Management of hypertension in the perioperative period

Abstract

This chapter focuses on common clinical challenges in hypertension management faced by intensive care providers. They include the treatment of patients with preexisting hypertension who cannot take oral medications, the treatment of hypertensive urgencies and emergencies, and the use of specific antihypertensive medications. The challenge for the clinician is not the lowering of blood pressure with parenteral drugs, but rather the more difficult questions about in whom to use them and what goals to achieve. We have learned a great deal about the treatment of chronic hypertension and the attendant long-term reduction in cardiovascular morbidity and mortality associated with effective blood pressure lowering. Currently, the definition of hypertension, goals for treatment, and benefits of therapy have been established in numerous clinical trials, and widely disseminated in evidence-based consensus documents to practicing physicians. Unfortunately, these goals do not necessarily apply to acutely ill surgical intensive care unit patients, some of whom benefit and some of whom are harmed from blood pressure lowering. Thus, the management of hypertension in the intensive care unit is highly individualized. There are few, if any, prospective trials regarding choice of antihypertensive medications in this setting. Recommendations are generally on the basis of consensus opinion, customary use, extrapolation from animal models, and common sense application of physiologic principles. The management of hypertension in the perioperative period remains a challenge despite an impressive array of effective antihypertensive medications. The need to reduce blood pressure while maintaining adequate end organ perfusion, and the various unavoidable factors that play a role in the postoperative period, make it easy to move from hypertension to hypotension with or without treatment. © 2010 Springer-Verlag US.