Hypertension after Induction - Case Discussion

[DrOwnage]

Hey guys I had a weird occurrence the other day and had to cancel a case. There probably aren't many explanations for what happened but I've been surprised by input on these forums before.

Patient is a 68 y/o female, 70kg, with a Hx of mild COPD (on stiolto), Hypertension, Hypothyroidism, and sleep apnea. She is scheduled for bilateral mastectomy with sentinel nodes for a 2 cm mass in the right breast, invasive lobular carcinoma. Hx both cataracts done in past 2 years. Hx hysterectomy and appendectomy >30 years ago.

Vitals in preop: BP: 178/86, HR: 80, RR:14, SaO2: 97%. Patient took her metoprolol this morning, skipped dose of losartan. Patient took stiolto this AM, made her take 2 puffs of albuterol before going back. IV works and flushes well. Patient voided prior to going back.

Note written by me (too lazy to write again):

"Patient was brought into the operating room and given 2mg of midazolam. Upon transferring over the patient's first blood pressure was 140/89 on the left leg. The patient was preoxygenated and induced using 50mcg of fentanyl, 160mg of propofol, 80mg lidocaine, and 40mg of rocuronium. The patient was masked once unconscious, subsequent blood pressure measured 200/90. This was without any manipulation or stimulation. At this point no patient rigidity, IV site appeared intact with IV flowing normally. The BP cuff was changed onto the upper extremity. At this point repeated attempts to deepen the patient were initiated. Aliquots of 50-100 of propofol were given along with masking the patient up to 1.0 MAC of anesthesia. No attempt at DL was ever initiated. The Patient's BP continued to be elevated, actually rising up to 220 over the course of 15 minutes with these attempts to deepen, again without any stimulation besides masking. The cuff was transferred to the opposing arm with confirmation of pressures. Patient with 0 twitches, IV still intact, no muscle rigidity, normal ETCO2 with good mask seal. Surgeon made aware of inability to treat BP adequately by deepening anesthesia. 10mg of labetalol given with gradual to decrease of BP to 170. However, with unknown cause of acute increase with anesthesia and inability to treat with deepening anesthesia warrants further elucidation. This decision was made knowing the semi-urgent nature of the patient's surgery. However the risk of untreatable hypertension (without definitive cause) along with chance of stroke with intubation/intraoperatively swayed the decision towards cancellation. Patient reversed, awakened without issues. BP normal in PACU after 10mg labetalol, will be followed up outpatient."

Patient remained within normal range blood pressures in PACU 120-140/70-80 after labetalol. Some atelectasis but discharged when sat'ing ok on RA.

I went the safe route. I've never had an occurrence where the patient's BP increased to such lengths after induction and repeated deepening in the absence of any kind of stimulation. Also The fact that her BP did not decrease masking with 1.0 MAC and giving her around 700mg of propofol over the course of 10 minutes and increased to 220 systolic. I was not a fan of force feeding her labetalol while masking to get her down then intubating and possibly having her shoot up again.

Thoughts?

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[nimbus]

Pheo?
Drug swap?

 

[Radetzky]

Sometimes these chronically hypertensive patients have an abnormal response to hypovolemia where their sympathetic system/RAA responds to poor flow with profound vasoconstriction. Volume paradoxically often fixes the problem.

Also acute hypertension doesn’t cause strokes

 

[DrOwnage]

Pheo?
Drug swap?

No chance of drug swap. Never opened the drawer with vasoactives in it. We have predrawn syringes and the 10mg vial phenylephrine is in a core pyxis. Only lido, prop, roc, versed, fent taken out.

Sometimes these chronically hypertensive patients have an abnormal response to hypovolemia where their sympathetic system/RAA responds to poor flow with profound vasoconstriction. Volume paradoxically often fixes the problem.

Also acute hypertension doesn’t cause strokes

I usually give my patients some fluid prior or during induction, she had at least 500ccs halfway through this period. There was no sympathetic stimulation. Her heart rate during this period was in the 80s like preop. Intubating a patient with a pressure of 220 that won't come down can most definitely cause a stroke. I was more so worried about feeding this patient labetalol or hydral and subsequent lability during the case.

