Hypertension

Differential Diagnosis

Hypoxemia, hypercarbia
Drugs:
- Vasopressors, cocaine, MAOIs, stimulants
- Drug errors
- Acute withdrawal: EtOH, benzodiazepines, opioids, clonidine, beta-blockers
Pain, inadequate anesthesia:
- Laryngoscopy/intubation
- Surgical stimulation, laparoscopy
- Remote (distended bladder)
- Awareness
Patient factors:
- Pre-existing hypertension
- Pre-eclampsia
- High ICP (Cushing reflex)
- Autonomic dysreflexia
Endocrine:
- Hyperthyroidism
- Pheochromocytoma
- Carcinoid
- Malignant hyperthermia
- Serotonin syndrome
- Hyperaldosteronism
- Cushing syndrome
Equipment error (falsely high reading)

Management

Inform surgeon, request cessation of surgical stimulation
Cycle BP, scan monitors for HR, ECG rhythm, EtCO2, temperature
Provided the patient is adequately oxygenated & ventilated, deepen anesthetic
Examine patient:
- Pupils (high ICP)
- Diaphoresis & flushing (carcinoid, pheochromocytoma, hyperthyroidism)
- Rigidity (malignant hyperthermia, serotonin syndrome)
- Bladder distension
- Hot (thyroid storm, malignant hyperthermia, serotonin syndrome)
Examine drugs & equipment:
- Potential drug error
- Possible TIVA or circuit disconnect (awareness)
- Tourniquet (pain)
- Equipment error (falsely high reading)
Temporize:
- Labetalol 5-20mg IV q10 min (max total 300mg)
- Esmolol 0.5mg/kg IV over 1 minute; start infusion at 50mcg/kg/min
- Hydralazine 5-20mg IV (max 30mg) slow IV push every 20 minutes
- Nitroglycerin 50-100mcg IV; start infusion at 10mcg/min
Treat underlying cause

Complications