Arterial Hypertension Before

Elective Surgery
GL731

Approval

Approval Group Job Title, Chair of Committee Date

Anaesthetics Clinical Chair of Anaesthetics Clinical Governance July 2016
Governance

Change History

Version Date Author, job title Reason

Version 1.0 July 2016 Simon Tunstill, Consultant New Guideline
Anaesthetist

Author: Simon Tunstill Date: July 2016

Job Title: Consultant Anaesthetist Review Date: July 2018
Policy Lead: Planned Care Group Director Version: Version 1
Location: Corporate Governance Shared Drive – Gl1022
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MANAGEMENT OF ARTERIAL HYPERTENSION BEFORE

ELECTIVE SURGERY

CONTENTS:
1. Purpose
2. Introduction
3. Scope
4. Primary care
5. Preoperative assessment clinic
6. Method for measuring blood pressure in preoperative assessment clinic
7. Hypertension on the day of surgery
8. References
9. Appendices

1. PURPOSE
The purpose of this guideline is to advise on the management of the hypertensive
patient in the preoperative assessment clinic. It is based on national guidance from
the Association of Anaesthetists of Great Britain and Ireland (AAGBI) and British
Hypertension Society 1. Further details of the evidence behind these
recommendations and guidelines for the chronic management of hypertension can be
found in that document.

2. INTRODUCTION
Hypertension has been described by the National Institute of Clinical Excellence
(NICE) as ‘one of the most important preventable causes of premature morbidity and
mortality in the UK’2. The majority of cases of hypertension are primary, are usually
asymptomatic, and are diagnosed and managed in primary care. There remains a
paucity of evidence for optimal management of hypertension in the perioperative
period and, until recently, national guidance was lacking. Management of
hypertension in the preoperative period involves balancing the risks of anaesthesia
and surgery against the risks and psychological/social/financial implications to the
patient of delaying surgical treatment.

3. SCOPE
These guidelines cover management of adult patients presenting for non-cardiac
elective surgery. The guidelines do not apply to obstetric patients.

Patients requiring emergency or urgent surgery by definition have no or very limited

time for investigation, treatment or postponement. Such surgery must almost always
proceed, but all those involved, including the patient, must be aware of any associated
increased risk. Please discuss these patients with the anaesthetist.
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4. PRIMARY CARE (SEE FLOW CHART A)

General Practitioners (GPs) should refer patients for elective surgery with mean blood
pressures recorded in primary care in the past 12 months of <160/100mmHg. This
information should be provided at the time of referral. (Investigations and treatment
should continue in primary care to achieve blood pressure measurements of
<140/90mmHg as per NICE guidelines2)

Patients with blood pressures 160/100mmHg or above in Primary Care should be

assessed with ambulatory or home blood pressure monitoring and treated if necessary
to reduce blood pressure to <160/100mmHg prior to referral for elective surgery.

Patients may be referred for elective surgery if they remain hypertensive despite
optimal antihypertensive treatment or if they decline antihypertensive treatment.
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Flow chart A (taken from AAGBI/BHS guidelines 1) – Primary care blood pressure
assessment of patients before referral for elective surgery. *Investigations and
treatment should continue to achieve blood pressures < 140/90mmHg. ABPM and
HBPM, ambulatory and home blood pressure measurement; DBP and SBP, diastolic
and systolic pressure.
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5. PREOPERATIVE ASSESSMENT CLINIC (SEE FLOW CHART B)

If the blood pressure is documented as less than 160/100mmHg in primary care within
the previous 12 months, blood pressure need not be measured in preoperative
assessment clinic and the patient should proceed to surgery.

If a blood pressure measurement within the past 12 months is not included in the GP
referral letter or summary, it should be requested from the GP.

If the blood pressure has not been measured in the past 12 months, it should be
measured in preoperative assessment clinic (see section 6 – method for measuring
blood pressure).

 Elective surgery should proceed if this measurement is less than

180/110mmHg.

 The GP should be informed if this reading is >140/90mmHg for ongoing

investigation and treatment if necessary (letter template Appendix A).

