The current paper will explore the care provided to a patient with severe hypertension at the preoperative assessment clinic to serve preparation for surgery in the private sector. The Gibbs Reflective model will be key in the analysis and evaluation of the care that the patient should receive by examining the current practice concerning the most appropriate literature. Additionally, I might recommend changes in practice if deemed necessary. Gibbs Reflective Model (Gibbs 1998) is one of the most commonly used cyclical models of reflection which focuses on the six stages of exploring an experience, that is, description, feelings, evaluation, analysis, a conclusion as well as an action plan.
Historically, the goal of preoperative assessment (POA) is to find outpatient factors that can significantly elevate the risk of having perioperative complications. It should be noted that over the years, POA has reduced the number of perioperative complications stemming from the fact that healthcare facilities are now using improved anaesthetic and surgical methods or techniques (Bossone et al., no date; Mihalj et al., 2020; Nguyen and Popovich, 2021; Wang et al., 2021). All the patients that are having an operation under both general and regional anaesthesia should have a POA. The goal of POA is to detect any medical comorbidities, thereby optimizing the patient’s physiological state to reduce the impact of surgical procedures and anaesthesia, reducing the cost of perioperative care, restoring the patient to their desired level of functions and getting the patient’s informed consent for the anaesthetic procedure (García-Miguel, Serrano-Aguilar and López-Bastida, 2003). It also ensures that there is the planning of care that is then communicated to the whole surgical team. In nutshell, POA is a proactive initiative that prevents the occurrence of complications during the perioperative period (Malley et al., 2015).
According to a review conducted by the NHS, more than 10 million people are having surgery in the UK annually, and more than a third of the hospital admissions are associated with surgical procedures (Royal College of Surgeons, 2015). The reports state that the NHS spends more than 16 billion pounds annually for conducting elective surgery. For the majority of the patients, surgery is usually a success, but there is evidence that 20% of the people have complications following their operation (Royal College of Surgeons, 2015). Therefore, this calls for well-coordinated care around the time of surgery, which entails deciding if surgery is appropriate. The UK is composed of a vast majority ageing population and a significant number of patients have chronic conditions which can increase the risk of having complications following surgery (Abbott et al., 2017). The components of perioperative care entail the whole surgical pathway, including the multidisciplinary teams working collaboratively, makings shared decisions with the patient, supporting people to be ready for surgery and evaluating the factors that can increase the risk of developing complications, employing safe and effective processes in surgery and assisting patients to recover from the operation (Ghaferi, Birkmeyer and Dimick, 2009).
Hypertension is of the common conditions that are daily diagnosed in the UK. It is defined as a condition in which BP is increased to the extent that clinical benefit is gained from lowering the BP. It should be noted that BP is continuously distributed in the population and there is no clear cut-off point to aid in differentiating between hypertensive and normotensive subjects, but there is consensus that a systolic BP of 140/90mmHg is the upper limit of “normal” (NHS, 2016). Hypertension is more common among the elderly. Even though diastolic pressure peaks at the age of 50, systolic pressure continue to increase with increasing age, and therefore, isolated systolic hypertension is most common among the elderly. According to Gill and Goldstein (2021), hypertension is associated with more cardiovascular disease (CVD) deaths as compared to any modifiable disease, as it contributes to 50% of deaths from coronary artery disease as well as stroke. Even though it can be managed easily by primary care providers such as internists, family practitioners as well as a nurse practitioners, severe HTN can cause severe surgical bleeding, myocardial ischemia and/or infarction, congestive heart failure as well as acute pulmonary oedema (Gill and Goldstein, 2020). Consequently, it is essential that anesthesiologists, nurses and all other members of the healthcare team who deal with patients in readiness for surgery, including the perioperative period, are updated and informed about the critical for patients with hypertension(Malley et al., 2015). The pre-assessment clinic is instrumental not only in identifying the patients that are at higher risk of having a hypertensive crisis but also in developing a management plan to help lower the BP.