 

[anaesthetic]

I've had severe hypertension from masking alone (with an arterial line in place), to the point where I had to check to make sure I didn't accidentally push NE/phenylephrine. Some patients (especially vasculopaths, younger patients, or hypovolemic patients as mentioned above) have extreme swings in BP with stimulation. I think mask ventilating with a good jaw thrust or lifting into the mask could cause enough stimulation to explain the hypertension.

 

[DrOwnage]

I've had severe hypertension from masking alone (with an arterial line in place), to the point where I had to check to make sure I didn't accidentally push NE/phenylephrine. Some patients (especially vasculopaths, younger patients, or hypovolemic patients as mentioned above) have extreme swings in BP with stimulation. I think mask ventilating with a good jaw thrust or lifting into the mask could cause enough stimulation to explain the hypertension.

With an a line preinduction I would presume that patient was sick and possibly on the lighter side? I wasn't jaw thrusting very hard and she was an easy mask because she was paralyzed. I still think with how deep she was, the stimulation from masking wouldn't be enough to explain the extent of her hypertension.

 

[GravelRider]

Rebound hypertension after stopping ARB? I wouldn’t think so, but maybe?

 

[dannyboy1]

Weird $hit happens. We’re you using desfurane? That can cause a sympathetic response. By the book the right thing to do is cancel but certainly surgeons in my neck of the woods would not be pleased. You can always use remi. That will get BP where you need it to be. Nitroglycerin and nicardepene as well….

 

[DrOwnage]

Weird $hit happens. We’re you using desfurane? That can cause a sympathetic response. By the book the right thing to do is cancel but certainly surgeons in my neck of the woods would not be pleased. You can always use remi. That will get BP where you need it to be. Nitroglycerin and nicardepene as well….

Sevo. Yeah he wasn't too happy, but I think that was probably because I couldn't give an absolute reason as to why. But I still can't soooo. I learned after the case that this patient has had a PET scan. I'm presuming a Pheo would show up on that? I was thinking along the lines of her primary getting her BP under a little more strict control and then having her take her BP meds in the morning of surgery. Plus drawing some obscure labs to possible explain why like metanephrines.

 

[GassYous]

Why roc?

 

[coffeebythelake]

presentation certainly unusual
pheo is a possibility
did you place an art line

 

[DrOwnage]

Why not low dose roc? It will be worn off before important parts of the surgery.

presentation certainly unusual
pheo is a possibility
did you place an art line

Thought about it, but cancelling was higher up on my makeshift "what to do" algorithm. Mostly because it was so out of the ordinary.

 

[coffeebythelake]

Thought about it, but cancelling was higher up on my makeshift "what to do" algorithm. Mostly because it was so out of the ordinary.

i think your decision to cancel was very reasonable
as you said.. with her BP like this without even DL, imagine what it would be like when you actually stimulate her

 

[coffeebythelake]

Sometimes these chronically hypertensive patients have an abnormal response to hypovolemia where their sympathetic system/RAA responds to poor flow with profound vasoconstriction. Volume paradoxically often fixes the problem.

Also acute hypertension doesn’t cause strokes

depends on how high the BP is, you don't think the patient could develop hemorrhagic stroke? and at 1.0 MAC of gas so her cerebro autoregulation is definitely thrown off

 

[Radetzky]

depends on how high the BP is, you don't think the patient could develop hemorrhagic stroke? and at 1.0 MAC of gas so her cerebro autoregulation is definitely thrown off

No. Hypertension causes bleeding over a long period of time not over a matter of minutes. Plenty of stroke and vasospasm pts have huge BPs that we don’t treat (or even purposely cause) and they don’t go around bleeding. Auto regulation is preserved with sevo up to 1.5 Mac.

There has been a interchange of BP management in already bleeding patients and BP management in perfectly healthy pts.

That said I would still cancel the case lol. Too much liability if something went wrong.

