Hypertension and issues with podiatric surgery under LA

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I have been looking at some of the issues around hypertension, and possible issues with foot surgery under LA.

I have worked in a number of UK NHS trusts over the last number of years,within these departments there is very often a ceiling figure for blood pressure above which a surgery would be cancelled or deferred. Over the years this theshold has changed a little, but seems to be slightly variable between organisations.

Having looked at some of the research available currently NICE has provided some guidelines regarding the medical management of hypertension generally. However I am not currently able to see much information relating to issues around hypertension in relation to foot surgery under LA. specifically regarding possible adverse events/sequelae and whether or not surgery should be cancelled in some cases

In the past I have come across patients who present on the day of surgery with a blood pressure in excess of the the normal range used by the particular department, rightly or wrongly these patients may have had their surgery cancelled on the day and referred back to their family physician for review. What I am currently struggling with, is whether these patients would be adversely affected by continuing with their surgery is their blood pressure was relatively elevated and whether there is any decent evidence to support or refute this

As podiatrists we are not in the business of medically managing hypertension, but in a fair proportion of cases I have seen where patients are referred back to their physician for investigation/treatment of hypertension, there is some degree if mild surprise that the patient had surgery cancelled for this reason alone.

Needless to say, pre operatively patients may be screened and referred accordingly based on findings

Would any one care to share with me their own guidelines on this area?

 

Hello Simon

This is a question that I have found almost impossible to find an answer to but I'll try and explain what we used to do and what we are doing now given the advice we received from our anaesthetic lead.

Up until 1st April of this year my service existed in a PCT and was based at a peripheral hospital. A blue light transfer could take up to 10 minutes to arrive after dialling 999 and a further 10 minutes to get them transferred. Hardly an ideal situation!! My predecessor had a protocol written which stated the cut off limit was170/100. Certainly a diastolic of 100 or more was a cause for concern.

However, April 1st saw my service integrate with a Teaching Hospital and I saught clarification on this issue as we were now working to different protocols and had had a change of service location. Hey presto - open that can of worms.

I have, in my discussions, had the following bits if advice.

At my hospital, preassessmenrs are done for GA or Spinal Anaesthesia. Peripheral nerve block surgery does not appear on their radar. (I can testify to this following a cervical block for an ulnar nerve decompression.)

With regard to the BP issues diastolic is the key issue anything over 100 will try to be managed before the day of operation. Systolic they are not too concerned with.

On day of the surgery the anaesthetist has the final say BUT what has become apparent is the ability to reasses the patient in front of you and look at them wholistically.

They gave a couple of examples ....

A 25 year old active individual with no comorbidities with and a BP of 170/101 on day of surgery. On preassessment he is normotensive. Are you sending him home? No. Under the old protocol probably yes. From a clinical standpoint he poses a low risk of a cardiovascular incident.

The 45 year old football fan who holds a season ticket. No comorbidities. On admission he's normotensive but has a HR of 115. Would he be cancelled. Under the new process a big no as all things considered his HR probably goes higher than this during a 90 minute match.

All told I'm now of the opinion it's what is in front of you rather than a sheet of paper witha list of numbers. I guess at the end of the day it's all about assessing clinical risk.

I'd be happy to discuss over phone if you would like. PM me for my number.

PG

 

I go along with PG here. I used the day theatre at a general hospital and the protocol was a diastolic of 100 or less. A problem occurred with two patients who were sent home with readings in excess of this and a request was sent to the GP to review and medicate accordingly. In later conversations with the GPs both patients had collapsed with hypotension. Following these incidents, I put such patients at the end of the lists and had the ward nurses chat to them. In the vast majority of cases this worked well which shows i) the value of team working and ii) that the elevated BP was almost certainly due to 'white coat' hypertension. I agree that you treat the patient and not a set of figures and that it's 'horses for courses'. It's also good to have an anaesthetist available from time to time.

All the best

Bill