Perioperative hypertension presents at various instances during surgery: inducing anaesthesia, intraoperatively which is linked to acute pain induced sympathetic stimulation which causes vasoconstriction and ultimately increases BP, during early post-anaesthesia which can be explained by volume overload because of excessive intraoperative intravascular volume fluid therapy (Gill and Goldstein, 2020). Hypertension associated with intraoperative volume overload can persist for 24-48 hours until fluid is mobilized from the extravascular space. It should be noted that this type of hypertension stems from the preoperative cessation of antihypertensive drugs.
However, elevated sympathetic nervous system stimulation is one of the causes of intraoperative hypertension and it is linked to tachycardia and arrhythmia. The same can be because of inadequate analgesia or anaesthesia, surgical stimulation or airway manipulation in such procedures as laryngoscopy, as well as extubating (Howell, 2018). The other factors that contribute to hypertension during surgery are related to hypoxemia, hypercapnia or related to overdose of drugs used in surgery such as vasoconstrictors (Latham and Yung, 2019a). However, all cases of hypertension must prompt rule out awareness and malignant hyperthermia as one of the causes. There is evidence that the response to sympathetic stimulation is significant as blood pressure can ride by 80mmHg and heart rate by 40 beats per minute as compared to normotensive individuals where blood pressure can rise by 20-30mmHg and the heart rate by 15-20 beats per minute (Howell, 2018). And in the present scenario, the blood pressure of the patient has already hit a hypertensive crisis.
The first assessment for any patient that is a candidate for surgery starts with a medical questionnaire which is sent to all patients as soon as the booking for the procedure is done or is provided to the patient at their first outpatient appointment. Through the document, the patient provides their demographical, medical, surgical and medication history data. In the current facility, there is a “Five days rule” which denotes that there should be a minimum of days between the out-patient consultation and the day of conducting the surgery. The rule is not strictly followed which is a major drawback in assessing the patient, even having the medical questionnaire back to decide if the patient will receive preassessment through a telephone conversation or a one-on-one preassessment or sending those patients with significant comorbidities to the anaesthetist for review. In practice, patients face a myriad of challenges when using the tool, for example, it is too long for some patients to complete it and it is written in English meaning that patients whose English is not their first language might find it challenging using it and sometimes patients are unsure when to return it to the facility. However, Mendes et al. (2013) found the questionnaire to be effective for screening the patients that require more evaluation and/or changes to their treatment plan before undergoing elective surgery. On top of that, it entails gaining information that was not covered by clinical evaluation. I have experienced many patients not completing the form fully and answering all the questions truthfully. In my first, we have simplified the tool by summarising the questions into two slides of paper that cover the most relevant clinical information such as the medical, surgical and medication history of the patient. Even then the document is not filled in. The questionnaire props information about the diagnosis of hypertension and the treatment that is required. The patients will be taken to the preoperative assessment clinic for further review. The medical questionnaire will provide a list of factors that predisposes a patient to develop hypertension.
The current clinical guidelines have it that patients that are diagnosed with hypertension should be reviewed by an anaesthetist to find out the best way possible of creating an environment for the patient to undergo their procedure (Oliveira et al., 2018; Latham and Yung, 2019b). The anaesthetist needs to assess the best possible anaesthetic agent that the patient should receive and also if they can be safely operated as a day-case or there will need for them to stay overnight as well as if they will be transferred to the high dependency unit or the intensive care unit (Oliveira et al., 2018). The need for a high dependency or intensive care unit postoperatively means that the patient will have to be transferred to the local national health service hospital as that level of care is not available at my current facility. The rationale behind requiring a higher-level facility stems from the fact that the majority of the patient hypertensive patients are sensitive to a wide range of sedative drugs including opioids. It is worth noting that not only the environment should be put into due consideration but also the type of surgery for example abdominal or thoracic surgery. Surgery that requires a prolonged period of anaesthesia increases the risk of having complications postoperatively (Nguyen and Popovich, 2021). No literature points out the number of patients that suffer post-operatively that have hypertension but they constitute a significant number of patients that are admitted to the high dependency as well as the intensive care unit. Major of the patients that have interacted with getting distressed when they are informed that their surgery should be conducted somewhere else as they have already set their minds on the current surgery and it is the leading cause of pain, anxiety and suffering. This can lead to the spiking of blood pressure to undesirable levels.
