Assessment and Nursing

Management of Hypertension
in the Perioperative Period
JANICE D. NUNNELEE, PhD, RN, CS/ANP
STEVEN D. SPANER, PhD

Over 50 million p e r s o n s in the United States h a v e h y p e r t e n s i o n , m a k i n g it

one o f the m o s t c o m m o n a b n o r m a l i t i e s f o u n d in the perioperative patient.
Often discovered during the preoperative a s s e s s m e n t o f the p a t i e n t sched-
uled for surgery, h y p e r t e n s i o n raises m a n y c o n c e r n s in the perioperative
period, i n c l u d i n g h e m o d y n a m i c control during anesthesia, p o s t o p e r a t i v e
c o m p l i c a t i o n s , a n d the risk o f c o m o r b i d i t i e s that m a y n o t be e v i d e n t until the
p a t i e n t is stressed. This article concentrates on the identification o f hyperten-
sion preoperatively, the p o t e n t i a l p r o b l e m s associated with h y p e r t e n s i o n in
the entire perioperative period, a n d p h a r m a c o l o g i c a n d nursing m a n a g e -
merit.
~ 2000 by A m e r i c a n Society of PeriAnesthesia Nurses.

Y P E R T E N S I O N affects over 50 million 109 mm Hg diastolic. Stage 3 (severe) is a systolic

H Americans. Treatment of the disease has
increased dramatically since the late 1970s~; how-
ever, many patients are either unaware of their
diagnosis or their blood pressure is inadequately
controlled. In the perioperative period, the knowl-
edge of a patient's hypertension is essential, as is
the management of the disease.
BACKGROUND
Hypertension in adults is defined as the presence
of a systolic blood pressure above 140 mm Hg or a
diastolic pressure above 90 mm Hg, found on 3
separate occasions. I,e The diagnosis is made if
either the systolic or diastolic pressure average is
equal to or higher than 140 or 90 mm Hg,
respectively, in 2 or more readings after the first
visit. Guidelines for proper blood pressure measure-
ment are found in Table 1.
The Joint National Committee VI (JNC-VI) j
defines ideal blood pressure in adults as a systolic
pressure below 120 mm Hg and a diastolic pressure
below 80 mm Hg. Stage 1 (mild) hypertension
ranges from 140 to 159 mm Hg systolic and 90 to
99 mm Hg diastolic, whereas stage 2 (moderate)
ranges from 160 to 179 mm Hg systolic and 100 to
pressure that exceeds I g0 nnn Hg and a diastolic
pressure exceeding 110 mm Hg.
The incidence of perioperative hypertension is
reported to be very low in patienls requiring
noncardiac surgery3: however, in patients requiring
cardiac surgery, the incidence increases. Other
causes of increased incidence of hypertension are
listed in Table 2. Hypertension is also found more
often with increasing age and in certain ethnic
populations. The incidence of hypertension is high-
est among blacks ~ but is also high in native
Americans. Hispanics have similar or lower blood
.hmice D. Nunnelee, PhD, RN, CS/ANP, is an Adult Nurse
Practitioner: Unity Medical Group, and Clinical Associate
Profi,ssor o/" Nursing, Universi(v of Missouri--St Louis, MO;
Steven D. Spaner, PhD, is an Associate Profi,ssor in the Division
o/' Educational P.s\vcholoy,y Research & Evaluation, University
eft'Missouri-St Louis, MO.
Presented at the .summer meeting qf the Illinois Society.fi;r
PeriAnesthesia Nurses, July 31, 1999.
Address correspondence to Janice D. Nunnelee, PhD, RN,
CS/ANP, WCFP, 14377 Woodlake #300, Chesterfield, MO
63017.
9 2000 by American Society q['PeriAnesthesia Nurses.
t 089- 9472/00/1503 -000453.00/0
doi: tO./053/jpan.2000. 7513

Journal of PeriAnesthesia Nursing, Vol 15, No 3 (June), 2000: pp 163 168 163
164
Table 1. Guidelines for Taking a Blood Pressure
The patient should:
Be seated with both feet flat on the floor
Be measured for the proper sized cuff
Be measured in both arms
Have rested quietly for at least 5-10 minutes
Not have smoked or ingested caffeine within 30 minutes
Not be talking or eating
Have the arm held relaxed and supported, not out
straight, at heart level
Have 2 measurements taken at least 2 minutes apart and
averaged
The first appearance of sound defines the systolic pressure,
and the disappearance of sound defines diastolic pres-
sure.
