Immediate approach

1. Confirm the BP
   • Repeat manually with correct cuff size after 5 minutes of rest.
   • Record trend, heart rate, oxygen saturation, respiratory rate, temperature, urine output, pain score, and mental status.
2. Look for and correct common reversible causes
   • Pain or agitation: give prescribed titrated analgesia, while monitoring for opioid-related hypoventilation.
   • Hypoxia or hypercapnia: check airway, SpO₂, respiratory effort, ABG/VBG if indicated; give oxygen and treat respiratory compromise.
   • Bladder distension/urinary retention: check catheter patency, bladder scan, catheterize if ordered.
   • Fluid overload: review IV fluids, input-output balance, lung examination, edema, and signs of heart failure.
   • Shivering, nausea/vomiting, anxiety, missed usual antihypertensive medication, or withdrawal from clonidine/beta-blocker.
   Postoperative guidance specifically recommends excluding or treating pain, agitation, hypercarbia, hypoxia, hypervolemia, and bladder distension, and reviewing the patient’s home antihypertensives. The Washington Manual of Medical Therapeutics, p. 34.
3. Assess for bleeding and other postoperative complications
   • Check wound/drains, NG output if present, abdominal distension, hemoglobin if clinically indicated, and hemodynamic trend.
   • Hypertension can increase risk of bleeding, myocardial ischemia, and heart failure, particularly if associated with tachycardia.

When to urgently escalate

• Persistent SBP ≥180 mmHg or DBP ≥110 mmHg, especially on repeated readings
• Chest pain, dyspnea, hypoxia, pulmonary edema, new arrhythmia
• Severe headache, confusion, seizure, focal neurologic deficit, visual symptoms
• Oliguria/acute kidney injury, ischemic ECG changes, or rapidly rising BP
• Suspected anastomotic/surgical bleeding or major fluid overload

Medication

• If BP remains markedly elevated after treating reversible causes, use titrated IV therapy only under the treating anesthetic/medical team’s prescription and monitoring.
• Common agent choices depend on heart rate, ischemia, bronchospasm, heart failure, renal status, and local protocol. Options may include titratable labetalol, esmolol, nicardipine, or hydralazine.
• Avoid blindly restarting oral drugs while the patient is NPO or has unreliable absorption after gastric surgery. Reconcile and restart appropriate chronic antihypertensives when clinically safe and permitted by the surgical team.
• Avoid rapid overcorrection. A reasonable perioperative goal is often within about 20% of the patient’s usual baseline BP, unless there is a specific emergency requiring another target. Barash, Cullen, and Stoelting’s Clinical Anesthesia, p. 3421.

Practical bedside advice