 If the preoperative assessment clinic BP measurement is 180/110mmHg

or above, the patient (assuming elective surgery) should be referred back
to the GP for investigation and treatment prior to elective surgery (letter
template - Appendix B).
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Flow Chart B (taken from AAGBI/BHS guidelines 1) Secondary care blood pressure
assessment of patients after referral for elective surgery. * The GP should be
informed of blood pressure readings in excess of 140mmHg systolic or 90mmHg
diastolic so that the diagnosis of hypertension can be refuted or confirmed and
investigated and treated as necessary. DBP and SBP, diastolic and systolic blood
pressure.
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6. METHOD FOR MEASURING BLOOD PRESSURE IN THE

PREOPERATIVE ASSESSMENT CLINIC1

Blood pressure should be measured by current calibrated equipment.

The patient should be seated and arm outstretched for at least one minute before the
initial reading.

The pulse rate and rhythm should be recorded before measurement. Automated
sphygmomanometers are inaccurate when the pulse is irregular, so blood pressure
should be measured manually.

If the first measurement is equal or higher than 140/90mmHg, the blood pressure
should be measured twice more, with each reading at least one minute apart. The
lower of these readings should be recorded as the blood pressure.

7. HYPERTENSION ON THE DAY OF SURGERY

National guidelines do not include advice concerning management of patients who

have blood pressures of >180/110mmHg when admitted on the day of surgery, when
their blood pressure had been previously ‘acceptable’. This omission is due to both a
paucity of evidence in this area, and the need for an individualised plan for each
patient depending on various factors including the degree of hypertension, age,
comorbidities, functional capacity, urgency of surgery and type of surgery. In such
cases anxiolytic medication may be of benefit in reducing blood pressure. The
decision as to whether or not to proceed with surgery will need to be taken, with these
factors in mind, by the perioperative team on the day.

This also applies to patients undergoing ophthalmic surgery under local anaesthesia.
The 2012 joint guidelines from the Royal College of Anaesthetists
and the Royal College of Ophthalmologists ‘Local anaesthesia for ophthalmic
surgery’4 states that “uncontrolled hypertension may increase the risks of systemic and
ophthalmic complications. However there is insufficient evidence to support a
specific value above which surgery should be deferred”. A suggested perioperative
blood pressure limit of 200/100mmHg has been agreed locally for ophthalmic
procedures. Patients with pre-existing ‘acceptable’ control, who then have a recorded
blood pressure >200/100mmHg on the day of surgery should managed in the first
instance with appropriate anxiolysis.
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8. REFERENCES

1. Hartle A et al. The measure measurement of adult blood pressure and management
of hypertension before elective surgery. Anaesthesia 2016; 7:326-337

2. National Institute for Health and Care Excellence. Hypertension: Clinical

management of primary hypertension in adults. 2011 NICE Clinical Guideline
CG127. http://www.nice.org.uk/guidance/cg127

3. ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and

management Eur Heart J (2014) 35 , 2383–243

4. Local anaesthesia for ophthalmic surgery. Joint guidelines from the Royal
College of Anaesthetists and the Royal College of Ophthalmologists. February
2012. www.rcoa.ac.uk/document.../local-anaesthesia-ophthalmic-surgery
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9. APPENDICIES

Appendix A

Letter to GP from pre-assessment clinic for patients requiring further

management of raised blood pressure (between 140/90 and 180/110 mmHg) for
whom surgery will continue.

Dear Doctor………..

Mr./Mrs. ……….’s blood pressure was measured in the preoperative assessment

clinic today in anticipation of their scheduled ……………. . It was ………..(between
140/90 and 180/110mmHg).

This blood pressure is acceptable for surgery to proceed, but we have asked the
patient to make an appointment with you for further measurements and
investigation/treatment if required.

Many thanks for your help.

Yours sincerely
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Appendix B

Letter to general practitioner from pre-assessment clinic following measurement

of raised blood pressure in patients who have not had readings taken in primary
care in the preceding 12 months.

Dear Doctor………..

Unfortunately, the procedure for Mr./Ms. …………………. has been postponed

because their blood pressure was found to be …………. in their pre-operative
assessment.

It was measured several times following the AAGBI/BHS guidelines. The guidelines
suggest a blood pressure level higher than 180/110 is unsuitable for elective
anaesthesia.

We have asked the patient to make an appointment at their surgery for further
assessment of their blood pressure. We would be grateful if you could verify that this
is the true blood pressure level and not a white coat effect and treat appropriately if
the patient has hypertension.

We will be pleased to accept the patient back for surgery if their clinic blood pressure
is below 160/100. Please ask the patient to contact on 0118 3226545 and inform us of
their current blood pressure and what medication, if any, was required to achieve this.

Many thanks in anticipation of your help with this matter

Yours sincerely