 

[Beeftenderloin]

depends on how high the BP is, you don't think the patient could develop hemorrhagic stroke? and at 1.0 MAC of gas so her cerebro autoregulation is definitely thrown off

They’ve done studies on power lifters with art lines. These guys are generating systolics approaching 400 mmHg when they valvsalva for a heavy deadlift. A couple minutes at 220 isn’t stroking anyone unless they have an undiagnosed paper thin aneurysm hiding somewhere. And if the pressure getting north of 200 under GA, it’s easily getting that high while they’re flipping someone off in traffic on the way to hospital.

 

[Planktonmd]

Don't stop ARBS the day of surgery.

 

[GuiltySpark]

Don't stop ARBS the day of surgery.

Can you educate me on why not? It does seem to be consensus at my institution and logically, i'd rather deal with hyper vs hypotension, but i've never dug into the literature.

 

[coffeebythelake]

Don't stop ARBS the day of surgery.

We've had a few patients with profound hypotension from ACEI or ARB use, and our institution now tells most pts not taking jt day of surgery. I think there was an article in APSF about this as well with the same recommendation

 

[jwk]

We've had a few patients with profound hypotension from ACEI or ARB use, and our institution now tells most pts not taking jt day of surgery. I think there was an article in APSF about this as well with the same recommendation

I'm a believer. I've seen a number of cases where ACE or ARB weren't stopped, and had no other explanation for significant and prolonged hypotension after induction. Vasopressin seems to work well in these cases.

 

[Planktonmd]

Can you educate me on why not? It does seem to be consensus at my institution and logically, i'd rather deal with hyper vs hypotension, but i've never dug into the literature.

It is the consensus in many places to stop these medications, and we did exactly that for a long time.
Eventually we realized that we were seeing way more rebound hypertension resulting in cancellations on DOS (just like this case), than we saw hypotension when the ARB/ACE were not held. So, for bout 5 years now we have stopped telling patients to hold any antihypertensives, and the few times we saw intra-op or post-op hypotension were otherwise asymptomatic, well tolerated, and resolved in a few hours.

 

[coffeebythelake]

It is the consensus in many places to stop these medications, and we did exactly that for a long time.
Eventually we realized that we were seeing way more rebound hypertension resulting in cancellations on DOS (just like this case), than we saw hypotension when the ARB/ACE were not held. So, for bout 5 years now we have stopped telling patients to hold any antihypertensives, and the few times we saw intra-op or post-op hypotension were otherwise asymptomatic, well tolerated, and resolved in a few hours.

U seem pretty confident what happened here is due to stopping the antihypertensive.

 

[GravelRider]

U seem pretty confident what happened here is due to stopping the antihypertensive.

That’s way more likely than a pheo, which was mentioned multiple times.

 

[coffeebythelake]

That’s way more likely than a pheo, which was mentioned multiple times.

u think missing a single dose of losartan is going to cause this tremendous rebound hypertension?
resistant to the vasodepressor effects of multiple high dose anesthetic drugs?
granted the half life of losartan isn't that long, but still...
in my opinion, a zebra like the endogenous release of vasoactive hormones is more likely than that.

 

[Hoya11]

Hey guys I had a weird occurrence the other day and had to cancel a case. There probably aren't many explanations for what happened but I've been surprised by input on these forums before.

Patient is a 68 y/o female, 70kg, with a Hx of mild COPD (on stiolto), Hypertension, Hypothyroidism, and sleep apnea. She is scheduled for bilateral mastectomy with sentinel nodes for a 2 cm mass in the right breast, invasive lobular carcinoma. Hx both cataracts done in past 2 years. Hx hysterectomy and appendectomy >30 years ago.

Vitals in preop: BP: 178/86, HR: 80, RR:14, SaO2: 97%. Patient took her metoprolol this morning, skipped dose of losartan. Patient took stiolto this AM, made her take 2 puffs of albuterol before going back. IV works and flushes well. Patient voided prior to going back.

