What is the most likely contributor to postoperative hypertension in this patient?

From the Guidelines

The most likely contributor to postoperative hypertension in this patient is pain, as inadequate pain control is a common cause of elevated blood pressure following surgery, triggering a sympathetic nervous system response, leading to increased heart rate and vasoconstriction, as noted in the 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM guideline for perioperative cardiovascular management for noncardiac surgery 1.

Potential Contributors to Postoperative Hypertension

• Pain: Inadequate pain control can lead to a sympathetic nervous system response, increasing heart rate and vasoconstriction, thus elevating blood pressure.
• Anxiety: Can also contribute to increased sympathetic activity, leading to hypertension.
• Urinary retention: Although the patient's indwelling urinary catheter was removed, this could still be a factor if the patient is experiencing discomfort or difficulty urinating.
• Hypoxemia, hypercarbia, and fluid overload: These conditions can also contribute to postoperative hypertension and should be assessed and addressed.

Management Approach

Management should focus on optimizing pain control with appropriate analgesics such as acetaminophen, NSAIDs if not contraindicated, or opioids as needed, as well as ensuring the patient's preoperative antihypertensive medications are continued appropriately during the perioperative period to avoid rebound hypertension, as recommended by the 2019 Perioperative Quality Initiative consensus statement on postoperative blood pressure, risk, and outcomes for elective surgery 1.

Key Considerations

• The patient's blood pressure has been significantly elevated since surgery, ranging from 175/95 to 205/115 mm Hg, indicating a need for prompt assessment and management of potential contributing factors.
• The patient reports low back and right knee pain rated as 8 of 10, suggesting that pain is a significant issue that needs to be addressed to manage the hypertension effectively.
• Ensuring adequate pain control and reviewing the patient's current medication regimen, including the potential restart of held antihypertensive medications like lisinopril-hydrochlorothiazide, are crucial steps in managing postoperative hypertension, as highlighted by the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APHA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1.

From the FDA Drug Label

The provided drug labels do not directly address the question of what is contributing most to the patient's postoperative hypertension.

The FDA drug label does not answer the question.

From the Research

Postoperative Hypertension Causes

The patient's postoperative hypertension can be attributed to several factors, including:

• Holding chronic anti-hypertensive medication: The patient's lisinopril-hydrochlorothiazide was held since the day of surgery, which may have contributed to the elevated blood pressure 2, 3.
• Ileus: Although the patient's abdomen is soft and non-tender, decreased bowel sounds are noted, which could be a sign of ileus. However, there is no direct evidence to suggest that ileus is a significant contributor to postoperative hypertension in this case.
• Pain: The patient reports low back and right knee pain, which he rates as 8 out of 10. Pain is a well-known cause of postoperative hypertension, as it can lead to sympathetic activation and increased blood pressure 2, 3, 4.
• Urinary retention: The patient's indwelling urinary catheter was removed two hours ago, and there is no indication of urinary retention at present.

Most Likely Contributor

Based on the available evidence, the most likely contributor to the patient's postoperative hypertension is:

• Pain: The patient's significant pain levels, as evidenced by his report of 8 out of 10 pain, are likely contributing to his elevated blood pressure. Studies have shown that pain can lead to sympathetic activation, which can increase blood pressure 2, 3, 4. Additionally, the patient has received multiple doses of pain medication, including intravenous morphine and oxycodone, which suggests that his pain is not well-controlled. Effective pain management may be necessary to control the patient's blood pressure 5.