You are paged by the nurse in the postoperative recovery room about a 57-year-old man who underwent laparoscopic cholecystectomy 1 hour ago and is now hypertensive—BP 210/95.
On arrival to the recovery room you find the patient mentating normally. Temperature 98.5°F, HR 105, BP 190/92, RR 22, and O2 98% on 2 L nasal cannula. He complains of 7 out of 10 abdominal pain, for which he has already received several doses of IV hydromorphone. He denies any headache, vision changes, chest pain, or difficulty breathing. He tells you that his systolic blood pressure normally runs in the 130s and that he took his prescribed metoprolol at home this morning. His cardiopulmonary exam is notable for mild tachycardia and clear lungs. He is obese, and his abdomen is soft with mild-to-moderate tenderness in his periumbilical region, right upper quadrant, and suprapubic region.
1. Name two possible reasons for his hypertension (HTN).
2. What is your next step in the management of this patient?
Postoperative HTN is a sympathetically mediated response that creates vasoconstriction and increased blood pressure. If left untreated, the acute rise in blood pressure can lead to endothelial injury and end-organ damage—hypertensive emergencies. These include neurologic (ie, hemorrhagic stroke, cerebral ischemia), cardiac (ie, ischemia/infarction), and surgically related problems (ie, failure of vascular anastomoses, surgical site bleeding). No absolute BP threshold exists for the occurrence of end-organ damage, and sometimes it is the rate of increase in BP that dictates organ damage.
It is critical to consider postoperative HTN in terms of increased afterload. Acute HTN in patients with coronary artery disease (CAD), left ventricular dysfunction, and/or congestive heart failure (CHF) can be very serious. Increased afterload increases myocardial oxygen demand. This can lead to myocardia ischemia/infarction in patients with underlying CAD and limited oxygen supply. In patients with left ventricular dysfunction the acute increase in afterload is poorly tolerated by the heart, leading to worsening CHF and pulmonary edema.
There are multiple possible reasons why a patient can become acutely hypertensive from vasoconstriction following surgery. These include:
Pain and anxiety: When a patient is in pain and/or is anxious, his/her sympathetic nervous system is activated, leading to tachycardia, peripheral vasoconstriction, and therefore HTN.
Urinary retention: A common occurrence in postoperative patients (particularly males) that can lead to significant HTN if left untreated. The mechanism is partly related to the pain/discomfort caused by bladder distension.
History of HTN: This is a major risk factor for developing postoperative HTN. Patients with poorly controlled HTN are at particular risk. Additionally, patients who do not take their normal blood pressure medications prior to surgery are likely to develop HTN postoperatively. (This is common because patients who follow instructions to remain “NPO” will often avoid both food and their pills.)
Volume overload: Patients often receive a large ...