Peri-Operative Hypertensive Urgencies; Etiologic Factors and Therapeutic modalities used
CCCF ePoster library. Hadi Tohidi S. 11/13/19; 283412; EP111
Sana Mohseni and Hadi Tohidi
Sana Mohseni and  Hadi Tohidi
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Topic: Retrospective or Prospective Cohort Study or Case Series

Shafiee, Mohammad Ali1; Mohseni, Sana1; Tohidi, Hadi1; Rashidi, Negin1; Montazeri, Mahdi1

Division of General Internal Medicine, Departement of Medicine, University of Toronto, University Health Network, Toronto General Hospital, Toronto, Canada

INTRODUCTION: Perioperative hypertension is seen commonly in up to 20% of patients undergoing surgery(1). Hypotension and hypertension have been reported to be associated with postoperative complications and mortality(2-4). Occasionally patients can have a hypertensive urgency or emergency during perioperative period due to hemodynamic changes in response to anesthesia and surgery. Such severe hypertension in operative patients usually occurs in chronic hypertension and other comorbidities. Identifying the underlying condition and factors responsible for acute severe rise in blood pressure in the unique intra/postoperative time is fundamental to effective treatment and prevention of perioperative hypertensive urgency and its complications. Hypertensive urgencies are situations associated with severe BP elevation in patients without acute or impending target organ damage.
OBJECTIVES: We hypothesized that finding the patients characteristics and etiologies of perioperative hypertensive urgency and assessing the treatments used can affect our evaluation in the future and prevent postoperative complications.
METHODS: We performed an observational study using data from University Health Network hospitals between 2015 and 2019 for noncardiac surgery to find patients with perioperative hypertensive urgency(defined as SBP>180 or DBP>120 or MAP>140 and >20% rise from the baseline BP) during or within 2 hours after surgery for whom all the required data was available. Patients with an acute intracranial event were excluded. Finally 300 patients were enrolled and the EPRs were reviewed to analyze the etiology of hypertension urgency and assess the treatment methods used. The research proposal was approved by the Research Ethics Board at UHN.
RESULTS: Based on our preliminary result, of all cases 38% had poorly controlled HTN before the surgery. Volume overload was the main reason in 16% of cases. Alcohol withdrawal detected in 8%. ESRD patients on hemo/peritoneal dialysis and other CKD patients comprised of 35% of cases, many of them received liberal fluid therapy and later needed aggressive diuretic therapy to lower BP. Withdrawal of antihypertensive medication was seen in 2% of all subjects. Renovascular HTN was detected in 6%, half of which diagnosed after surgery. primary aldosteronism and pheochromocytoma each were 1% of subjects.
29% had 3 or more etiologic factors. 31% of patients with hypertensive urgency had an episode of intraoperative hypotension requiring treatment and in 34% of them treatment including vasopressors led to severe HTN.
CONCLUSION: Volume overload in general and specially in ESRD patients during operation can cause hypertensive urgency in a relatively significant number of patients. So adequate treatment of HTN and hypervolemia before surgery is crucial in preventing HTN crises. We suggest performing prolonged and more frequent hemodialysis in ESRD individuals and more stringent fluid management during surgery for such patients.
The percentage of patients with post-op HTN crisis due to alcohol withdrawal was more than expected, they may remain unrecognized possibly due to incomplete history or refusal/denial of patients. Labile BP was seen in a significant number of perioperative HTN urgencies which requires more cautious management. In this study we found that a significant portion of patients have noticeable causes for Perioperative hypertensive urgency which are quite preventable.

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