Intraoperative Hypertension - Guidelines for Crises in Anaesthesia

Hypertension is most commonly due to inappropriate depth of anaesthesia or inadequate analgesia.

You should rapidly exclude a problem in adequate oxygen delivery, airway and breathing first.



❶ Immediate actions

  • Recheck blood pressure AND increase anaesthesia AND reduce stimulus.

❷ Adequate oxygen delivery

  • Check fresh gas flow for circuit in use AND check measured FiO2.

  • Visual inspection of entire breathing system including valves and connections.

  • Rapidly confirm reservoir bag moving OR ventilator bellows moving.

❸ Airway

  • Check position of airway device and listen for noise (including larynx and stomach).

  • Check capnogram shape compatible with patent airway.

  • Confirm airway device is patent (consider passing suction catheter).

❹ Breathing - exclude hypoxia and hypercarbia as causes:

  • Check chest symmetry, rate, breath sounds, SpO2, measured VTexp, ETCO2.

  • Feel the airway pressure using reservoir bag and APL valve <3 breaths.

❺ Circulation

  • Check rate, rhythm, perfusion; increase frequency of BP check.

  • Check cuff size and location, consider intra-arterial monitoring.

❻ Depth

  • Ensure adequate depth of anaesthesia and analgesia.

❼ Consider underlying problem (Box B).

❽ Call for help and consider temporising drug (Box C) if problem not resolving.



POTENTIAL UNDERLYING PROBLEMS

• Inadequate anaesthesia / analgesia (alfentanil can be diagnostic – see Box C for dose)

• Inadequate neuromuscular blockade

• Consider whether you could have made a drug error

• Omission of usual antihypertensives

• Distended bladder

• Vasopressor administered by surgeon

• Surgical tourniquet

• Excess fluid (over-administration / overload / TURP syndrome)

• Medical causes: drug interaction, renal failure, raised intracranial pressure, seizure, thyrotoxicosis, phaeochromocytoma



By Association of Anaesthetists @ https://twitter.com/AAGBI

Quick Reference Handbook - Guidelines for crises in anaesthesia 



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