HTN

Question 1

What is HTN

Answer 1

BP greater than 140/90 on at least two readings

Readings should be 1-2 weeks apart

Question 2

How many adults have HTN in the US

Answer 2

About 24%

Question 3

What causes essential HTN

Answer 3

Unknown

Strong genetic link

Associated with ETOH, smoking, OSA

Question 4

Essential HTN makes up what percentage of HTN

Answer 4

95%

Question 5

Secondary HTN is caused by

Answer 5

Renal problems (primary cause)
Endocrine problems
Pregnancy
Neuro dysfunction
Drug induced
OSA

Question 6

Tx for essential HTN

Answer 6

Lifestyle modification- for those with no CV disease or end organ damage. We know how Dr.E feels about these…

Drugs for anyone with increased morbidity/mortality risk and/or end organ damage (i.e. everyone…)

Question 7

Lifestyle mods for HTN

Answer 7

Weight loss
Decrease ETOH
Increase physical activity
Adequate Ca and K intake
Decrease Na intake
Stop smoking

Question 8

Tx for secondary HTN

Answer 8

Treat the underlying cause if possible- typically related to renal stenosis or primary aldosteronism, so surg

Drugs are also appropriate if underlying cause cannot be corrected

Question 9

Considerations for Beta blockers

Answer 9

Rebound SNS stim

AVOID in asthmatics, COPD, CHF, HB, Sick sinus syndome

Question 10

Considerations for methyldopa

Answer 10

Rebound HTN

DECREASED anesthetic requirements

Question 11

Considerations for clonidine

Answer 11

Rebound HTN

DECREASED anesthetic requirements

Question 12

Considerations for prazosin (alpha 1 blockers)

Answer 12

Compensatory vasoconstriction is lost, so large drop in BP may occur with spinal/epidural block

Question 13

Considerations for hydralazine

Answer 13

ANGINA in pts with ischemic heart disease

Question 14

Considerations for ACE inhibitors

Answer 14

Associated with hemodynamic instability and low BP during GETA

Question 15

Considerations for ARBs

Answer 15

Decreased BP during induction

Question 16

HTN crisis- What is it, what can it result in, and how is it treated

Answer 16

Acute DBP > 130 mmHg

Can result in encephalopathy, congestive HF, SAH, renal insufficiency

Decrease by 20% during first two hours, continue to normalize BP over next 24-48 hours

Question 17

Management for HTN crisis

Answer 17

Place a-line

SNP 0.5-10mcg/kg/min IV is drug of choice

Nitro 5-200mcg/min IV
Labetalol 40-80mg IV q10min
Esmolol 50-300 mcg/kg/min IV

Question 18

Things to consider when a pt has essential HTN

Answer 18

Is it controlled?

Is the surg emergent or elective?

Evidence of end organ damage? (Angina, CHF, CVA, Renal insufficiency, PVD)

Drug regimen?

Question 19

Goal for BP in HTN?

Answer 19

Stay within 20% of baseline

Question 20

Management of induction with HTN

Answer 20

Anticipate exaggerated SBP changes

Limit duration of DVL

Attenuate DVL response with additional opioid, increase VA, use lidocaine (IV or topical)

Question 21

Maintenance of anesthesia with HTN

Answer 21

VA is good at blunting HTN response

Monitor for myocardial ischemia

Minimize wide shifts in hemodynamics

Question 22

Postop management with HTN

Answer 22

Anticipate periods of systemic HTN

Minimize SNS responses secondary to pain and N/V

Continue to monitor for end organ damage

Question 23

Intraop HTN is usually due to

Answer 23

PAIN

Question 24

Tx for intraop hypotension

Answer 24

Decrease anesthetic depth (is your gas still set for overpressure?)

Fluids

Neo gtt may be needed if unable to maintain adequate anesthesia depth

Is there a new junctional rhythm?- maintain normocapnia, avoid high concentrations of IA

Question 25

Monitoring to consider for HTN pts

Answer 25

5 lead EKG

A-line, CVP, PA if major surg and ventricular dysfunction

TEE

Question 26

Emergence with HTN

Answer 26

Minimize SNS outflow. Consider pluses and minuses of-
Narcotics
Lidocaine
Labetalol, Esmolol, NTG
Deep extubation

Question 27

If pain is controlled, treat postop HTN with

Answer 27

Hydralazine 2.5-10mg IV q10-20 min (long onset time)

Labetalol 5-20mg IV q10 min

Nipride 0.5-10mcg/kg/min IV