Note written by me (too lazy to write again):

"Patient was brought into the operating room and given 2mg of midazolam. Upon transferring over the patient's first blood pressure was 140/89 on the left leg. The patient was preoxygenated and induced using 50mcg of fentanyl, 160mg of propofol, 80mg lidocaine, and 40mg of rocuronium. The patient was masked once unconscious, subsequent blood pressure measured 200/90. This was without any manipulation or stimulation. At this point no patient rigidity, IV site appeared intact with IV flowing normally. The BP cuff was changed onto the upper extremity. At this point repeated attempts to deepen the patient were initiated. Aliquots of 50-100 of propofol were given along with masking the patient up to 1.0 MAC of anesthesia. No attempt at DL was ever initiated. The Patient's BP continued to be elevated, actually rising up to 220 over the course of 15 minutes with these attempts to deepen, again without any stimulation besides masking. The cuff was transferred to the opposing arm with confirmation of pressures. Patient with 0 twitches, IV still intact, no muscle rigidity, normal ETCO2 with good mask seal. Surgeon made aware of inability to treat BP adequately by deepening anesthesia. 10mg of labetalol given with gradual to decrease of BP to 170. However, with unknown cause of acute increase with anesthesia and inability to treat with deepening anesthesia warrants further elucidation. This decision was made knowing the semi-urgent nature of the patient's surgery. However the risk of untreatable hypertension (without definitive cause) along with chance of stroke with intubation/intraoperatively swayed the decision towards cancellation. Patient reversed, awakened without issues. BP normal in PACU after 10mg labetalol, will be followed up outpatient."

Patient remained within normal range blood pressures in PACU 120-140/70-80 after labetalol. Some atelectasis but discharged when sat'ing ok on RA.

I went the safe route. I've never had an occurrence where the patient's BP increased to such lengths after induction and repeated deepening in the absence of any kind of stimulation. Also The fact that her BP did not decrease masking with 1.0 MAC and giving her around 700mg of propofol over the course of 10 minutes and increased to 220 systolic. I was not a fan of force feeding her labetalol while masking to get her down then intubating and possibly having her shoot up again.

Thoughts?

i personally would have done the case and not cancelled.

i agree that you dont want to intubate with SBP around 200 or higher.

But it seems that your reluctance to give BP medication, and instead gave propofol, was where you went astray IMO.

If the problem is a BP problem, I give BP meds, not anesthetics (usually). Yes it may drop her pressure more than I would want, but I can control that too and bring it up.

I am confident that I can control this pressure. Whatever it takes.

I would have masked with 5-6% sevo and given labetolol or hydral as needed to get me to a more reasonable pressure.

Then intubate or my plan A would be an LMA.

Once asleep with a secure airway, aline and BP control becomes the focus.

I know that you feel it was safer to cancel.

But personally I really doubt anything is going to be tweaked or different next time. Someday, somebody is going to have to take this on and control the pressure...

 

[deleted875186]

They’ve done studies on power lifters with art lines. These guys are generating systolics approaching 400 mmHg when they valvsalva for a heavy deadlift. A couple minutes at 220 isn’t stroking anyone unless they have an undiagnosed paper thin aneurysm hiding somewhere. And if the pressure getting north of 200 under GA, it’s easily getting that high while they’re flipping someone off in traffic on the way to hospital.

Do you have the study? Would be a good one to read.

 

[deleted875186]

i personally would have done the case and not cancelled.

i agree that you dont want to intubate with SBP around 200 or higher.

But it seems that your reluctance to give BP medication, and instead gave propofol, was where you went astray IMO.

If the problem is a BP problem, I give BP meds, not anesthetics (usually). Yes it may drop her pressure more than I would want, but I can control that too and bring it up.

I am confident that I can control this pressure. Whatever it takes.

I would have masked with 5-6% sevo and given labetolol or hydral as needed to get me to a more reasonable pressure.

Then intubate or my plan A would be an LMA.

Once asleep with a secure airway, aline and BP control becomes the focus.

I know that you feel it was safer to cancel.

But personally I really doubt anything is going to be tweaked or different next time. Someday, somebody is going to have to take this on and control the pressure...

I think we all would have deepened, I probably would stop at 300 mg prop for this normal size lady.