Almost 95% of the patients that present with elevated levels of BP are considered to have primary hypertension. It is essential to note that hypertension is classified into primary and secondary hypertension based on the aetiology. Primary or essential hypertension is the most common affecting more than 90-95% of hypertensive patients (NHS, 2016; Princewel et al., 2019; Gill and Goldstein, 2020). In secondary hypertension, the chronic rise in BP is due to other underlying disease states. Gender, race, age and heredity is are factors that contribute to the development of hypertension but can be modified. The UK has a huge ageing population which contributes to developing hypertension (Office for National Statistics, 2019). Other risk factors that contribute to the development of hypertension include obesity, diet, physical inactivity, stress, smoking, use of certain medications and excessive consumption of alcohol (Princewel et al., 2019). These are modifiable meaning that a patient can make adjustments to correct the raised BP. Notably, other diseases can cause hypertension such as diabetes and dyslipidaemias. The major goal of the management of hypertension is lowering the likelihood of having a cardiovascular event for individual patients as well as the general population as a whole (Alshami et al., 2018). If it is left without proper management it can lead to such complications as heart attack, stroke, cardiomegaly, and kidney damage because of the high BP.
Overwhelming evidence supports the idea that cigarette smoking predisposes a person to develop a wide range of cardiovascular events. Smoking causes a transient increase in BP and heart rate and is linked to malignant hypertension (Primatesta et al., 2001). Nicotine is an adrenergic agonist, thereby mediates local and systemic catecholamine release and also release of vasopressin (Appel, 2019). Cigarette smoking exhibits synergism with hypertension and dyslipidaemia to increase the risk of developing coronary heart disease. Patients need counselling on the risks of smoking and accorded the help they need to quit smoking (Primatesta et al., 2001). The patient needs to be advised to see their GP or should be referred to the best organization such as Livewell Dorset. The British Lung Foundation contains vital information in the form of leaflets that patients can be received.
The global prevalence of obesity and its linked comorbidities keeps on increasing at a pandemic scale. According to the World Health Organization (WHO), in the year 2016, there were more than 1.9 billion adults that were overweight and out of the same, 650 million people were obese (WHO, 2017). Additionally, 340 million children, as well as adolescents that were between 5-19 years and 24 million children under the age of 5, were estimated to struggle with overweight and obesity in 2016 (WHO 2017). A growing body of evidence indicates that obesity is one of the causative factors for the development of hypertension. The WHO defines normal weight as BMI 18.5-24.9kg/m2, overweight as BMI 25-29.9kg/m2 as well as obesity BMI more than 30kg/m2 (Princewel et al., 2019). However, BMI is not a perfect indicator of body weight as it does not show a demarcation between lean muscle and fat mass and does not provide information regarding the distribution of body fat (Shariq and Mckenzie, 2020). This is essential because evidence shows that visceral or retroperitoneal fact is more vital than peripheral or subcutaneous fact in predicting the risk of cardiometabolic outcomes linked to obesity (Shariq and Mckenzie, 2020). Consequently, alternative anthropometric measures of adiposity such as waist circumference (WC) as well as a waist-to-hip ratio are being employed. Central obesity is defined as WC of more than 102cm in males and more than 88cm in females.
