HIPERTENSI & PERIOPERATIVE

Klasifikasi menurut JNC 7:

-

normal
prehipertensi
hipertensi st 1
hipertensi st 2

SBP
<120

DBP
<80
120-139
140-159
160

80-89
90-99
100

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A diuretic is any drug that elevates the rate of urination and thus provides a
means of forced diuresis. There are several categories of diuretics. All diuretics
increase the excretion of water from bodies, although each class does so in a
distinct way.

Types
1. High ceiling loop diuretics
High ceiling diuretics are diuretics that may cause a substantial diuresis up to
20% of the filtered load of NaCl and water. This is huge when compared to
normal renal sodium reabsorption which leaves only ~0.4% of filtered sodium in
the urine.
Loop diuretics have this ability, and are therefore often synonymous with high
ceiling diuretics. Loop diuretics, such as furosemide, inhibit the body's ability to
reabsorb sodium at the ascending loop in the kidney which leads to a retention
of water in the urine as water normally follows sodium back into the
extracellular fluid (ECF). Other examples of high ceiling loop diuretics include
ethacrynic acid, torsemide and bumetanide.
2. Thiazides
Thiazide-type diuretics such as hydrochlorothiazide act on the distal convoluted
tubule and inhibit the Sodium-chloride symporter leading to a retention of water
in the urine, as water normally follows penetrating solutes. Frequent urination is
due to the increased loss of water that has not been retained from the body as a
result of a concomitant relationship with sodium loss from the convoluted
tubule. The short-term anti-hypertensive action is based on the fact that
thiazides decrease Preload, decreasing blood pressure. On the other hand the
long-term effect is due to an unknown vasodilator effect that decreases blood
pressure by decreasing resistance.
3. Potassium-sparing diuretics
These are diuretics which do not promote the secretion of potassium into the
urine; thus, potassium is spared and not lost as much as in other diuretics. The
term "potassium-sparing" refers to an effect rather than a mechanism or
location; nonetheless, the term almost always refers to two specific classes that
have their effect at similar locations:

Aldosterone antagonists: Spironolactone, which is a competitive

antagonist of aldosterone. Aldosterone normally adds sodium channels in
the principal cells of the collecting duct and late distal tubule of the
nephron. Spironolactone prevents aldosterone from entering the principal
cells, preventing sodium reabsorption. A similar agent is potassium
canreonate.

Epithelial sodium channel blockers: amiloride and triamterene.

2

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4. Calcium-sparing diuretics
The term "calcium-sparing diuretic" is sometimes used to identify agents that
result in a relatively low rate of excretion of calcium.
The reduced concentration of calcium in the urine can lead to an increased rate
of calcium in serum. The sparing effect on calcium can be beneficial in
hypocalcemia, or unwanted in hypercalcemia.
The thiazides and potassium-sparing diuretics are considered to be calciumsparing diuretics.

The thiazides cause a net decrease in calcium lost in urine.

The potassium-sparing diuretics cause a net increase in calcium lost in

urine, but the increase is much smaller than the increase associated with
other diuretic classes.

By contrast, loop diuretics promote a significant increase calcium excretion. This

can increase risk of reduced bone density.
5. Osmotic diuretics
Compounds such as mannitol are filtered in the glomerulus, but cannot be
reabsorbed. Their presence leads to an increase in the osmolarity of the filtrate.
To maintain osmotic balance, water is retained in the urine.
Glucose, like mannitol, is a sugar that can behave as an osmotic diuretic. Unlike
mannitol, glucose is commonly found in the blood. However, in certain
conditions such as diabetes mellitus, the concentration of glucose in the blood
(hyperglycemia) exceeds the maximum reabsorption capacity of the kidney.
When this happens, glucose remains in the filtrate, leading to the osmotic
retention of water in the urine. Glucosuria causes a loss of hypotonic water and
Na+ leading to a hypertonic state with signs of volume depletion such as: dry
mucosa, hypotension, tachycardia, and decreased turgor of the skin. Use of
some drugs, especially stimulants may also increase blood glucose and thus
increase urination.
6. Low ceiling diuretics
The term "low ceiling diuretic" is used to indicate that a diuretic has a rapidly
flattening dose effect curve (in contrast to "high ceiling", where the relationship
is close to linear). It refers to a pharmacological profile, not a chemical structure.
However, there are certain classes of diuretic which usually fall into this
category, such as the thiazides.