Would be interested if she had any prior anesthetics. Also, would be good to follow up in a month to see how the case goes Shem she rebooks.


Agree with pheo, labeled BP from chronic hypertension with either jaw thrust or hypovolemia plus lack of anti hypertensives, drug error still possible. Bad batch of propofol (never seen this personally).

Illicit drug use perhaps on day of surgery??

 

[GravelRider]

u think missing a single dose of losartan is going to cause this tremendous rebound hypertension?
resistant to the vasodepressor effects of multiple high dose anesthetic drugs?
granted the half life of losartan isn't that long, but still...
in my opinion, a zebra like the endogenous release of vasoactive hormones is more likely than that.

Yes, I do think rebound hypertension from missing a dose of medications is more likely than pheo. Sure, send off some labs (although I think it’s a waste of time and resources), but I would have gotten her BP down with some antihypertensive medications and proceeded with the case. He actually got the BP down with a reasonable dose of labetalol. I would have intubated at the systolic of 170.

I wouldn’t have cancelled and she doesn’t have a pheo.

 

[Volatile]

Probably a long shot but possibly some inadvertent beta agonism from albuterol contributed as well. Knowing myself, I probably would have continued on with esmolol, even nitroglycerin if needed to get the BP where I want it quickly. Definitely not saying that’s the right way to do it, but most likely what I would have done. Im pretty happy treating hypertension as opposed to the alternative.

 

[Beeftenderloin]

Do you have the study? Would be a good one to read.

MacDougall JD, Tuxen D, Sale DG, Moroz JR, Sutton JR. Arterial blood pressure response to heavy resistance exercise. J Appl Physiol (1985). 1985 Mar;58(3):785-90. doi: 10.1152/jappl.1985.58.3.785. PMID: 3980383.

Palatini P, Mos L, Munari L, Valle F, Del Torre M, Rossi A, Varotto L, Macor F, Martina S, Pessina AC, et al. Blood pressure changes during heavy-resistance exercise. J Hypertens Suppl. 1989 Dec;7(6):S72-3. doi: 10.1097/00004872-198900076-00032. PMID: 2632751.

 

[nimbus]

I have never actually seen a patient’s blood pressure go up after a big bolus of propofol.

 

[nimbus]

No chance of drug swap. Never opened the drawer with vasoactives in it. We have predrawn syringes and the 10mg vial phenylephrine is in a core pyxis. Only lido, prop, roc, versed, fent taken out.

Yeah my thought was a metoclopramide/phenylephrine swap. Sometimes look alike vials end up in cubbies where they don’t belong but I wasn’t there. The pharmacy techs who restock are not always on their A game.

 

[vector2]

i personally would have done the case and not cancelled.

i agree that you dont want to intubate with SBP around 200 or higher.

But it seems that your reluctance to give BP medication, and instead gave propofol, was where you went astray IMO.

If the problem is a BP problem, I give BP meds, not anesthetics (usually). Yes it may drop her pressure more than I would want, but I can control that too and bring it up.

I am confident that I can control this pressure. Whatever it takes.

I would have masked with 5-6% sevo and given labetolol or hydral as needed to get me to a more reasonable pressure.

Then intubate or my plan A would be an LMA.

Once asleep with a secure airway, aline and BP control becomes the focus.

I know that you feel it was safer to cancel.

But personally I really doubt anything is going to be tweaked or different next time. Someday, somebody is going to have to take this on and control the pressure...

Given that this is cancer and not an elective boob job, I would've done the same (mask down with gas, labetalol, intubate, aline). And I agree with the reasoning that it's extremely unlikely that any outpt workup is going to explain what was a very strange post-induction paradoxical reaction.

 

[woopedazz]

What's her entire medication list.
Is it usual for you to give 50mcg fentanyl for a double mastectomy induction? Did you consider giving more once the hypertension was noted?
How much IVT went into this patient prior to cancelling the case?

 

[GravelRider]

Yeah my thought was a metoclopramide/phenylephrine swap. Sometimes look alike vials end up in cubbies where they don’t belong but I wasn’t there. The pharmacy techs who restock are not always on their A game.