The negative consequences of obesity include an elevated risk of death as a result of cardiovascular disease (CVD), type 2 diabetes mellitus, cancer and chronic kidney disease. The relationship between obesity and hypertension is well explained in children and adults and both sexes. For example, the Framingham Offspring Study findings show that 78% of the new cases of essential hypertension in men and 65% in women were linked to excess body fat (Feinleib et al., 1975). Additionally, an in weight of 5% was attributed to 20-30% increases in the number of cases of hypertension (Feinleib et al., 1975). The second Nurses’ Health Study, whereby 82,8832 adult women were prospectively followed for 14 years., BMI was concluded as the strongest risk factor for developing hypertension, whereby the obese women had five times the incidence of hypertension in sharp contrast to those with a BMI less than 23.0kg/m2 (Anonim, 2021). Based on this observation, even a modest weight reduction can lead to a decrease in BP in the patient.
Being one of the vital signs, blood pressure (BP) is supposed to be measured after every 5 minutes employing a non-invasive method more specifically in patients that are on anaesthesia and surgery. In the vast majority of the cases, BP is monitored beat by beat using an invasive transduction method. The rationale behind perioperative BP monitoring stems from the fact that: BP is extremely volatile; abnormal BP is associated with poor outcomes; BP is easily manageable using drugs; BP management using protocols improves outcomes as evidenced by randomized clinical trials (RCT) (Gill and Goldstein, 2020). It should be noted that although BP monitoring is essential in perioperative care, currently there is little consensus on the appropriate BP target for a patient that is receiving anaesthesia and surgery (Royal College of Surgeons, 2015). It should be noted that the situation is not similar to BP monitoring in chronic hypertension in primary care. The most recent and revised guidelines dictate that BP cutoffs should be 130mmhg for systolic BP and 80mmhg for diastolic BP (NICEH, 2019). Therefore, the BP target for the patient should correspond the 130/80mmhg.
The medical questionnaire will inform the clinician of any other substance of abuse that the patient is indulging themselves. For example, consumption of alcohol, as well as recreational drug use. In getting the answers to this question, the clinician should assume that the patient has been honest concerning the answers that they supply. The use of alcohol and smoking of tobacco is associated with developing hypertension. The patient needs to be informed of the dangers of abuse of the mentioned substances and a referral should be initiated either to the GP or appropriate organization for help.
Patients from the medical questionnaire that have detected risk factors for hypertension need face to face preoperative assessment carried out by a qualified practitioner. Having an elevated need for preassessment clinic appointment availability, time from appointment to operation, assessment via the telephone is always used to gain relevant information and can play a significant role in determining if the patient requires review in the clinic setting. The telephone assessment presents several challenges such as inaccessibility of patients during their work hours which has impacted work shifts as patients that work during the day can only be contacted in the evening when they are back home. The patient might not be available for telephone conversation even when at home, for example, if they are taking a meal.
The patient with hypertensive crisis needs to be reviewed at the preoperative assessment clinic by the anaesthetist. The clinical team should make sure that the patient is compliant with their current treatment regimen and also advise the patient accordingly concerning their admission, length of stay and more importantly to have their equipment with them. The anaesthetist will develop a management plan for the patient which should be communicated to the ward staff and operating theatre team.
The patient should be educated on her condition and the necessary steps she can take to take the driver’s seat in managing the condition. Lifestyle changes can be suggested at the preassessment clinic such as weight loss, smoking cessation and a significant number of organizations in the community exists that can help. The patient GP needs to be abreast of the patients’ abnormal findings to arrange further examination and treatment. In the current healthcare systems, there are standardized procedures and policies for the management of patients, and while planning to use my organization’s policy for the care of the same patient, I could not find any specific policy.
In conclusion, considering my experience and having initiated changes to practice in the unit based on my findings, I will recommend that to further improve the care of these patients a corporate policy should be devised to set standards across the organization more specifically about examination and management of conditions. This calls for staff education to understand the most common predisposing factors to hypertension and be more aware on the screening of the condition to avert any major long-term complication to our patients.