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Mechanism of action
Classification of common diuretics and their mechanisms of action:
Examples

Mechanism

Acidifying salts
Arginine vasopressin
receptor 2 antagonists
Aquaretics
Na-H
exchanger antagonists
Carbonic anhydrase in
hibitors

Ethanol, Water
CaCl2, NH4Cl
amphotericin B, lithium
citrate
Goldenrod, Juniper
dopamine[8]

inhibits vasopressin secretion

acetazolamide[8],
dorzolamide

Loop diuretics

bumetanide[8],
ethacrynic acid[8],
furosemide[8], torsemide
glucose (especially in
uncontrolled diabetes),
mannitol

inhibit H+ secretion, resultant

promotion of Na+ and K+
excretion
inhibit the Na-K-2Cl symporter

Osmotic diuretics

Potassium-sparing
diuretics

amiloride,
spironolactone,
triamterene, potassium
canrenoate.

Thiazides

bendroflumethiazide,
hydrochlorothiazide

Xanthines

caffeine, theophylline,
theobromine

inhibit vasopressin's action

Increases blood flow in kidneys
promote Na+ excretion

promote osmotic diuresis

inhibition of Na+/K+ exchanger:

Spironolactone inhibits
aldosterone action, Amiloride
inhibits epithelial sodium
channels[8]
inhibit reabsorption by Na+/Clsymporter
inhibit reabsorption of Na+,
increase glomerular filtration
rate

Location
(numbered in
distance
along
nephron)
1.
1.
5. collecting
duct
1.
2. proximal
tubule[8]
2: proximal
tubule
3. medullary
thick ascending
limb
2. proximal
tubule,
descending
limb
5. cortical
collecting ducts

4. distal
convoluted
tubules
1. tubules

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Chemically, diuretics are a diverse group of compounds that either stimulate or

inhibit various hormones that naturally occur in the body to regulate urine
production by the kidneys. Herbal medications are not inherently diuretics. They
are more correctly called aquaretics.
Adverse effects
The main adverse effects of diuretics are hypovolemia, hypokalemia,
hyperkalemia, hyponatremia, metabolic alkalosis, metabolic acidosis and
hyperuricemia. Each are at risk of certain types of diuretics and present with
different symptoms.

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Namo Siddham

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Namo Siddham

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Namo Siddham

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Namo Siddham

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Namo Siddham

10

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Drug
Betablockers

Day Before
Surgery
Usual dose

Calcium
channel
blockers

Usual dose

ACE
inhibitors

Usual dose

Diuretics

Stop day
before

Potassium
supplements

Stop day
before;
consider
checking

11

Day of
Surgery
Usual dose on
morning of
surgery with
sip of water
Usual dose on
morning of
surgery with
sip of water
Usual dose on
morning of
surgery with
sip of water

During Surgery

After Procedure

IV bolus or
infusion
(usually not
required)
IV bolus or
infusion
(usually not
required)
IV formulations
(usually not
required)

Continue IV dose
until medication
can be taken PO

IV betablockers/IV
calcium
channel
blockers

Restart when
patient on oral
liquids

Continue IV dose
until medication
can be taken PO
Continue IV dose
until medication
can be taken PO

Restart when
patient on oral
liquids

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Centralacting
sympatholyti
cs
Peripheral
sympatholyti
cs

potassium
level
Usual dose

Usual dose

Alphablockers

Usual dose

Vasodilators

Usual dose

12

Usual dose on
morning of
surgery with
sip of water
Usual dose on
morning of
surgery with
sip of water
Usual dose on
morning of
surgery with
sip of water
Usual dose on
morning of
surgery with
sip of water

Transdermal
clonidine/IV
methyldopa

Restart when
patient on orals
liquids

Any IV
formulation
(usually not
required)
Any IV
formulation
(usually not
required)
IV formulation
(usually not
required)

Restart when
patient on oral
liquids
Restart when
patient on oral
liquids
Continue IV
dose until
medication can
betaken PO

Dr. Ni Putu Wardani Residen Anestesiologi Reanimasi| Om Awighnam Astu

Namo Siddham