Understanding How do you manage hypertension during surgery?

October 11, 2025 •

3 min read

According to a 2017 review, hypertension independently increases the risk of cardiovascular complications by 35% in people undergoing surgery. The careful management of this condition is crucial for patient safety during the perioperative period, which is why understanding how do you manage hypertension during surgery is so important.

Quick Summary

Managing high blood pressure during surgical procedures involves distinct strategies for the pre-, intra-, and post-operative periods. Anesthesiologists employ fast-acting intravenous medications to stabilize blood pressure, carefully adjust chronic drug regimens, and use continuous monitoring to prevent cardiovascular complications. The approach is tailored to each patient's needs and underlying health status.

Key Points

Preoperative Preparation: Continue most antihypertensive drugs, but withhold ACE inhibitors and ARBs 24 hours before non-cardiac surgery to prevent hypotension.
Intraoperative Control: Anesthesiologists use short-acting, titratable intravenous medications like esmolol and nicardipine to manage blood pressure fluctuations.
Intensive Monitoring: Continuous intraoperative arterial pressure monitoring is recommended for high-risk patients to rapidly detect and treat blood pressure changes.
Avoiding Abrupt Cessation: Abruptly stopping medications like beta-blockers or clonidine can cause severe rebound hypertension and cardiovascular events.
Postoperative Monitoring: Hypertension is common post-surgery due to pain and fluid shifts; IV agents can be used until oral medication is resumed.
Risk Thresholds: Elective surgery may be postponed if blood pressure is severely uncontrolled (>180/110 mmHg) to reduce the risk of major complications.
Patient-Specific Targets: Optimal blood pressure targets are individualized, especially for patients with chronic hypertension, who may have altered organ autoregulation.

The Importance of Perioperative Blood Pressure Control

High blood pressure is a significant risk factor during surgery, capable of amplifying risks associated with other pre-existing conditions like coronary artery disease. Hemodynamic instability, which includes both hypertensive and hypotensive episodes, can lead to serious complications such as myocardial ischemia (heart attack), stroke, and kidney injury. Proper management of blood pressure (BP) throughout the surgical process—before, during, and after—is a cornerstone of safe anesthesia and surgery. The goal is to maintain mean arterial pressure (MAP) within a tight, individualized range to ensure adequate blood flow to all organs.

Preoperative Management: The Phase Before Surgery

The planning phase is critical for optimizing a patient's BP before they enter the operating room. A patient's usual BP and underlying health are key considerations. While mild-to-moderate hypertension may not require delaying surgery, severe, uncontrolled hypertension (often defined as $\geq$180/110 mmHg) may necessitate postponement until better control is achieved.

Medication Considerations

Continue most medications: Most antihypertensive medications, including beta-blockers and calcium channel blockers, are typically continued with a sip of water on the morning of surgery. {Link: PubMed Central https://pmc.ncbi.nlm.nih.gov/articles/PMC4178624/}

Intraoperative Management: Real-Time Intervention

During surgery, the anesthesiologist monitors and manages blood pressure fluctuations caused by anesthesia, surgical stimulation, pain, blood loss, or fluid shifts.

Postoperative Management: Stabilizing After Surgery

Postoperative hypertension is common and can be caused by pain, anxiety, and fluid changes.

Comparison of Common Intraoperative Antihypertensives


Medication Class	Example(s)	Mechanism of Action	Clinical Considerations	References
Beta-blockers	Esmolol, Labetalol	Decrease heart rate and contractility.	Esmolol is short-acting and titratable. Labetalol has alpha and beta-blocking effects.	,
Calcium Channel Blockers	Nicardipine, Clevidipine	Cause vasodilation.	Rapid-acting and titratable for acute BP control. {Link: PubMed Central https://pmc.ncbi.nlm.nih.gov/articles/PMC4178624/}.	,
Vasodilators	Nitroglycerin, Hydralazine	Direct vasodilation.	Nitroglycerin mainly affects veins, hydralazine affects arterioles. Hydralazine has an unpredictable response.
Alpha-2 Agonists	Clonidine	Reduce sympathetic outflow.	Useful for long-term control but can cause rebound hypertension if stopped abruptly.

Conclusion

Effective hypertension management during surgery requires collaboration between the patient, their doctor, and the anesthesia team. {Link: PubMed Central https://pmc.ncbi.nlm.nih.gov/articles/PMC4178624/}

Key Medication Classes for Perioperative Management

Preoperative adjustments: Continue most blood pressure medicines (beta-blockers, calcium channel blockers), but consider holding ACE inhibitors, ARBs, and diuretics on the morning of surgery as directed by your care team.
Intraoperative control: Anesthesiologists rely on fast-acting, titratable intravenous agents such as esmolol or nicardipine to address any spikes in blood pressure during the procedure.
Postoperative transition: Following surgery, oral medications are restarted as soon as feasible, with intravenous formulations used as needed to maintain control until then.
Avoiding rebound effects: Certain medications, like beta-blockers and clonidine, must not be stopped suddenly due to the risk of dangerous rebound hypertension.
Risk-based decisions: Surgical delays due to high BP are typically reserved for severe, uncontrolled cases ($>180/110$ mmHg) or those with evidence of end-organ damage, particularly in non-emergency situations.
Patient-Specific Targets: Optimal blood pressure targets are individualized, especially for patients with chronic hypertension, who may require higher MAP targets than normotensive individuals.
Continuous monitoring: For high-risk patients, continuous arterial line monitoring is used to provide real-time blood pressure data, enabling rapid intervention for hemodynamic shifts.

Frequently Asked Questions

You should continue taking beta-blockers, calcium channel blockers, and clonidine on the morning of surgery with a small sip of water. ACE inhibitors and ARBs are often withheld 12 to 24 hours beforehand, while diuretics may be held to prevent dehydration.

Yes, if your blood pressure is severely uncontrolled, such as systolic pressure over 180 mmHg or diastolic pressure over 110 mmHg, an elective surgery may be postponed until your blood pressure is better managed.

Anesthesiologists typically use fast-acting, short-duration intravenous medications such as esmolol, labetalol, nicardipine, or clevidipine to treat intraoperative hypertension. These drugs are easily titratable, allowing for precise control of blood pressure.

Blood pressure is continuously monitored to quickly detect any fluctuations. Anesthetic induction, surgical stimulation, blood loss, and other factors can cause sudden BP changes. Rapid detection and intervention prevent dangerous periods of hypoperfusion (low blood flow) or hypertension that can damage organs.

Postoperative hypertension is common and can be caused by pain, anxiety, or fluid shifts. The anesthesiologist or care team may administer intravenous antihypertensives until your oral medications can be resumed. Adequate pain control is also a key part of management.

Suddenly stopping certain medications, like beta-blockers or clonidine, can lead to a withdrawal syndrome characterized by a rapid and dangerous increase in blood pressure (rebound hypertension). This can cause serious cardiovascular complications.

Yes, patients with chronic hypertension may have altered autoregulation in their organs. The goal is often to maintain blood pressure within 20% of their baseline preoperative values, which may be higher than for a normotensive person, to ensure proper organ perfusion.