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INTRODUCTION

Perioperative hypertension and hypotension are frequently seen, and in a subset of patients, these events are associated with adverse outcomes, the extent of which is determined by the degree and duration of the fluctuation in blood pressure.1 Careful attention to blood pressure changes and rapid intervention can influence outcomes. The Perioperative Quality Initiative Group (PQIG) recently summarized the literature regarding perioperative management of blood pressure in a series of articles (Figure 35-1).

FIGURE 35-1

A rational approach to Postoperative BP Assessment

Reprinted with Permission from Elsevier. McEvoy MD, Gupta R, Koepke EJ, et al. Perioperative Quality Initiative consensus statement on postoperative blood pressure, risk and outcomes for elective surgery. Br J Anaesth. 2019;122(5):575-586.

Intraoperative Hypertension

Factors impacting blood pressure intraoperatively include the type of surgery, fluid status, bleeding, anesthesia depth, and agents used, as well as preexisting comorbidities. Non anesthesiologists need to be aware of intraoperative processes to know what to anticipate postoperatively. Etiologies of intraoperative hypertension are listed in Table 35-1.

TABLE 35-1Etiologies of Intraoperative/Postoperative Hypertension

Chronic hypertension predisposes to intraoperative fluctuations in blood pressure. With induction of anesthesia and intubation, blood pressure can increase by 20–30 mmHg and heart rate by 15–20 beats per minute, and with untreated hypertension this response is exaggerated.2 Over time, the reverse can happen with blood pressure dropping below preinduction levels. This hemodynamic instability (fluctuations in MAP > 20%) rather than simply being hypertensive intraoperatively increases the risk of adverse perioperative outcomes. There is no consensus definition of intraoperative hypertension. The PQIG consensus states that for noncardiac surgery there is insufficient evidence to recommend a general upper limit of blood pressure requiring treatment.3 A multicentered randomized trial studied a restrictive versus liberal intraoperative blood pressure control protocol, aiming to maintain the patient’s systolic blood pressure within 10% of baseline versus keeping systolic blood pressure ≥ 80 mmHg and preventing a 40% drop in blood pressure. The restrictive (tighter control) group had a lower incidence of a composite of SIRS and organ dysfunction (OR 0.73).4 A large retrospective cohort study of over 18,000 patients found that if the duration was > 5 minutes, SBP < 180 mmHg, MAP > 130 mmHg, DBP > 120 mmHg, or relative to baseline SBP > 50%, MAP > 50%, or DBP > 50%, did not result in ...

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