Management of postoperative hypertension.pptx

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2. GOALS FOR CARDIO-CIRCULATORY THERAPY
Parameters recommended:
• MAP >65 mm Hg
• Cardiac Index >2.0 L/min/m2
• SvO2 >65%
• PAD 10–15 mm Hg
• CVP 8–12 mm Hg (dependent on ventilation mode)
• Lactate <3 mmol/L
• Diuresis >0.5 ml/kg BW/h
Carl M, et al: S3 guidelines for intensive care in cardiac surgery patients. GMS 2010;8:1-25.

3. GOALS FOR CARDIO-CIRCULATORY THERAPY
Blood Pressure targets during the first 48 hours:
• Normal (MAP >65 mm Hg) Default BP goal
• High (MAP >75 mm Hg) Age >75
Poorly controlled HTN
Pre- or postop- renal impairment
Uncorrected carotid artery stenosis
Pre- or postop- ischemic stroke
• Low (MAP 55-60 mm Hg) Age <50 (with low preop- BP)
High bleeding risk
Surgery for chronic valve regurgitation
Sidebotham D, et al: Cardiothoracic critical care. Butterworth-Heinemann, Philadelphia 2007;20:295-297.

4. GOALS FOR CARDIO-CIRCULATORY THERAPY
Postoperative hypertension:
• Surgical stress
• Inadequate analgesia
• Anxiety
• Withdrawal of antihypertensive medications
• Hypothermia
• Patient-ventilator dysynchrony
Sidebotham D, et al: Cardiothoracic critical care. Butterworth-Heinemann, Philadelphia 2007;20:295-297.

5. GOALS FOR CARDIO-CIRCULATORY THERAPY
Postoperative hypertension may cause:
• Low cardiac output and tissue hypoperfusion
• Myocardial ischemia and arrhythmias
• Pulmonary edema
• Precipitate or exacerbate mediastinal bleeding
• Cerebral edema
• Precipitate intracranial bleed
Sidebotham D, et al: Cardiothoracic critical care. Butterworth-Heinemann, Philadelphia 2007;20:295-297.

6. GOALS FOR CARDIO-CIRCULATORY THERAPY
Management of postoperative hypertension:
• Adequate analgesia and sedation
• Assess intravascular volume status
• IV vasodilators (nicardipine, nitroglycerine, nitroprusside)
• Selective arterial vasodilators (hydralazine)
• IV metoprolol, esmolol or diltiazem (if patient tachycardic)
• IV diuretics (if filling pressures are elevated)
• Reversed Trendelenburg (if filling pressures are elevated)
Sidebotham D, et al: Cardiothoracic critical care. Butterworth-Heinemann, Philadelphia 2007;20:295-297.

7. MANAGEMENT OF POSTOPERATIVE
HYPERTENSION
Nicardipine (Cardene):
• Standard Dilution:
Total volume: 250 mL [25 mg/10 mL] [240 mL D5W or NS]
• Dosage and Administration:
Initial: 5 mg/hour
increase by 2.5 mg/hour every 15 minutes
to a maximum of 15 mg/hour
• Consider reduction to 3 mg/hour after response is achieved.
Titrate to lowest dose necessary to maintain stable BP.

8. MANAGEMENT OF POSTOPERATIVE
HYPERTENSION
Hydralazine (Apresoline):
• Standard Dilution:
[20 mg] [50 mL NS]
• Usual dosage:
10 to 40 mg IV q4-6h prn
• IV push rate: 10 mg/min
• May be given q20-30 minutes (until adequate response)
for the treatment of severe hypertension.

9. MANAGEMENT OF POSTOPERATIVE
HYPERTENSION
Metoprolol (Lopressor):
• Standard Dilution:
[20 mg] [50 mL D5W or NS]
• Usual dosage:
5 mg IV bolus x3 q2min
• Followed by 2 to 5 mg IV hourly
• Titrate to minimum HR of 60 or minimum systolic BP of 90

10. MANAGEMENT OF POSTOPERATIVE
HYPERTENSION
Esmolol (Brevibloc):
• Standard Dilution:
[2500 mg] [250 mL D5W or NS]
• Initial dosage:
500 mcg/kg over 1 min
• Followed by 50-100 mcg/kg/min
• Titrate to minimum HR of 60 or minimum systolic BP of 90