Hypertension PDF

Hypertension By: Lamees Fathi Shams algozlan Mosa Maha Abdulgader Ragd Abuaraki Anfal Esam Contents:  definition and normal level  stages  causes and symptoms  treatments and management  antihypertensive drugs  history and reoperation  intraopretion  post operation  co...

Hypertension By: Lamees Fathi Shams algozlan Mosa Maha Abdulgader Ragd Abuaraki Anfal Esam Contents:  definition and normal level  stages  causes and symptoms  treatments and management  antihypertensive drugs  history and reoperation  intraopretion  post operation  conclusion and cases DEFINITION: Hypertension ( HTN or HT ), also known as high blood pressure ( HBP ), is a long term medical condition in which the blood pressure in the arteries is persistently elevated. The SBP will be more than or equal of 140 mmHg and DBP will be more than or equal of 90 mmHg ETIOLOGY  Primary HTN : it is the elevation in BP without an identified cause  Secondary HTN : it is the elevation in BP with an exact cause. This type is account for 5-10 % of total cases. PATHOPHYSIOLOGY: The normal blood pressure is maintained by four mechanisms 1- Sympathetic nervous system activities 2- Activities of vascular endothelium 3- Activities of renal system 4- Activities of endocrine system Primary hypertension doesn’t have a single, clear cause. Usually, many factors come together to cause it. Common causes include:- 1- Unhealthy eating patterns (including a diet high in sodium). 2- Lack of physical activity. 3- High consumption of alcohol. Common causes of secondary hypertension include: 1- Certain medications, including (immunosuppressants, NSAIDs ) 2-.Kidney disease. 3- Obstructive sleep apnea. 4- Renal vascular diseases. 5- Tobacco use (including smoking, vaping and using smokeless tobacco).Most people with hypertension don't feel any symptoms. Very high blood pressures Symptoms can be: 1- Severe headaches. 2- chest pain 3- Dizziness. 4- difficulty breathing 5- Nausea and vomiting. 6- Vision changes. 7- Anxiety. 8- Confusion. 9- Nosebleeds. 10- Abnormal heart rhythm. Treatment and management of hypertension: Simple lifestyle changes can help reduce high blood pressure, although some people may need to take medicine as well. Lifestyle changes can help lower high blood pressure. These include: 1- Eating a heart-healthy diet with less salt 2- Getting regular physical activity 3- Maintaining a healthy weight or losing weight 4- Limiting alcohol 5- Not smoking 6- Getting 7 to 9 hours of sleep daily Sometimes lifestyle changes aren't enough to treat high blood pressure. If they don't help, your provider may recommend medicine to lower your blood pressure. The type of medicine used to treat hypertension depends on your overall health and how high your blood pressure is. Two or more blood pressure drugs often work better than one. It can take some time to find the medicine or combination of medicines that works best for you. To decide if you need medicine, we supposed look at your: blood pressure readings risk of developing problems such as heart attacks or strokes. There are five main classes of medication that are usually in the first line of treatment for hypertension:  Angiotensin-converting enzyme inhibitors keep your blood vessels from narrowing as much.  Angiotensin II receptor blockers also keep blood vessels from narrowing  Calcium channel blockers prevent calcium from entering the muscle cells of your heart and blood vessels. This allows blood vessels to relax.  Diuretics : (including potassium-sparing, loop, thiazide and thiazide-type diuretics) They help your blood vessels get wider and make your kidneys move extra fluid and salt into your pee.  Direct vasodilators They make your blood vessels more open.  Preoperative hypertension : _Assessment of the hypertensive : surgical patient should include blood pressure measurements taken using the correct technique. Preoperative blood pressures of less than 180/100 mmHg are not grounds for deferring surgery in the absence of active comorbid disease. Preoperative investigations : of patients with diagnosed hypertension or raised blood pressure should be aimed at identifying and assessing these conditions. Recommended investigations include serum electrolytes, creatinine, estimated glomerular filtration rate, cholesterol, a 12- lead electrocardiogram and urinalysis. *Severe HT ≥180/110 mmHg can increase the risk of surgery. Therefore, sufficient BP control prior to the surgery is recommended. In general, oral hypertensive medication should be continued before and after surgery. In particular, sympathetic blockers, such as beta-blockers, must be continued. * Statin and aspirin medications are often prescribed for patients with hypertension. It is recommended to continue intake of statins in the perioperative period. Aspirins are recommended for low-risk patients undergoing noncardiac surgery. Intraoperative hypotension (IOH) : i.e., low arterial blood pressure (AP) during surgery is common in