controlling pain and anxiety, is appropriate. Clonidine and similar drugs may result in severe rebound hypertension when discontinued abruptly before surgery. Administer with a sip of water on the day of surgery, and continue with transdermal administration (therapeutic systemic levels of transdermal clonidine are not reached for 48 h) or substitute with intravenous methyldopa, nitroprusside, or phentolamine.

Although not commonly used, methyldopa may be discontinued in the perioperative period if needed. Reserpine and prazosin must be given until the day before surgery, then resumed postoperatively. Hydralazine is typically used in combination with beta-blockers. Observe caution with intravenous formulations because the dose required is less than the oral dose.

Table 2. Perioperative Drug Management for Patients With Hypertension (Open Table in a new window)

Drug

Day Before Surgery

Day of Surgery

During Surgery

After Procedure

Beta-blockers

Usual dose

Usual dose on morning of surgery with sip of water

IV bolus or infusion (usually not required)

Continue IV dose until medication can be taken PO

Calcium channel blockers

Usual dose

Usual dose on morning of surgery with sip of water

IV bolus or infusion (usually not required)

Continue IV dose until medication can be taken PO

ACE inhibitors

Stop day before

Do not take day of surgery

IV formulations (usually not required)

Continue IV dose until medication can be taken PO

Diuretics

Stop day before

 

IV beta-blockers/IV calcium channel blockers

Restart when patient on oral liquids

 

Potassium supplements

Stop day before; consider checking potassium level

 

 

Restart when patient on oral liquids

 

Central-acting sympatholytics

Usual dose

Usual dose on morning of surgery with sip of water

Transdermal clonidine/IV methyldopa

Restart when patient on orals liquids

 

Peripheral sympatholytics

Usual dose

Usual dose on morning of surgery with sip of water

Any IV formulation (usually not required)

Restart when patient on oral liquids

 

Alpha-blockers

Usual dose

Usual dose on morning of surgery with sip of water

Any IV formulation (usually not required)

Restart when patient on oral liquids

 

Vasodilators

Usual dose

Usual dose on morning of surgery with sip of water

IV formulation (usually not required)

Continue IV dose until medication can betaken PO

 


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