Postoperative Hypertension Management

Pathophysiology

Postoperative hypertension is characterized by sympathetic stimulation resulting in catecholamine release, vasoconstriction, tachycardia, and impaired baroreceptor sensitivity, according to the British Journal of Anaesthesia 1
Abnormal increases in circulating plasma levels of norepinephrine and epinephrine occur in response to surgical stress, as reported by the British Journal of Anaesthesia 2
Loss of the arterial baroreflex is manifest by both low and high extreme swings in blood pressure during the perioperative period, as noted by the British Journal of Anaesthesia 2, 3
Anaesthetic agents impair baroreflex sensitivity, removing a key defense mechanism that helps ensure integrative blood pressure control, according to the British Journal of Anaesthesia 2, 4

Postoperative hypertension is defined as "a significant elevation in blood pressure" with most episodes occurring in the first 20 minutes of the postoperative period, as defined by the British Journal of Anaesthesia 1
The accepted threshold for intervention is systolic pressure >180 mmHg and diastolic pressure >110 mmHg, which has been validated in numerous acute care situations and is predictive of end-organ dysfunction, as reported by the British Journal of Anaesthesia 1
Untreated postoperative hypertension increases the risk of myocardial ischemia, myocardial injury, myocardial infarction, arrhythmia, pulmonary edema, stroke, and surgical-site bleeding, according to the British Journal of Anaesthesia 1

Evaluate volume status, pain control, and urinary retention as these are common reversible causes of hypertension in postoperative patients, as recommended by the American College of Cardiology, based on guidelines from Praxis Medical Insights 8
Resume or initiate oral antihypertensive medications immediately, as delayed resumption of ACE inhibitors/ARBs is associated with increased 30-day mortality, according to the American Heart Association, based on guidelines from Praxis Medical Insights 8
Aim for blood pressure <130/80 mmHg for general hypertension management, or approximately 10% above baseline if baseline is known, as recommended by the American College of Cardiology, based on guidelines from Praxis Medical Insights 8

Patients demonstrate a more labile hemodynamic profile perioperatively, with airway instrumentation leading to pronounced increases in sympathetic activation, as reported by Anaesthesia 5, 6, 7
Both adrenergic and vagal dysfunction promote higher blood pressure, with aberrant autonomic regulation preceding the development of altered blood pressure, according to the British Journal of Anaesthesia 2, 4