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What is the differential diagnosis of postoperative hypertension?
Postoperative hypertension is an extremely common finding, even in patients with no previous history of hyper-tension. The most common cause is pain. The blood pres-sure should normalize as pain is controlled with analgesics. Other common causes include: (1) a full urinary bladder, which should be suspected after any prolonged procedure or administration of large amounts of intravenous fluids in a patient without a bladder catheter, (2) respiratory dis-tress, especially when there is hypercapnia, (3) head and neck or carotid artery surgery, with carotid sinus denerva-tion, and (4) cyclosporin or tacrolimus administration in patients undergoing transplantation. Of course, a previous history of hypertension should always be taken into account, especially if the patient did not take their antihy-pertensive medication(s) on the day of surgery.
The presence of a combined bradycardia and hyperten-sion in a patient who had a craniotomy leads one to suspect a primary neurologic event causing what is known as the Cushing response or Cushing’s triad. This consists of an increase in systemic blood pressure, a reflex bradycar-dia, and bradypnea, and occurs when there is an elevation in intracranial pressure. In this situation, hypertension should not be aggressively treated because it is a comp-ensatory mechanism in an attempt to maintain cerebral perfusion pressure. Rather, measures should be taken to control intracranial pressure (head elevation, mannitol, hyperventilation, possibly cerebrospinal fluid drainage after neurosurgical consultation). Diagnostic imaging should be obtained to delineate the need for neurosurgical intervention.
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