A mercury sphygmomanometer is the preferred instru-
ment.
pressure than whites and Asians. 4,5 These differ-
ences in elderly patients and ethnic minorities
should be considered during assessment for hyper-
tension.
PREOPERATIVE ASSESSMENT
AND MANAGEMENT
Preoperative assessment of the newly diagnosed
or new-onset hypertensive patient should include
an evaluation for any secondary causes of hyperten-
sion such as renal artery stenosis, pheochromocy-
toma, and so forth. Preoperative management should
include continuation of current antihypertensive
medications (generally managed by the primary
care provider), initiation of pharmacological inter-
Table 2. Conditions Associated With an Increased
Incidence of Hypertension
Coronary artery bypass grafting
Valve replacement
Severe burns
Intracranial pathology (including injury)
Hyperthyroidism
Renal artery stenosis
Renal disease
Drug abuse
Alcoholism
Myocardial infarction
Pheochromocytoma
Pregnancy with preeclampsia/eclampsia
Malignant hyperthermia
Fluid overload
Status post cardiopulmonary resuscitation
Severe pain
Data from references 1,3, 4, 5, and 15.
NUNNELEE AND SPANER
vention for hypertension identified during the pre-
operative evaluation, and frequent blood pressure
monitoring during the entire perioperative period.
HYPERTENSION DURING
AND AFTER SURGERY
The patient with hypertension is at risk for
increased blood pressure fluctuations during sur-
gery, even if hypertension has been previously well
controlled.6 Generally, the patient experiences de-
creased blood pressure during induction of general
anesthesia, increased pressure during intubation,
and stabilization of both pressure and heart rate as
the case progresses. At the end of a procedure, the
patient again has a rise in pressure and heart rate
during awakening and extubation. In the patient
with hypertension, these increases and decreases
may be extreme and may result in problems
identified in Table 3.
Postoperatively, levels of the catecholamines
epinephrine and norepinephrine may be elevated,
secondary to sympathetic stimulation from stress
and pain. 7 Peripheral vascular resistance (PVR) is
also increased because of hypothermia and vasocon-
striction. This increase in PVR and elevation of
catecholamines may combine to result in hyperten-
sion. Studies have found that this is more likely to
occur in the patient with a history of hypertension,
even if it is well controlled. 8-~~
Mild to moderate hypertension alone is not
predictive of a perioperative cardiac complications,
but it can be a contributing factor. Patients with
coronary artery disease who have major vascular
surgery, such as aortic aneurysm resection or tibial
bypass procedure, may experience an increased
risk of death due to myocardial infarction, particu-
larly if they have hypertension. 3,11 Some studies in
noncardiac, nonvascular surgery do not support this
finding3,12; however, it is evident that hypertension
may contribute to myocardial ischemia. Whether
Table 3. Potential Risks for the Hypertensive Patient With
Wide Swings in Blood Pressure During Surgery
Myocardial ischemia
Myocardial infarction
Congestive heart failure
Increase in S-T segment depression
Cerebral ischemia
Bleeding from arterial anastomoses
Arrhythmias
Data from references 3, 6, 8, and 12.
ASSESSMENT AND MANAGEMENT OF HYPERTENSION
preoperative control of hypertension reduces mor-
tality from myocardial infarction or cerebrovascu-
lar accident in the perioperative period is unknown.
MEDICATIONS USED IN THE TREATMENT
OF HYPERTENSION
Essential hypertension, a polygenic disorder in
which patients have many different genetic traits
that result in hypertension, constitutes 95% of all
hypertension. The degree of hypertension is thought
to be a result of the balance of high and low blood
pressure alleles in the patient, t3,14 The remaining
5% of hypertension is attributable to secondary
causes such as renal artery stenosis, pheochromocy-
toma, or aldosteronism.
The recommended drug therapy by the Joint
National Council VI l includes beta-blockers and
diuretics as first-line therapy for essential hyperten-
sion. However, few health care providers follow
the exact guidelines. ~5 Antihypertensive medica-
tions are discussed with the specifics to each class.
Diuretics
Approximately 50% to 60% of hypertensive
patients respond to diuretics in low doses with a
decrease in blood pressure. In patients in whom
fluid volume expansion is a central factor, such as
the black population and the elderly, diuretics work
well. 15,16 Types of diuretics are shown in Table 4.
