PERIOPERATIVE HYPERTENSION The Role of DA-1 Agonists (Fenoldopam) R. Sheinbaum M.D. O. Wenker M.D.
-
Upload
laurence-briggs -
Category
Documents
-
view
217 -
download
2
Transcript of PERIOPERATIVE HYPERTENSION The Role of DA-1 Agonists (Fenoldopam) R. Sheinbaum M.D. O. Wenker M.D.
PERIOPERATIVE PERIOPERATIVE HYPERTENSIONHYPERTENSION
The Role of The Role of
DA-1 Agonists DA-1 Agonists (Fenoldopam)(Fenoldopam)
R. Sheinbaum M.D.
O. Wenker M.D.
Perioperative HTNPerioperative HTNIncidenceIncidence
DefinitionDefinitionWide range of definitionsWide range of definitions
systolic systolic >110-170>110-170
diastolicdiastolic 95-100-10795-100-107
% change in BP% change in BP
– Leslie JB Acta Anaesthesiol Scand 1993; 37: 5-9
Perioperative HTNPerioperative HTNIncidenceIncidence
Patient FactorsPatient Factors• underlying risk factorsunderlying risk factors• increasing age base of populationincreasing age base of population• higher risk procedureshigher risk procedures
Type of SurgeryType of Surgery• cardiac cardiac 40-60 %40-60 %• non cardiacnon cardiac 5 % 5 %
– Estafanos FG Am Heart J 1973 ; 85 : 732-738
– Viljoen JF J Thorac Cardiovasc Surg 1976 ; 71 : 548
– Leslie JB Acta Anaesthesiol Scand 1993 ; 37 : 5-9
Perioperative HTNPerioperative HTNEtiologyEtiology
Primary HTNPrimary HTN Secondary HTNSecondary HTN Surgically Associated HTNSurgically Associated HTN Anesthesia Related HTNAnesthesia Related HTN OtherOther
Perioperative HTNPerioperative HTNSignificanceSignificance
Organ DamageOrgan Damage• heartheart
• brainbrain
• kidneykidney
Surgical ConsiderationsSurgical Considerations MorbidityMorbidity
HypertensionHypertensionTreatmentTreatment
BP = Q x SVRBP = Q x SVRQ = HR x SV
SV preload, contractility, afterload
SVR viscosity, vessel radius
Blood PressureBlood Pressure
Sympathetic Nervous System Sympathetic Nervous System Regulation of Blood PressureRegulation of Blood Pressure
Adrenergic Adrenergic ToneToneBaroreceptor Baroreceptor
ReflexesReflexes
Volume/Volume/PressurePressure
Renin/AngiotensinRenin/Angiotensin
PreloadPreload
Cardiac OutputCardiac Output
CatecholaminesCatecholamines
Adrenal Adrenal GlandGland
CNSCNS
VeinsVeins ArteriesArteries
CapacitanceCapacitance ResistanceResistance
HeartHeartKidneyKidney
AfterloadAfterload
Anti HTN AgentsAnti HTN AgentsFENOLDOPAMFENOLDOPAM
Ideal CharacteristicsIdeal Characteristics– effectiveeffective– predictable onsetpredictable onset– easily titratableeasily titratable– few side effectsfew side effects– metabolically inertmetabolically inert
Comparison to NitroprussideComparison to Nitroprusside• just as effective in just as effective in reaching target BPreaching target BP
• just as quick in reaching just as quick in reaching target BPtarget BP
• Panacek EA Acad Emerg Med 1995 ; 2 : 959-965
Anti HTN AgentsAnti HTN AgentsFENOLDOPAMFENOLDOPAM
Fenoldopam Fenoldopam versus versus
NitroprussideNitroprusside BenefitsBenefits
• HeartHeart• > EF, CI> EF, CI• < PCWP, PVR< PCWP, PVR• minimal change in HR (dose related)minimal change in HR (dose related)
• RenalRenal• > renal blood flow, Na excretion> renal blood flow, Na excretion• > Cr Cl> Cr Cl
• Elliot WJ Circulation 1990 ; 81 : 970-977• Shusterman NH Am J Med 1993 ; 96 : 161-168• Hill AJ J Cardiothorac Vasc Anesth 1993 ; 7 : 279-284
Comparison of Renal Effects Comparison of Renal Effects in Severe Hypertensionin Severe Hypertension
140
Fenoldopam
Nitroprusside
Cha
nge
from
Bas
elin
e (%
)
0
20
40
60
80
100
120
-10
Urinary Flow Rate Sodium Excretion Creatinine Clearance
Elliott WJ, et al. Circulation 1990;81:970-977
CONTROLCONTROL
CORLOPAMCORLOPAMAdvantagesAdvantages
ControlControl EffectivenessEffectiveness End Organ BenefitsEnd Organ Benefits Unique ActionUnique Action Potential Renal BenefitsPotential Renal Benefits
Perioperative HTNPerioperative HTNSummarySummary
IncidenceIncidence End Organ EffectsEnd Organ Effects Impact on Morbidity/ MortalityImpact on Morbidity/ Mortality Treatment ImpactTreatment Impact Treatment OptionsTreatment Options