Hypertension after Induction - Case Discussion

[DrOwnage]

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.

I get your point with time constants, but I was also masking her for a solid 15 minutes with a good seal.

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[coffeebythelake]

I get your point with time constants, but I was also masking her for a solid 15 minutes with a good seal.

actually i think vector was knocking on your mask ventilation skills

 

[propadope]

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.

I would think you would also see a compensatory bradycardia with phenylephrine

I have almost always seen hypotension after induction with ACEI/ARB even with stopping the morning or night before dose. They usually come in preop hypertensive

 

[coffeebythelake]

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

I've seen the initial BP go up from the pain of propofol injection, but this usually settles down once they are unconscious

 

[GravelRider]

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.

You’re right, I wasn’t there, and I said it was a fair decision to cancel. However, my perspective is I wouldn’t have cancelled in this instance for this surgery based on the info presented here.

 

[FiO2@21]

I've definitely had 1 or 2 patients (one with an art line pre-induction) who had a dramatic (SBP 190-200) spike following induction and nothing else. I blamed the pain from the etomidate.

We had the same exact scenario as OP at the VA. 220s in OR, cancelled after induction. Went to the clinic, checked BP at home, all acceptable. So secondary HTN very unlikely. Took their ARB 2nd time around. Pt BP STILL high in pre-op and around induction. We just stuck an arterial line in and proceeded, didn't seem like any other course of action would benefit the patient at that point.

 

[NITRAS]

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"?

I can’t find the exact article. UpToDate and a AACC article both reference it, but don’t point to it which of the References. It does look old. I likewise haven’t had issues with such severe rebound hypertension with ARBs, And I do usually hold them before surgeries. I would more likely blame medication error, weird drug reaction, painful stimuli of an ETT over a condition that in all like-hood, none of us will see, or might see once in a long career.

A few days, no. But my healthcare system is quite busy. A delay will often mean weeks or months delay. Seeing a specialist can take months for an initial consult, much less a completed evaluation.

 

[Radetzky]

One could actually take a history and see if she has paroxysmal episodes consistent with an diagnosis of pheo?

 

[nimbus]

One could actually take a history and see if she has paroxysmal episodes consistent with an diagnosis of pheo?

This is the anesthesia forum

 

[repititionition]

Lots of options here.

Check clinic notes etc for a documented BP (agree with others, likely high 2/2 chronic poorly-treated htn)

Check BP on all extremities

Place a-line, start esmo infusion and provide stimulus, assess adequacy of BP control with short acting vasoactives

Quick surface echo and ECG to demonstrate lack of untoward cardiac sequelae at these pressures

I am not second guessing decision to cancel, just saying that I see a few options to protect yourself AND patient while continuing case