Thiazide diuretics tend to work better on essential
hypertension than the loop diuretics because of
increased duration and the fact that there is little
rebound sodium retention. Potassium-sparing diuret-
ics are seldom used alone because they are usually
ineffective in lowering the blood pressure. Side
effects of diuretics include sexual dysfunction,
hypokalemia, increased lipids, increased insulin
Table 4. Types of Diuretics and Their Method of Action
Type Action
Thiazide Block reabsorption of sodium in the
early distal tubule
Loop Block sodium reabsorption proximally
in the Loop of Henle, a more potent
action
Potassium-sparing Act in the distal tubule to prevent the
exchange of sodium for potassium
Indapamide A separate class, nonthiazide, long-
acting
Data from references 1, 15, and 17.
16s
resistance, precipitation of gout, and hypercalce-
mia)6,17
Beta-Blockers
Beta-blockers work on smooth muscle by acting
on the beta receptors in cardiac muscle and arteries,
resulting in vasodilation. In addition, beta-blockers
antagonize the sympathetic stimulation of renin.
Approximately 40% to 50% of patients respond to
beta-blockers as monotherapy. Fewer blacks and
elderly respond well. Long-term studies indicate
that beta-blockers reduce long-term mortality and
morbidity in all hypertensive patients. 8,15,17
Adverse effects of beta-blockers include fatigue,
exercise intolerance, impotence, bronchospasm,
and vasoconstriction. Use of these drugs may cause
worsening of peripheral arterial disease, Raynaud's
phenomenon, hypoglycemia in insulin-dependent
diabetic patients, and worsening of depression. 8,15,17
Desirable effects of beta-blockers include de-
creased pulse rate, cardiac output, and myocardial
oxygen demand. Beta-blockers should not be
stopped abruptly in the patient with identified or
suspected cardiac disease.
Alpha-Blockers
Alpha-blockers inhibit receptors in smooth
muscle in both the artery walls and cardiac muscle
with little stimulation of cardiac output. These
drugs blunt vasoconstriction and cause peripheral
vasodilation. They work as monotherapy 70% of
the time, lowering blood pressure by approximately
8% to 10%. 18
Alpha-blockers are often used for nonhyperten-
sive patients for reduction of benign prostatic
hypertrophy. This is one positive side effect of the
drug. In addition, alpha-blockers increase insulin
sensitivity and may improve glycemic control.
Low-density lipoproteins (LDLs) also may be
lowered.6,s,18
A less desirable side effect is first-dose hypoten-
sion. Although patients may not be receiving all of
their discharge instructions in the perioperative
setting, nurses should be aware of this side effect. It
may be applicable to patients who are discharged
after outpatient surgery, or who resume medication
after a period without it. Patients should be in-
structed to take their first dose at bedtime and not
be up for at least an hour after they take the pill.
Postural hypotension may occur at any time, as can
tachycardia, dizziness, priapism, and gastrointesti-
166
nal distress. 15,17 These drugs do not limit exercise
tolerance or cause impotence.
Alpha-Beta Blockers
This group of drugs blocks both the alpha- and
beta-adrenergic receptors, resulting in reduced blood
pressure by several means. 15,19 The medication
reduces heart rate and contractility like pure beta-
blockers but also lowers PVR, like alpha-blockers.
Two drugs in this class, labetalol and carvedilol, are
effective in rapidly lowering blood pressure. Labeta-
lol is available in parenteral form and is very useful
for controlling hypertensive emergencies during
and after surgery. An overview of the actions of
these drug classes is presented in Table 5.
ACE Inhibitors/Angiotensin Receptor Blockers
Angiotensin-converting enzyme (ACE) inhibi-
tors prevent conversion of angiotensin I to angioten-
sin II, raising levels of bradykinins and prostaglan-
dins. 8,2~This results in vasodilation and decreased
peripheral vascular resistance.
These drugs work well as monotherapy approxi-
mately 85% of the time. They are not as effective in
certain subgroups such as the elderly or blacks.
Blacks may need higher doses or combination
therapy more often than other subgroups of pa-
tients. This may be because of their low-renin,
salt-sensitive nature of hypertension. 2~
Side effects of ACEs include cough (dry and
nonproductive), dizziness, angioedema, rash, loss
of taste, hyperkalemia, leukopenia, and a phenom-
enon known as functional renal insufficiency. 8,15,2~
The last complication occurs in patients with a
Table 5. Classes of Beta-Blockers and Combined Alpha-Beta
Blockers and Their Method of Action
Class Action
Cardioselective (beta) Decrease: cardiac output, plasma
renin activity, blood pressure,
and heart rate
Noncardioselective Less effect on heart rate, vascular
(intrinsic sympathomi- and smooth muscle
metic action) (beta)
Alpha Decreased peripheral vascular
resistance without increase in
cardiac output
Combined alpha/beta Decrease peripheral vascular resis-
tance, less effect on heart rate
and cardiac output
Data from references 1, 15, 17, and 19.
