MANAGEMENT TREE  h  ANESTHESIA  h  PEER REVIEWED

ANESTHETIC HYPOTENSION
Maria Angeles Jimenez Lozano, DVM, CertVA, DECVAA, MRCVS
North Downs Specialist Referrals
Bletchingley, United Kingdom

ANESTHETIC HYPOTENSION
(MABP ≤60 mm Hg)

DIAGNOSIS
Low SVR (ie, too much vasodilation)

DIFFERENTIAL DIFFERENTIAL
Sympathetic blockade Vasodilation from drug (eg, acepromazine,
(epidural/spinal anesthetics) propofol, alfaxalone, inhalant)

TREATMENT TREATMENT
Reduce inhalants1-5; use Reduce anesthetic doses, balance
vasopressors to treat vasodilation, anesthetic technique
fluids for relative hypovolemia
correction

DIFFERENTIAL
Patient-related conditions (eg, sepsis,
SIRS, toxins, histamine release)

TREATMENT
Use vasopressors to treat vasodilation, fluids to treat
relative hypovolemia correction, antihistaminics or steroids
to treat histamine release

CO = cardiac output
HR = heart rate PERTINENT CALCULATIONS
MABP = mean arterial blood pressure
h Blood pressure = CO × SVR
SIRS = systemic inflammatory response syndrome
SV = stroke volume h CO = SV × HR
SVR = systemic vascular resistance

Continues on page 28

March 2017  [Link]  27

MANAGEMENT TREE  h  ANESTHESIA  h  PEER REVIEWED

ANESTHETIC HYPOTENSION DIAGNOSIS

(MABP ≤60 mm Hg) Low cardiac output

DIAGNOSIS DIAGNOSIS DIAGNOSIS

Low contractility High afterload Low preload (low venous return,
low-end diastolic volume)

DIFFERENTIAL TREATMENT
Anesthetic drugs, 6-8 inhalants, Reduce vasopressors
injectables (eg, halothane, thiopental, and α-2 agents
α-2 agonists, propofol, ketamine in
catecholamine-depleted patients)

TREATMENT TREATMENT
Use positive inotropes (eg, Avoid strong cardiovascular
ephedrine, dobutamine, suppressant drugs, reduce anesthetic
dopamine, epinephrine) doses, balance anesthetic technique

DIFFERENTIAL DIFFERENTIAL DIFFERENTIAL

Increased intrathoracic Low circulatory volume, relative Patient-related conditions (aorta
pressure, IPPV, pneumothorax, hypovolemia with vasodilation, absolute caval compression)
intrathoracic mass hypovolemia with dehydration, GI losses,
crystalloid and/or blood loss

DIFFERENTIAL
INVESTIGATION Dorsal recumbency for obese/
Spontaneous breathing, low-tidal TREATMENT pregnant/ascitic/abdominal
volume IPPV, permissive Vasopressors (eg, phenylephrine, mass patients; iatrogenic,
hypercapnia,* no PEEP vasopressin, norepinephrine) to treat surgical manipulation
vasodilation; crystalloids, colloids,
blood products

TREATMENT TREATMENT
Thoracocentesis if fluid Tilt operation table, treat mass/
present, remove mass pressure, add bolus of
crystalloids

AV = atrioventricular
*Permissive hypercapnia is a
BOAS = brachycephalic obstructive airway syndrome
ventilation strategy in which
MABP = mean arterial blood pressure oxygenation is prioritized over
expired carbon dioxide. Higher than
IPPV = intermittent positive pressure ventilation normal carbon dioxide levels are
PEEP = positive end-expiratory pressure allowed because of low ventilation
that preserves the lungs.

