Management of Hypertension in the Perioperative Period

  • Nicholas P. Tsapatsaris
  • Durathun Farha


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.


Elevated Blood Pressure Beta Blocker Renin Angiotensin Aldosterone System Nervous System Damage Surgical Intensive Care Unit Patient 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Hogenson KD. Acute postoperative hypertension in the hypertensive patient. J Post Anesth Nurs. 1992;7:38–44.PubMedGoogle Scholar
  2. 2.
    Halpern NA. Today’s strategies for treating postoperative hypertension. J Crit Illn. 1995;10(7):478–490.PubMedGoogle Scholar
  3. 3.
    Haas CE, LeBlanc JM. Acute postoperative hypertension: a review of therapeutic options. Am J Health Syst Pharm. 2004;61:1661–1673.PubMedGoogle Scholar
  4. 4.
    Brown OW, Brown M. Control of hypertension following carotid endarterectomy. Am Surg. 1986;52:581–584.PubMedGoogle Scholar
  5. 5.
    Hans SS, Glover JL. The relationship of cardiac and neurological complications to the blood pressure changes following carotid endarterectomy. Am Surg. 1995;61:356–359.PubMedGoogle Scholar
  6. 6.
    Gal TJ, Cooperman LH. Hypertension in the immediate postoperative period. Br J Anaesth. 1995;47:70–74.CrossRefGoogle Scholar
  7. 7.
    Howell SJ, Sear JW, Foex P. Hypertension, hypertensive heart disease and peri-operative cardiac risk. Br J Anaesth. 2004;92:570–583.PubMedCrossRefGoogle Scholar
  8. 8.
    Eagle K, Berger PB, Calkins H. ACC/AHA guideline update for peri-operative cardiovascular evaluation for noncardiac surgery. N Engl J Med. 2005;353:349–361.CrossRefGoogle Scholar
  9. 9.
    Volini IF, Flaxman N. The effect of nonspecific operations on essential hypertension. JAMA. 1939;112:2126–2128.CrossRefGoogle Scholar
  10. 10.
    Smith MS, Muir H, Hall R. Peri-operative management of drug therapy. Clinical considerations. Drugs. 1996;51:238–259.PubMedCrossRefGoogle Scholar
  11. 11.
    Lindenauer PK, Pekow P, Wang K, et al. Peri-operative beta-blocker therapy and mortality after major noncardiac surgery. N Engl J Med. 2005;353:349–361.PubMedCrossRefGoogle Scholar
  12. 12.
    Ellis JE, Drijvers G, Pedlow S, et al. Premedication with oral and transdermal clonidine provides safe and efficacious postoperative sympatholysis. Anesth Analg. 1994;79:1133–1140.PubMedCrossRefGoogle Scholar
  13. 13.
    Azer S. Management of postoperative hypertension and hypotension in the recovery room. Mt Sinai J Med. 1981;48:365–368.PubMedGoogle Scholar
  14. 14.
    Vidt DG. Management of hypertensive emergencies and urgencies. In: Oparil S, Weber MA, editors. Hypertension: a companion to Brenner and Rector’s the kidney – 2nd Edition. Chapter 78.Google Scholar
  15. 15.
    Gourine A, Gonon A, Sjoquist PO, et al. Short-acting calcium antagonist Clevidipine protects against reperfusion injury via local nitric oxide-related mechanisms in the jeopardized myocardium. Cardiovasc Res. 2001;51:100–107.PubMedCrossRefGoogle Scholar
  16. 16.
    Cheung AT. Exploring an optimum intra/postoperative management strategy for acute hypertension in the cardiac surgery patient. J Card Surg. 2006;21:S8–S14.PubMedCrossRefGoogle Scholar
  17. 17.
    Samson RH. Periprocedural hypertension: current concepts in management for the vascular surgeon. Vasc Endovasc Surg. 2004;38:361–366.CrossRefGoogle Scholar
  18. 18.
    Olyaei AJ, DeMattos AM, Bennett WM. A practical guide to the management of hypertension in renal transplant recipients. Drugs. 1999;58(6):1011–1027.PubMedCrossRefGoogle Scholar
  19. 19.
    Skydell JL, Machleder HI, Baker DJ, Busuttil RW, Moore WS. Incidence and mechanism of post-carotid endarterectomy hypertension. Arch Surg. 1987;122:1153–1155.PubMedCrossRefGoogle Scholar
  20. 20.
    Nishigaki R, Ito A, Kamei J, Takahashi T, Fujii E. Risk factors for development of postoperative hypertension. Methods Find Exp Clin Pharmacol. 2001;23(4):203–207.PubMedCrossRefGoogle Scholar
  21. 21.
    Fremes SE, Weisel RD, Baird RJ, et al. Effects of postoperative hypertension and its treatment. J Thorac Cardiovasc Surg. 1983;86:47–56.PubMedGoogle Scholar
  22. 22.
    Keiler-Jensen N, Jolin-Mellgard A, Nordlander M, et al. Coronary and systemic hemodynamic effects of Clevidipine, an ultra-short-acting calcium antagonist, for treatment of hypertension after coronary artery surgery. Acta Anaesthesiol Scand. 2000;44:186–193.CrossRefGoogle Scholar
  23. 23.
    Bailey JM, Lu W, Levy JH, et al. Clevidipine in adult cardiac surgical patients. A dose-finding study. Anesthesiology. 2002;96:1086–1094.PubMedCrossRefGoogle Scholar
  24. 24.
    Powroznyk AVV, Vulysteke A, Naughton C, et al. Comparison of clevidipine with sodium nitroprusside in the control of blood pressure after coronary artery surgery. Eur J Anesthesiol. 2003;20:697–703.CrossRefGoogle Scholar
  25. 25.
    Huraux C, Makita T, Szlam F, et al. The vasodilator effects of clevidipine on human internal mammary artery. Anesth Analg. 1997;85:1000–1004.PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  • Nicholas P. Tsapatsaris
    • 1
  • Durathun Farha
    • 2
  1. 1.Department of Cardiovascular MedicineLahey Clinic Medical CenterBurlingtonUSA
  2. 2.Department of Vascular MedicineLahey Clinic Medical CenterBurlingtonUSA

Personalised recommendations