NUNNELEE AND SPANER
single kidney or bilateral renal artery stenosis. 2~
ACE inhibitors are contraindicated in pregnancy.
ACEs work well in subgroups such as patients
with diabetes, where the drug protects the kidney
and decreases protein excretion in patients with
renal involvement. It improves survival in patients
with congestive heart failure and may decrease or
reverse left ventricular dilation. In the elderly
patient with cerebrovascular disease, the ACE
inhibitor is protective because it does not reset the
cerebro-antoregulatory mechanisms. 2~
Angiotensin receptor blockers differ from ACE
inhibitors in that they do not stimulate bradykinins.
They bind selectively to the AT1 receptor in the
brain and block the vasoconstricting effects of
angiotensin II.
Calcium Channel Blockers
There are 2 types of calcium channel blockers
(CCBs): nondihydropyrines (which act on heart
muscle) and dihydropyrines (which only act on
peripheral arterioles). 22,23 The primary effect of
both types is vasodilation through reduction in
vascular tone and contractility. Calcium agonists
also increase coronary arterial flow and may de-
crease angina. Used as monotherapy, these drugs
are effective in approximately 50% to 80% of
patients. 22-24 CCBs lower blood pressure even in
the presence of high salt intake.
Positive effects of CCBs include decreased pulse
rate, an additive effect with other agents such as
ACEs and diuretics, and a steep dose-response
c u r v e . 23 Side effects include flushing, headache,
postural hypotension, palpitations, tachycardia,
ankle edema (more common with dihydropyri-
dines), and constipation.15,22,23 Withdrawal of CCBs
may precipitate angina. A recent study found
increased coronary events when using short-acting
CCBs to rapidly reduce blood pressure. 24 This use
is not recommended by the Food and Drug Admin-
istration.
SPECIAL CONCERNS IN THE ELDERLY
In the preoperative period and in the postopera-
tive follow-up, the elderly patient with hyperten-
sion warrants special concern. The side effects of
medications may not seem as clear-cut in the
elderly population and may be mistaken for normal
aging responses. These patients may experience
postural hypotension, especially after meals, when
the blood is shunted to the gut to promote diges-
ASSESSMENT AND MANAGEMENT OF HYPERTENSION
tion. 25 Also, falls, clouding of the sensorium, and
depression (or worsening of depression) may occur.
In the postoperative patient, these mental changes
or postural hypotension may be problematic when
getting the patient out of bed for the first time.
Additionally, patients who are elderly are at
increased risk for stroke and cardiovascular events
postoperatively. 25 For this reason, perioperative
nurses must be particularly attuned to neurological
changes, even in the patient who is not undergoing
surgery for neurological or vascular reasons.
Constipation may be a concern with diuretics
and CCBs. Patients taking these medications should
be encouraged to increase fiber and fluids. This is a
specific concern after surgery, because pain medica-
tion may also slow gut function.
More elderly patients have left ventricular dys-
function than patients younger than age 60; there-
fore, ACEs may be effective for hypertension
control, e6 Should ventricular dysfunction be discov-
ered in the preoperative evaluation, nurses should
be aware of the need for ACE inhibitors and be
careful to explain the reasoning for and potential side
effects associated with the use of these medications.
CONCLUSION
Hypertension is a concern in all phases of the
perioperative period. The patient with known hyper-
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tension should be evaluated and treated appropri-
ately throughout the perioperative experience. The
patient who is newly diagnosed should have opti-
mum intervention within a reasonable time frame
to decrease the potential for adverse events. Nurses
in all phases of perianesthesia and perioperative
care should be aware of the signs and symptoms of
complications and the drugs used in treating this
common diagnosis.
INFORMATION
The Joint National Committee (currently the
sixth committee, therefore JNC VI) is a na-
tional panel of experts who have developed the
national guidelines for diagnosis and treatment of
hypertension. It is based on research on hyperten-
sion from the world, not just the United States. The
JNC VI emphasizes prevention and also the abso-
lute risks and benefits of treatment (and types of
treatment), as well as definitive treatment. The JNC
VI is part of the National Heart, Lung and Blood
Institute of the National Institutes of Health. These
guidelines are considered the standard of care lbr
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