28    [Link]    March 2017

 DIAGNOSIS
Inadequate heart rate and rhythm

DIAGNOSIS DIAGNOSIS DIAGNOSIS

Bradycardia Tachycardia Arrhythmias

INVESTIGATION INVESTIGATION
Inadequate ventricular filling if No synchrony on atrial or
heart rate too high ventricular contraction

DIFFERENTIAL DIFFERENTIAL DIFFERENTIAL

Anesthetic drugs (eg, Patient-related condition (eg, AV blocks, atrial
ketamine, alfaxalone, hypovolemia, hyperthermia, fibrillation, ventricular
sympathomimetic drugs) hypoxemia, hypercapnia, pain, arrhythmias
cardiac disease)

TREATMENT TREATMENT TREATMENT

Stop/decrease Replace volume, cool patient, administer IPPV Treat arrhythmia
drugs, avoid use and 100% oxygen analgesia; if all are normal
but cardiac disease, use antiarrhythmics

DIFFERENTIAL DIFFERENTIAL DIFFERENTIAL

Increased vagal tone (GI stimulation, Anesthetic drugs (propofol, 6,8,9 Patient-related condition
cervical surgeries, respiratory disease, opioids, α-2 agonists) (hypothermia, hyperkalemia
IPPV, oculocardiac reflex, breed end-stage metabolic disease, cardiac
predisposition [BOAS]) disease, extreme hypoxemia)

TREATMENT TREATMENT TREATMENT

Stop vagal stimulus; use Avoid strong cardiovascular suppressant Warm patient, treat
anticholinergics (eg, atropine, drugs, lower doses, or reverse drugs; use hyperkalemia, use
glycopyrrolate) anticholinergics (eg, atropine, anticholinergics,
glycopyrrolate) or sympathomimetics if improve oxygenation
anticholinergics ineffective

See page 116 for references.

March 2017    [Link]    29

MANAGEMENT TREE  h  CONTINUED FROM PAGE 29

References
1. Mutoh T, Nishimura R, Kim H, Matsunaga S, Sasaki N. 6. Short CE, Bufalari A. Propofol anaesthesia. Vet Clin North Am Small
Cardiopulmonary effects of sevoflurane, compared with halothane, Anim Pract. 1999;29(3):747-778.
enflurane and isoflurane, in dogs. Am J Vet Res. 1997;58(8):885. 7. Patrick MR, Blair IJ, Feneck RO, Sebel PS. A comparison of the
2. Hikasa Y, Ohe N, Takase K, Ogasawara S. Cardiopulmonary effects of haemodynamic effects of propofol (‘Diprivan’) and thiopentone in
sevoflurane in cats: comparison with isoflurane, halothane, and patients with coronary artery disease. Postgrad Med J. 1985;61(Suppl
enflurane. Res Vet Sci. 1997;63(3):205. 3):23-27.
3. Hikasa Y, Kanwanabe H, Takase K, Ogasawara S. Comparison of 8. Mulier JP, Wouters PF, Van Aken H, Vermaut G, Vandermeersch E.
sevoflurane, isoflurane, and halothane anesthesia in spontaneously Cardiodynamic effects of propofol in comparison with thiopental:
breathing cats. Vet Surg. 1996;25(3):234-243. assessment with a transesophageal echocardiographic approach.
4. Ebert TJ, Harkin CP, Muzi M. Cardiovascular responses to Anaesth Analg. 1991;72(1):28-35.
sevoflurane: a review. Anaesth Analg. 1995;81(6 Suppl):S11-S22. 9. Ebert TJ, Muzi M, Berens R, Goff D, Kamppine JP. Sympathetic
5. Eger EI 2nd. The pharmacology of isoflurane. Br J Anaesth. 1984;56 responses to induction of anesthesia in humans with propofol or
(Suppl 1):71S-99S. etomidate. Anesthesiology. 1992;76(5):725-733.

Suggested Reading
Seymour C, Duke-Novakovski T, eds. BSAVA Manual of Canine and Feline Tranquilli WJ, Thurmon JC, Grimm KA, eds. Lumb and Jones’ Veterinary
Anaesthesia and Analgesia. 2nd ed. Gloucester, England: British Anesthesia and Analgesia. 4th ed. Ames, IA: Lippincott Williams and
Small Animal Veterinary Association; 2007. Wilkins; August 21, 2007.

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