CONTROLLED HYPOTENSIVE

ANAESTHESIA

…what is safe ?

Dr Hussain Almejadi
AL RAZI Hospital
• Definition.
• History and evolution.
• Physiology.
• Blood pressure goal.
• Contraindications.
• Techniques.
• Anaesthetic management.
• Our experience in Al RAZI hospital.
• why should we be bothered with
hypotensive anaesthesia ?
– Decrease blood loss.
– Improve operative field.
– Decrease duration of surgery.
Decrease in blood loss by 55 % and
shorten the operating time by one
hour .

. Sum DC, Chung PC, Chen WC: Deliberate hypotensive anesthesia with
labetalol in reconstructive surgery for
scoliosis. Acta Anaesthesiol Sin 1996 Dec;34(4):203-207
Significant less blood loss and
improving of the surgical field.

Precious DS, Splinter W, Bosco D: Induced hypotensive anesthesia for

adolescent orthognathic surgery
J Oral Maxillofac Surg 1996 Jun;54(6):680-683
Intraoperative blood loss is 40% less.

Nelson CL, Fontenot HJ: Ten strategies to reduce blood loss in

orthopedic surgery Am J Surg 1995, N°6A (Suppl.), 170:64-68
 Deliberate hypotension in orthopedic surgery
reduces blood loss, a meta analysis of RCT.

CANADAIN JOURNAL OF ANESTHESIA 2007

McMaster ,Hamilton,Ontario.

17 ARTICLES.

CONCLUSION : Deliberate hypotension does

reduce blood loss.
Definition

• It is a State of induced hypotension during

anaesthesia to reduce bleeding and
improve the surgical field adjusted to the
patient’s age ,pre-operative blood
pressure and past medical history.
Definition
• Effect VS Safety .
• Reduction in systolic blood pressure to
80 -90 mmHg.
• Decrease in MAP to 50-60 mmHg in
normotensive patients.
• Reduction in MAP by 30% of the baseline
values.
History
• 1917 Harvey Cushing for neurosurgery.
• 1943 Kolhstaedt and Page on dogs arterial bleeding.
• 1946 Gardner arteriotomy.
• 1948 High spinal.
• 1951 High epidural.
• 1951 Enderby ganlion blockade .
• 1960 Murtagh halothane.
• 1962 Moraca sodium nitroprusside.
• 1967 Dimant pacemaker.
• 1978 Fahmy nitroglycerin.
• 1981 Zimpfer verapamil.
• 1982 Fukunaga adenosine .
 Physiology

• Cerebral circulation.
• Coronary circulation.
• Renal circulation.
Cerebral Autoregulation
Cerebral Circulation

• PaCO2 .
• PaO2.
• Temperature.
• Volatile agents.
• Vasodilators.
Coronary Circulation

• Dependent on aortic diastolic blood

pressure.
• Myocardium extracts most of the oxygen
delivered.
• Circulation is autoregulated .
Renal Circulation

• Autoregulation over the range 80-180

mmHg ( Miles and Venton 1954 )
• MAP less than 75 mmHg leads to decrease
in GFR ( Larson et al, 1974 )
• Opioids and inhalational agents stimulate
ADH release (Stunn 1974 )
Respiratory System

• Increase in blood flow to the dependent

areas.
• Vasodilators inhibits hypoxic pulmonary
vasoconstriction.
• PaCO2 and EtCO2 gradient increase.
Blood Pressure Goal

• Reduce blood loss.

• Improve the surgical field .
Contraindications

• Anaethetist factors.
• Patients factors.
Anaesthetist factors

• Lack of understanding of the technique.

• Lack of technical experience.
• Inability to monitor the patient adequately.
Patient factors
• Cardiac disease .
• Diabetes .
• Anemia.
• Hepatic disease.
• Ischaemic cerebrovascular disease.
• Renal disease.
• Respiratory insufficiency.
• Severe systemic hypertension.
• Intolerance to drugs used for hypotensive
anaesthesia.
Absolute contraindications

• Known drug allergy.

• Inability to monitor the patient adequately.
• Unfamiliarity with the technique.
Morbidity and Mortality

1954 little et al
– mortality 1 in 291
– morbidity 1 in 31.
– Systolic pressure below 80 mmHg.

2008 karol et al Anaesthes and Anlgesia.

– NO DIFFERENCE.
Techniques

MAP = CO x SYSTEMIC VASCULAR

RESISTANCE
Decrease cardiac output

• Reduce blood volume.

• Dilate capacitance vessels.
• Decrease cardiac contractility .
• Decrease of heart rate.
Peripheral vascular resistance

• Blockade of alpha adrenergic receptors.