patients having non-cardiac surgery under general anaesthesia. It has a multifactorial aetiology, and is associated with major postoperative complications including acute kidney injury, myocardial injury and death. Therefore, IOH may be a modifiable risk factor for postoperative complications. However, there is no uniform definition for IOH. is not a distinct disease entity that only occurs during surgery. About one third of perioperative hypotensive episodes occur in the period after the induction of general anaesthesia but before surgical incision and can be described as postinduction or pre-incision hypotension.Several Risk factors for IOH : have been identified, such as  older age  male sex  lower pre-induction SAP  general anaesthesia with propofol, Postoperative care:- Patients must be followed up after anaesthesia to ensure post operative complications are minimised and treated appropriately if they occur. It is important to ensure patients continue their antihypertentsives after surgery and alternative routes of administration are considered for those patients who are nil by mouth. Patients with severe hypertension must be closely monitored and ward and anaesthetic staff alerted if management becomes difficult or is uncontrolled. High risk patients should also be given supplementary oxygen to prevent hypoxia and therefore reduce ischaemic episodes after anaesthesia. The continuation of prevention of hypertensive triggers on the ward must also be highlighted. CONCLUSION:- It is known that hypertension patients may develop hypertensive crisis during anesthesia, hypotension attacks may be observed, and end-organ damage that may have developed in the preoperative period may increase mortality and morbidity in the peroperative process. For this reason, it is necessary to evaluate the patients, to determine their comorbidities, and to evaluate the drugs they use. Although there is still debate about whether the antihypertensives used by the patients preoperatively should be discontinued in the pre-anesthesia period or when the last dose will be given, it is not recommended to discontinue longterm antihypertensives in recent studies. In conclusion, preoperative diagnosis of hypertensive patients and detailed preoperative evaluation of diagnosed patients are very important in terms of preventing complications that may develop peroperative and postoperatively. SUMMARY:- 1- Defection. 2- Etiology and Pathophysiology  PB regulation by autonomic nervous system 3- Stages 4- Causes 5- Signs and Symptoms 6- Treatments and Management 7- Antihypertensive drugs:-  elderly pt => thiazides  younger pt=> ACE inhibitors   drugs avoid in first line => Beta blockers because can precipitate lethargy, nausea and general malaise  ACE inhibitors=> can cause 100% hypertension (txt= iv cystalloid or phenylephrine- ephedrine) 8- peri operation care of hypertensive pt:- a,preoperation :-  pre medication  assessment and investigation b, interoperation:-  induction=> sedation=> iv 1-3 mg midazolam with short acting opioid fentanyl ( drugs must avoided in induction is Ketamine= increase HR and PB)  management:-opioid analgesics=> nitrous oxide  recovery:- monitoring=> ecg- bp c, postoperation  assessment of pain because pain increase PB=> opioid SELF ASSESSMENT: Complete the following questions before reading this tutorial. 1-A 65yr old man is listed for a total knee replacement. During your assessment for anaesthesia you notice his pre-assessment blood pressure is 190/100. What is your management?  Answer:-This patient initially needs standard anaesthetic assessment before anaesthesia. History of hypertension, is he on any antihypertensive drugs? Is the reading a one off value? Is there evidence of end organ damage? He needs repeat measurements in a relaxed environment and an ECG. Routine bloods should be checked. If after assessment, the hypertension is new and persists at this level, postponement of surgery and commencement of a thiazide diuretic prior to rescheduling and GP liaison would be the most sensible management of this elective case. 2-Which drugs are commonly used to treat hypertension both in the long term and acute situation? Answer:- for long term(Thiazide diuretics, ACE inhibitors, calcium channels blockers, Beta blockers) For acut(Beta blockers ,Calcium channel blockers, Alpha 2 blockers, Vasodilators) 3- You are called to recovery to review a 77yr old patient with a blood pressure of 210/110 after a laparoscopic cholecystectomy. What is your management? Answer:-This patient is severely hypertensive postoperatively. The causes of this may be multiple. Exclude pain, urinary retention, hypoxia, anxiety.Repeat blood pressure measurements regularly in addition to other routine monitoring. If hypertension persists, consider labetalol 5mg/ml and titrate to normotension for the patient concerned. 4-What are the complications of long standing hypertension? Answer:- end organ damage and peri operation complications. thanks