From the Guidelines
The most appropriate next step in the preoperative management of this patient's acute hypertension is option D: Initiation of antihypertensives is not indicated. This patient presents with elevated blood pressure (168/94 mm Hg) in the setting of acute trauma with multiple fractures requiring surgery. While the patient has a history of hypertension treated with enalapril, which he hasn't taken for 2-3 months, this current elevation is likely a physiologic response to pain and stress from his injuries. Treating this reactive hypertension preoperatively is not necessary and could potentially lead to hypotension during surgery when anesthesia is administered. The blood pressure of 168/94 mm Hg, while elevated, does not represent a hypertensive emergency requiring immediate intervention, as defined by the ESC Council on Hypertension position document on the management of hypertensive emergencies 1. There are no signs of end-organ damage such as papilledema, hematuria, or ECG changes indicating myocardial ischemia.
The appropriate approach is to proceed with surgical management of the fractures, which will address the pain and stress contributing to the blood pressure elevation. Anesthesia during surgery will also help control the blood pressure. After recovery from surgery, the patient's chronic hypertension can be reassessed and his enalapril therapy resumed as appropriate. According to the guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery, there is no clear evidence favouring one mode of antihypertensive therapy over another in patients undergoing non-cardiac surgery, and patients with arterial hypertension should be managed according to existing ESC Guidelines 1. Additionally, the KDOQI US commentary on the 2017 ACC/AHA hypertension guideline suggests that in patients with hypertension undergoing major surgery, discontinuation of ACE inhibitors or ARBs perioperatively may be considered 1.
In this case, given the patient's blood pressure is not at a level that represents a hypertensive emergency and there are no signs of end-organ damage, proceeding with surgical management without initiating antihypertensives preoperatively is the most appropriate course of action, as it prioritizes the management of the patient's immediate need for surgical repair of his fractures while minimizing the risk of potential complications associated with acute blood pressure management 1.
From the FDA Drug Label
Administer Nicardipine Hydrochloride by slow continuous infusion by a central line or through a large peripheral vein. Titration For a gradual reduction in blood pressure, initiate therapy at a rate of 5 mg/hr. If desired blood pressure reduction is not achieved at this dose, increase the infusion rate by 2. 5 mg/hr every 15 minutes up to a maximum of 15 mg/hr, until desired blood pressure reduction is achieved.
The most appropriate next step in the preoperative management of this patient's acute hypertension is Intravenous nicardipine.
- The patient has acute hypertension with a blood pressure of 168/94 mm Hg and requires immediate surgical repair.
- Intravenous nicardipine can be used to gradually reduce blood pressure, with a recommended initial infusion rate of 5 mg/hr, which can be titrated as needed to achieve the desired blood pressure reduction 2.
From the Research
Preoperative Management of Acute Hypertension
The patient's elevated blood pressure requires immediate attention before surgery. The following options are considered for preoperative management:
- Intravenous esmolol
- Intravenous nicardipine
- Oral enalapril
- Initiation of antihypertensives is not indicated
Analysis of Options
Considering the patient's condition and the need for rapid blood pressure control, intravenous administration is preferred.
- Intravenous esmolol is a beta-blocker that can be used to control heart rate and blood pressure, but its use may not be ideal in this scenario due to the patient's left ventricular hypertrophy and potential for negative inotropic effects.
- Intravenous nicardipine is a calcium channel blocker that has been shown to be effective in controlling blood pressure in hypertensive crises, with a study indicating its efficacy in achieving a systolic blood pressure of <160 mm Hg at 2-6 hours from the start of the infusion 3.
- Oral enalapril is an ACE inhibitor that the patient has not been taking for the past two to three months, and its use may not provide the rapid blood pressure control needed in this preoperative setting.
- Initiation of antihypertensives is not indicated is not a viable option given the patient's elevated blood pressure and the need for preoperative management.
Recommended Course of Action
Based on the available evidence, intravenous nicardipine is a suitable option for the preoperative management of this patient's acute hypertension, given its efficacy in controlling blood pressure and its relatively favorable safety profile 4, 3, 5.