• Blockade of autonomic ganglion.
• Ralaxation of vascular smooth muscle.
Mechanical manoeuvers

• Positioning .
• Positive airway pressure.
• Spinal anesthesia.
• Epidural anesthesia.
Pharmacologic technique
• Ideal agent
- Ease of administration
- Predictable & dose-dependent effect
- Rapid onset/offset
- Quick elimination without the
production of toxic metabolites
- Minimal effects on blood flow to vital
organs
Inhalational anesthetics
negative inotropic effect
vasodilation

Advantage Disadvantage
• Provides surgical • Decreases CO
anesthesia
• Rapid onset/offset
• Cerebral vasodilation
• Easy to titrate
• Cerebral protection
Sodium nitroprusside
Direct vasodilator (nitric oxide release)
Advantage Disadvantage
• Rapid onset/offset • Cyanide/thiocyanate
• East to titrate toxicity
• Increases CO • Increased ICP
• Increased pulm. shunt
• Sympathetic stimulation
• Rebound hypertension
• Coronary steal
• Tachycardia
Nitroglycerin
Direct vasodilator (nitric oxide release)
Advantage
• Rapid onset/offset
• East to titrate
• Limited increase in
heart rate
• No coronary steal
Disadvantage
• Lack of efficacy-
depending on
anesthetic technique
• Increased ICP
• Increased pulm. shunt
• Methemoglobinemia
• Inhibition of plt.
aggregation
Beta adrenergic antagonist
Beta adrenergic blockade (decreased myocardial
contractility)

Advantage Disadvantage

• Rapid onset/offset • Decreased CO

• Decreased myocardial • Heart block
O2 consumption • Bronchospasm
• No increase in ICP • Limited efficacy
• No increase in pulm. when used alone
shunt
Calcium channel blocker
- vasodilation

Advantage Disadvantage

• Rapid onset • Prolonged duration of

• Limited increase in HR action
• Increase CO • Increased ICP
• No effect on airway • Increased pulm. shunt
reactivity
• Increased GFR/urine
output
Remifentanil

• Remifentanil is an OPIOID
• Pure m agonist
– little binding at k, s, and d receptors
 Rapid onset/offset
 Decreases blood pressure & heart rate
 No need for additional use of a potent
hypotensive or adjunct agents
Remifentanil Key Concepts
• Remifentanil is an ESTER
. Metabolized by nonspecific esterases in blood
and tissue
• Anesthesia maintained with high-dose
remifentanil will be associated with rapid
recovery.
 Within 5-10 minutes of turning off an infusion there is
virtually no residual remifentanil drug effect
Dosing and Administration
• Dex. should be administered using a controlled
infusion device.
• Dex. dosing should be individualized and titrated
to the desired clinical effect
• For adult patients Dex. is generally initiated with
a infusion of 1mcg/kg over 10 minutes, followed
by a maintenance infusion of 0.2 to 0.7
mcg/kg/hr
• It is not necessary to discontinue Dex. prior to
extubation
• Comparison between dexmedetomidine and remifentanil
for controlled hypotension during tympanoplasty.

• CONCLUSIONS: Infusion of dexmedetomidine, at the

doses used in this study, was less effective than
remifentanil in achieving controlled hypotension, good
surgical field exposure condition and surgeons'
satisfaction during tympanoplasty.

2008-05, Eur J Anaesthesiol., 25(5):369-74. Epub 2008 Feb 25.

Preoperative management

• Thorough knowledge by the anaesthetist.

• Proper patient evaluation and selection.
• HB of 10 g/dl.
• Arterial blood gas analysis sampling.
• Good level of anxiolytics ,analgesics .
• Vagolytic drugs should be avoided.
Intraoperative management

• Stress free induction.

• Nasal intubation ?.
• Enough peripheral venous access.
• Pressure points.
Monitoring

• Invasive blood pressure .

• Invasive blood pressure.
• ECG V5 lead with ST segment analysis.
• Central venous pressure.
• Urine output.
• Temperature.
• Blood loss.
Fluid therapy

• Deficit replacement.
• Maintenance.
• Blood loss.
• Induced hypotension should start at the
time of mucosal incision .
• Only to the level needed to reduce
bleeding.
• Only during specific surgical phase.
Postoperative management

• Rebound hypertension.
• Reactionary hemorrhage.
Our experience in AL RAZI hospital

• Strong points.
• Area of improvement.
Strong points

• One OT is allocated for hypotensive

anaesthesia/TIVA.
• Propofol – remifentenyl.
• Invasive monitoring is a must.
Area of improvement

• Patients selection.
• Reduction in blood transfusion.
Future studies

• Prospective.
• Control of age and physical status.
• Bigger sample size.
• Type of surgery.
• Controlled studies.
• Same technique.
• Doppler technique.
THANK YOU
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