Wouldn’t a vial of full strength phenylephrine have caused a much more serious hypertensive reaction than the one here? This hypertensive episode seemed to respond appropriately to labetalol.

 

[NITRAS]

u think missing a single dose of losartan is going to cause this tremendous rebound hypertension?
resistant to the vasodepressor effects of multiple high dose anesthetic drugs?
granted the half life of losartan isn't that long, but still...
in my opinion, a zebra like the endogenous release of vasoactive hormones is more likely than that.

Sorry to butt in. I recently reading about pheo’s. The rate that physicans who think they find a pheo and actually find one is 1 in 300. The first line screening is a 24 hour urine. You can get fractionated and unfractrionated serum metenephrines, but the positive predictive value is low. It is better if drawn from a cannula after a patient has been supine for 30 minutes.

It is a an interesting discussion, but pheochromocytoma is always going to be low on the differential. I’m not an endocrinologist nor an anesthesiologist. But I will say that if you canceled my mother’s cancer case because of some hypertension adequately treated with a dose of labetalol, I’d be pissed.

 

[coffeebythelake]

Sorry to butt in. I recently reading about pheo’s. The rate that physicans who think they find a pheo and actually find one is 1 in 300. The first line screening is a 24 hour urine. You can get fractionated and unfractrionated serum metenephrines, but the positive predictive value is low. It is better if drawn from a cannula after a patient has been supine for 30 minutes.

It is a an interesting discussion, but pheochromocytoma is always going to be low on the differential. I’m not an endocrinologist nor an anesthesiologist. But I will say that if you canceled my mother’s cancer case because of some hypertension adequately treated with a dose of labetalol, I’d be pissed.

Interesting the statistic. Source for 1 in 300 ??

Also your thoughts as a hospitalist if missing a single dose of ARB will cause such treatment resistant rebound hypertension. I don't have a statistic to quote, but anecdotally taken care of thousands of patients taking and not taking their ARB or ACEI on DOS I have no encountered this sort of profound hypertensive scenario.

FYI cases get postponed all the time. Sometimes surgeon schedule runs over. Sometimes equipment issues. Sometimes anesthesia concerns. If there is a legitimate patient safety concern, the fact it is cancer surgery doesn't play much into decision making to postpone. It would just get rescheduled earlier. Do you think that waiting a few days would make such a difference in your mother's cancer outcomes to make you so "pissed"?

 

[DG51]

We've had a few patients with profound hypotension from ACEI or ARB use, and our institution now tells most pts not taking jt day of surgery. I think there was an article in APSF about this as well with the same recommendation

ACC/AHA recommends using clinical judgment regarding expected intra-op fluid shifts, blood pressure changes, etc. when counseling a patient regarding whether or not to stop an ace-i/arb prior to non-cardiac surgery. Definitely not a requirement to discontinue these medications.

 

[coffeebythelake]

ACC/AHA recommends using clinical judgment regarding expected intra-op fluid shifts, blood pressure changes, etc. when counseling a patient regarding whether or not to stop an ace-i/arb prior to non-cardiac surgery. Definitely not a requirement to discontinue these medications.

of course not a requirement (in the strictest sense very few things in anesthesia are "required")
it is a recommendation
the existing studies do not quite reach the size and quality to change everyone's practice, but i think the data is compelling enough, and
in most situations I would have patients stop their ACEI/ARB
perhaps not for MAC / regional + sedation cases as i would not expect the same hemodynamic effects vs. GA
like others have said here, personally i would prefer to treat hypertension than refractory hypotension

This has been editorialized by both APSF and in Anesthesiology

Does withholding an ACE inhibitor or ARB before surgery improve outcomes?​

https://www.mdedge.com/familymedicine/article/200313/cardiology/does-withholding-ace-inhibitor-or-arb-surgery-improve#:~:text=Withholding%20angiotensin%2Dconverting%20enzyme%20inhibitors,%25%20adjusted%20relative%20risk%20reduction).

