Poorly controlled hypertension for laparoscopic colectomy74-year-old woman, 68 kg, for elective laparoscopic sigmoid colectomy for recurrent diverticulitis

The patient

The examiner asks

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1. Consider

   What are your considerations?

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   • A 74-year-old with long-standing hypertension and LVH, for elective laparoscopic colectomy. Patient
   • At 74, after 20 years of hypertension, her stroke risk is real; I screen cognition as a baseline.
   • Home readings of 150/90 are above 135/85, so this is true hypertension, not white coat. Disease
   • Uncontrolled pressure loads her thick ventricle and risks subendocardial ischaemia.
   • Her autoregulation is shifted right, so a usual pressure may underperfuse her brain.
   • Elective surgery: there is time to correct anything I find before she goes ahead. Surgery

2. Prepare

   Take me through her risk assessment. Will you proceed today?

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   • Urgency first: elective, so there is time to assess and correct. Stem trigger
   • Active cardiac conditions: she has none, with no unstable angina, failure, severe valve lesion or fast arrhythmia. Disease
   • Risk score: intraperitoneal surgery is her only RCRI item; creatinine 1.3 is under 2.0. RCRI 1.
   • Functional capacity: two flights of stairs without stopping, so over 4 METs.
   • Decision: RCRI 1 with good capacity, so she proceeds without further cardiac testing.
   • Today's 172/102 is under 180/110, so the reading alone doesn't cancel her.
   • I still look for end-organ damage and secondary causes such as kidney disease or sleep apnoea.

3. Plan

   How do you manage her medicines and the induction?

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   • Perindopril is withheld for 24 hours to reduce hypotension after induction. Disease
   • Amlodipine continues; her long-term treatment carries on through the operation.
   • On a thiazide with potassium 3.3: replace 20–40 mEq IV by pump over 30 minutes.
   • Arterial line before induction, with esmolol drawn up for the swings.
   • Before laryngoscopy, remifentanil 1 mcg/kg or esmolol 10–25 mg to blunt the pressor response. Airway
   • I hold her pressure near her own baseline; older hypertensive patients may need a higher target. Disease
   • Perindopril restarts once she is haemodynamically stable after surgery. After surgery

4. Crisis

   At laryngoscopy her BP rises to 214/118, HR 112, and V5 shows 2 mm ST depression. What do you do?

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   • A pressor surge causing ischaemia in her hypertrophied ventricle: I treat pressure and rate together. (Crisis)
   • Deepen her anaesthetic and pause any further airway stimulation.
   • Esmolol 10–25 mg IV: a slower heart and less oxygen demand.
   • Nitroglycerin 50–100 mcg IV to bring her pressure down.
   • Bring it down in steps; overshoot hypotension is dangerous with her right-shifted autoregulation.
   • Twelve-lead ECG if the ST change outlasts the surge; troponin checks after surgery.

5. Crisis

   In recovery she is awake with a headache; BP 206/112, HR 92, SpO2 91% on air. What do you do?

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   • Acute postoperative hypertension: I correct the causes before any antihypertensive. Crisis
   • SpO2 91%: oxygen, and look for hypoventilation and a rising CO2.
   • Then pain, shivering, anxiety and a distended bladder.
   • Headache at this pressure: a quick neurological check for encephalopathy or a bleed.
   • Still at 180/110 or above: labetalol 5–10 mg IV, repeated, or clevidipine 2–21 mg/h.
   • Lower it slowly toward her baseline; a sudden fall can make her brain ischaemic.
   • HDU if it persists; referral for long-term blood pressure control after discharge. After surgery