From the Guidelines
For a patient with elevated blood pressure of 168/94 without papilledema requiring emergency surgery, proceed with the operation without delay while implementing perioperative blood pressure management. According to the latest guidelines from the Association of Anaesthetists of Great Britain and Ireland and the British Hypertension Society 1, there is no clear evidence that patients with stage 1 or 2 hypertension without evidence of target organ damage have increased peri-operative cardiovascular risk. The patient's blood pressure reading of 168/94 falls into stage 2 hypertension, and the absence of papilledema indicates no immediate end-organ damage.
Perioperative Management
To manage the patient's blood pressure during surgery, the following steps can be taken:
- Administer intravenous labetalol (10-20 mg) or hydralazine (5-10 mg) to achieve a modest reduction in blood pressure, aiming for no more than a 20-25% decrease initially 1.
- Continue monitoring blood pressure throughout the perioperative period, with additional doses as needed.
- Avoid aggressive blood pressure reduction as this could compromise organ perfusion.
- During surgery, maintain hemodynamic stability with careful anesthetic management, potentially using short-acting agents like esmolol (50-200 mcg/kg/min) for acute elevations.
Postoperative Management
Postoperatively, the following steps can be taken:
- Transition to oral antihypertensives when feasible.
- Arrange follow-up for long-term blood pressure management. This approach balances the urgency of emergency surgery with the risks of uncontrolled hypertension, which include increased bleeding, myocardial ischemia, and stroke. The European Heart Journal guidelines also support the continuation of antihypertensive therapy up to the morning of surgery and restarting promptly in the post-operative period 1.
From the FDA Drug Label
Inclusion in ESCAPE-1 required a systolic pressure ≥160 mmHg Cleviprex was infused in ESCAPE-1 preoperatively for 30 minutes, until treatment failure, or until induction of anesthesia, whichever came first. The maximum infusion rate of 16 mg/hour was used in order to achieve the desired blood pressure-lowering effect.
The patient's blood pressure reading is 168/94 mmHg, which is above the inclusion criterion for ESCAPE-1 (systolic pressure ≥160 mmHg). Preoperative recommendations for this patient would be to consider using clevidipine (Cleviprex) infusion, starting at a dose of 1-2 mg/hour and titrating upwards as tolerated, to achieve the desired blood pressure-lowering effect, with a maximum infusion rate of 16 mg/hour. However, the specific target blood pressure range for this patient is not directly stated in the label, and the decision to use clevidipine should be made on a case-by-case basis, considering the patient's individual needs and medical history 2.