NEJM Journal Watch: Summaries of and commentary on original medical and scientific articles from key medical journals

NEJM Journal Watch reviews over 250 scientific and medical journals to present important clinical research findings and insightful commentary

www.jwatch.org

Withholding versus Continuing Angiotensin-converting Enzyme Inhibitors or Angiotensin II Receptor Blockers before Noncardiac Surgery: An Analysis of the Vascular events In noncardiac Surgery patIents cOhort evaluatioN Prospective Cohort

In a secondary analysis of 4,802 patients on these drugs in the Vascular events In noncardiac Surgery patIents cOhort evaluatioN prospective cohort study, those in whom the drugs were withheld in the 24 h before surgery were less likely to suffer a composite outcome of 30-day all-cause death...

pubs.asahq.org

Effect of pre-operative discontinuation of angiotensin-converting enzyme inhibitors or angiotensin II receptor antagonists on intra-operative arterial pressures after induction of general anesthesia

Medical guidelines advise perioperative continuation many antihypertensives, but discontinuing angiotensin antagonists before surgery.This study is aimed to determine the effect of preoperative discontinuation of angiotensin-converting enzyme inhibitors ...

www.ncbi.nlm.nih.gov

 

[GravelRider]

Interesting the statistic. Source for 1 in 300 ??

Also your thoughts as a hospitalist if missing a single dose of ARB will cause such treatment resistant rebound hypertension. I don't have a statistic to quote, but anecdotally taken care of thousands of patients taking and not taking their ARB or ACEI on DOS I have no encountered this sort of profound hypertensive scenario.

Rebound hypertension, poorly controlled hypertension…it’s all sort of the same thing. Her hypertension is poorly controlled. She was hypertensive in pre-op. I bet she would have been hypertensive even after taking her dose of losartan. I’m sure there is a possible explanation related to up or down regulation of receptors that could explain her lack of the typical vasodilatory response to propofol…an explanation I am not smart enough to come up with. However, she did respond appropriately to an antihypertensive medication, so it wasn’t really treatment resistant. Cancelling this case because her hypertension is not under control is a weak argument, but fair. Cancelling to send her for a pheo work up is silly.

 

[coffeebythelake]

Rebound hypertension, poorly controlled hypertension…it’s all sort of the same thing. Her hypertension is poorly controlled. She was hypertensive in pre-op. I bet she would have been hypertensive even after taking her dose of losartan. I’m sure there is a possible explanation related to up or down regulation of receptors that could explain her lack of the typical vasodilatory response to propofol…an explanation I am not smart enough to come up with. However, she did respond appropriately to an antihypertensive medication, so it wasn’t really treatment resistant. Cancelling this case because her hypertension is not under control is a weak argument, but fair. Cancelling to send her for a pheo work up is silly.

I think we should appreciate that the anesthesiologist on the case is also drawing from their experience and judgement in making such decisions. If something doesn't seem right I think it is deserving of attention. This was not my case. Do I think what happened was unusual? Yes. Do I understand the thought process that prompted @DrOwnage to cancel the case? Yes. Do I think it was a reasonable decision? Yes. And if you polled 100 anesthesiologists I'm sure he wouldn't be the only one that would have cancelled.

 

[Planktonmd]

Since we live in a litigious society no one can blame you for cancelling the case, but just remember that when she comes back for surgery next time she needs to take her ARB in the morning.

 

[MirrorTodd]

I have never actually seen a patient’s blood pressure go up after a big bolus of propofol.

I have when I started my background fluid infusion after already having run epi through the line for cardiac case.

 

[coffeebythelake]

I have when I started my background fluid infusion after already having run epi through the line for cardiac case.

hopefully u had that epi gtt on the port closest to the patient

 

[pgg]

i personally would have done the case and not cancelled.

i agree that you dont want to intubate with SBP around 200 or higher.

But it seems that your reluctance to give BP medication, and instead gave propofol, was where you went astray IMO.

If the problem is a BP problem, I give BP meds, not anesthetics (usually). Yes it may drop her pressure more than I would want, but I can control that too and bring it up.

