Not reviewed. This deck cannot be opened, downloaded or sent
until you approve it. Read every point and its source first — they were drafted
from search results, not from clinical judgement.
Start with the patient rather than the pressure, because a noxious stimulus alone will do this: in unpremedicated control patients, laryngoscopy and intubation raised mean arterial pressure by an average of 39 mmHg and heart rate by about 20 beats per minute.
Look at the capnograph and the saturation before you look at the drug drawer, because both derangements raise blood pressure through the sympathetic nervous system - allowing arterial carbon dioxide to reach 56 to 65 mmHg under anaesthesia raised systolic pressure, heart rate and cardiac output with a two- to threefold rise in plasma catecholamines, and hypoxia is a recognised driver of sympathoexcitation in its own right.
A full bladder deserves a place on the list rather than a joke, because in a patient with a high spinal cord injury bladder distension is the classic trigger for autonomic dysreflexia and suprapubic pressure alone has been documented driving systolic pressure to 230 mmHg in a woman whose resting pressure was 100/64.
Phaeochromocytoma is the rare cause worth naming out loud, because in an unprepared patient the catecholamine surge provoked by induction or by the surgeon's hand on the tumour produces cardiovascular complications that are life-threatening rather than merely inconvenient.
Labetalol given as 5 mg intravenous increments lowered systolic and diastolic pressure within ten minutes and held the effect for at least two hours with only a moderate fall in heart rate, whereas esmolol in the same elderly patients produced bradycardia severe enough that the infusion had to be stopped in two of them - so labetalol is the easier choice when the pressure is high and the heart rate is not.
Hydralazine 10 mg intravenously matched incremental labetalol for lowering mean arterial pressure in a randomised trial of severe hypertension in pregnancy, but hypertensive-crisis reviews still place nicardipine, labetalol and esmolol ahead of both hydralazine and nitroglycerine, because the agents you want in an operating room are the short-acting titratable ones you can stop when the stimulus stops.
Before you give anything: what are the three things on this monitor that could be causing this number?
How would you tell light anaesthesia from inadequate analgesia here, and would your treatment differ?
Why might I be reluctant to give hydralazine to this patient in the middle of a case?
The pressure comes down and then, ten minutes later, it is 200 systolic again with a temperature of 38.4 - what has changed in your differential?