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Postoperative hypertension, though transient, requires immediate attention. Clinical variables include the patient's preoperative blood pressure, medications, and acute medical status; the surgical procedure performed; and the physiologic changes induced by surgery. Evaluate and treat any reversible causes of hypertension. Initiate drug therapy when organ failure or dysfunction is present or when the patient is at high risk for such complications. In choosing an agent, look for ease of administration, titratability of blood pressure response, rapid onset and cessation of action, and a low incidence of adverse effects. Options are nitrovasodilators, calcium channel blockers, ACE inhibitors, direct-acting vasodilators, adrenergic blockers, and neuromodulators (narcotics and anesthetics).

Objectives: To estimate the incidence of silent myocardial ischemia, its pattern over time and its relationship to the time and mode of weaning high-risk cardiac patients after noncardiac surgery., Design: Prospective study with random assignment to one of three weaning modes., Setting: A surgical intensive care unit in a university hospital and a Veterans Administration hospital., Patients: Sixty-two patients meeting standard criteria for extubation were randomized to one of three modes of weaning: synchronized intermittent mandatory ventilation (n = 19), T-Bar (n = 21) or continuous positive airway pressure (n = 22)., Methods: Ischemia was monitored with a continuous two-lead (V5, III) ST segment analyzer. Tracings were reviewed by a cardiologist. Ischemia was defined as greater than 1 mm ST segment depression 60 milliseconds after the J point. The monitoring period included a prewean (mean 654.0 minutes), wean (mean 46.5 minutes) and postwean (mean 1223.4 minutes) period., Results: Of 62 patients, 12 (19.3%) experienced ischemia at some time during the monitoring period, most often during the weaning period. Ischemia during weaning was detected in 3 of 21 (14.3%) T-Bar patients and 2 of 22 (9.1%) continuous positive airway pressure patients but in no synchronized intermittent mandatory ventilation patients., Conclusion: This study demonstrates that silent myocardial ischemia occurs frequently in high-risk postoperative patients, with the highest incidence during weaning.

Objective: To determine if postoperative diagnostic abdominal paracentesis is a useful clinical tool in the abdominal evaluation of the critically ill septic patient., Design: Retrospective review., Setting: Surgical ICU patients in a Veterans Administration medical center., Patients: Ten patients were studied from a total of 1,053 patients admitted to the surgical ICU between September 1985 and May 1989., Interventions: Diagnostic abdominal paracentesis performed by the open or closed approaches., Measurements and Main Results: Results are presented in three patient groups (A, B, and C): Group A (n = 4) had positive diagnostic abdominal paracentesis. Abdominal causes for the sepsis were found at reexploration. One of these four patients survived. Group B (n = 3) had negative diagnostic abdominal paracentesis. No abdominal septic source was found at reexploration; all three patients died. In group C (n = 3), diagnostic abdominal paracentesis was negative, patients were not reexplored, and all survived. Diagnostic accuracy correlated with three variables: a) the gross appearance and smell of the fluid, b) WBC count greater than 5000 or less than 500/mm3, and c) Gram stain demonstrating bacterial organisms., Conclusions: Diagnostic abdominal paracentesis proved accurate, reliable, simple, safe, and rapid in evaluating the abdomen in the postoperative septic patient. The use of this procedure should be considered in postoperative septic patients in whom an abdominal source for the sepsis needs to be excluded.

Nicardipine hydrochloride, a new calcium channel blocker for intravenous use, has been compared with placebo in a prospective, randomized, double-blind trial on postoperative hypertension. Of 175 patients who signed preoperative consent, 24 (13.7%) met entry criteria. Hypertension was significantly better controlled in nicardipine-treated patients compared with those receiving placebo (93% versus 30%, p less than 0.05). All the placebo failures were subsequently successfully treated with nicardipine. There were no significant complications in either group. The authors conclude that nicardipine HC1 is an effective, safe therapy for postoperative hypertension. Further studies are now indicated comparing it with other drugs currently used to treat this condition.

The therapy of postoperative hypertension (POH) after head and neck surgery was evaluated in a prospective, randomized, double-blind trial. Nicardipine hydrochloride, a Ca channel-blocker for iv use, was compared with placebo. Patients were initially randomized to receive nicardipine infusion or placebo. Those not responding to placebo were given nicardipine infusion on an open basis. Hypertension was significantly better controlled in patients treated with nicardipine infusion compared with placebo (83% vs. 22%, p less than .002). Subsequently, six (86%) of seven of the placebo failures were successfully treated with nicardipine. There were no significant complications in either group. We conclude that the titratable infusion of nicardipine is an effective and safe method for the control of POH after surgery of the head and neck. Further studies are now warranted comparing nicardipine with other drugs currently used to treat this condition.

This retrospective review of 37 cases of abdominoperineal resection for adenocarcinoma sought to correlate preoperative clinical characteristics and intraoperative events with the likelihood of subsequent development of specific complications in the postoperative period. Mortality was 3% (1/37), and the complication rate was 76% (28/37), with urologic (49% [18/37]) and pulmonary (30% [11/37]) complications being the most common. Significant perioperative risk factors included a history of cardiac disease, current cardiac medications, diabetes mellitus, an abnormal preoperative electrocardiogram, and extended operation. Factors not associated with an increased risk included age, sex, a history of pulmonary disorders, previous abdominal operations, operative time, and need for transfusions, management of the pelvic peritoneum, or perineal drainage. Such information should reliably identify high-risk patients and therefore should be useful for selecting such patients for palliative or other limited techniques of tumor control.