I am confident that I can control this pressure. Whatever it takes.

I would have masked with 5-6% sevo and given labetolol or hydral as needed to get me to a more reasonable pressure.

Then intubate or my plan A would be an LMA.

Once asleep with a secure airway, aline and BP control becomes the focus.

I know that you feel it was safer to cancel.

But personally I really doubt anything is going to be tweaked or different next time. Someday, somebody is going to have to take this on and control the pressure...

Agreed on all points though I'd prefer nitroglycerin and esmolol over drugs like hydralazine and labetalol. With these labile patients you often find yourself struggling in the other direction a few minutes later, and hydralazine/labetalol stick around for a while.

 

[coffeebythelake]

I went the safe route. I've never had an occurrence where the patient's BP increased to such lengths after induction and repeated deepening in the absence of any kind of stimulation. Also The fact that her BP did not decrease masking with 1.0 MAC and giving her around 700mg of propofol over the course of 10 minutes and increased to 220 systolic. I was not a fan of force feeding her labetalol while masking to get her down then intubating and possibly having her shoot up again.

Any substance use history? Big time Marijuana user? Cocaine? Meth? I can't get over how 1.0 MAC gas plus 700 mg propofol over 10 minutes was unable to drop the BP of a 70 kg old lady. This is a much much higher dose than I've ever had to give for anyone during induction phase, and that includes the young potheads.

 

[deleted875186]

Any substance use history? Big time Marijuana user? Cocaine? Meth? I can't get over how 1.0 MAC gas plus 700 mg propofol over 10 minutes was unable to drop the BP of a 70 kg old lady. This is a much much higher dose than I've ever had to give for anyone during induction phase, and that includes the young potheads.

Let me just say, in the pain clinic I get 70-80 yo people using cocaine. Cocaine is quite prevalent these days.

 

[coffeebythelake]

Let me just say, in the pain clinic I get 70-80 yo people using cocaine. Cocaine is quite prevalent these days.

And that begs the next question, *IF* this patient was acutely intoxicated with these substances would you want to do the case.

 

[vector2]

This study in ASA from 1997 (Mechanisms whereby Propofol Mediates Peripheral Vasolidation in Humans: Sympathoinhibition or Direct Vascular Relaxation?) demonstrated that the vast majority of the hypotensive effect of propofol comes from its inhibitory effect on sympathetic vasoconstrictor nerve activity. If you inject propofol into the brachial artery, the vasculature of the arm doesn't vasodilate because there's simply not much direct smooth muscle vasodilatory action.

What this means is that old people with longstanding poorly controlled hypertension, i.e. people who likely have some degree of autonomic dysfunction, may not have predictable hypotensive responses to propofol. And that may explain why labetalol (with direct alpha antagonist activity) may have worked while propofol didn't. As to the volatile, I think we all know that the Et agent readings while masking are not accurate compared to intubation with controlled mechanical ventilation.

 

[DrOwnage]

Any substance use history? Big time Marijuana user? Cocaine? Meth? I can't get over how 1.0 MAC gas plus 700 mg propofol over 10 minutes was unable to drop the BP of a 70 kg old lady. This is a much much higher dose than I've ever had to give for anyone during induction phase, and that includes the young potheads.

No she was a sweet little old lady with no substance hx. Yeah that's why I was adamant to cancel. I didn't think a week or so would hurt her in the long run. I've never had anything happen like this in over 1000's of anesthetics. The fact her systolic jumped up 80 points from her preinduction after deepening is very concerning. I know some people will say its "weak anesthesia" or be pissed if it was their family member. Some people on the forum here seem to not cancel cases for anything besides active myocardial ischemia. But something just felt very wrong and I don't like ignoring those feelings. I don't like punting cases where there's a high chance it will just happen again, but I'm also not a fan of masking issues to overcome them. This lady maybe ramping up her antihypertensives and taking her ARB the day of surgery might make the difference. But yeah the chance of a pheo or carcinoid is slim to none. If I happen to be the one who gets the case again, which is totally possible, I would probably LMA and A line her if she responded the same way again.