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HYPERTENSION IN ICU Common causes include: pain agitation cold, shivering hypoxia, hypercarbia increased ICP transducer height etc. Urinary retension Positional discomfort Omission of pre_admission anti hypertensives (esp.B blockers) withdrawal Hypertension in the ICU Dr Danie Babypaul Worthing Anaesthetic Department HYPERTENSION IN ICU Underlying hypertension Essential or primary Secondary Phaechromocytoma Aortic stenosis Renal artery stenosis Cushing’s syndrome PIH Pain Adequate analgesia Opioid analgesics Simple analgesics NSAIDS Dexmeditomedine &tramadol – novel agents Local anaesthetic agents Volatiles Ketamine Supplemental – acupuncture,acupressure,massage,TENS Sedation Primarily in ventilated patients Benzodiazepines –midazolam,diazepam Anaesthetic agents- propofol,thiopentone Butyrophenones- haloperidol Phenothiazines- chlorpromazine Volatiles Opioids Dexmeditomedine Cold , Shivering Passive –warm environment,warm blanket Active ,external- warmed pads,blankets,Bair Hugger Active, core humidified inspired gases warm intravenous fluids Body cavity lavage-gastric,pleural,peritoneal Extra corporeal methods-hemodialysis, Bypass Other therapies Hypoxia- oxygen therapy(masks,cpap,bipap,ventilator) Hypercarbiabronchodilators,steroids,CPT,NIV,ventilator Maneuvers to reduce ICP- medications,ventilator Adjust transducer height Urinary retension-catheterize,definitive treatment Comfortable position for the patients Reintroduction of pre admission antihypertensives Psychological support- trust with staff Look for possible secondary causes-eg:renal artery stenosis Antihypertensives &vasodilators Mechanisms Diuretics – bendrofluothiazide, frusemide α antagonistslabetalol,phentolamine,phenoxybenzamine,prazosin, carvedilol,haloperidol,chlorpromazine β antagonists-propranolol,metoprolol,atenolol,esmolol CCB- nifedipine,nimodepine,verapamil,diltiazem,magnesium Direct vasodilators-SNP,GTN,isosorbide,hydralazine,diazoxide ACE inhibitors-captopril,enalapril,lisinopril Angiotensin receptor blockers- losartan,irbesartan,eprosartan Centrally acting-clonidine,methyl dopa,trimetaphan α antagonists Act by alpha adrenergic blockade Phentolamine-nonselective-1-10mg I.v. boluses,530mg/hr Phenoxybenzamine-nonselective-1mg/kg/day Labetolol-α1, α2,β1- 20-80mg I.v boluses,0.54mg/min infusion Prazosin- α1—2-10mg/day,8th hourly Carvedilol –oral preparation Side effects Can cause tachycardia, idiosyncratic hypotension CCBs Acts by blocking voltage gated calcium channels Nifedipine– 5-10mg po/sl Nimodepine- mostly used in SAH Amlodepine- 5-10mgpo b.d. Magnesium- physiological calcium antagonist 40-60mg/kg loading, 2-4 gm/hr infusion Side effects: hypotension, tachycardia,peripheral oedema β blockers Widely used now,acts by β blockade, inhibit release of renin from juxtaglomerular cells Prejunctional inhibition of nor epinephrine Atenolol- 1-10 mg iv boluses,25-100mg pob.d Metoprolol-same doses Esmolol-loading 0.5mg/kg,50-200mic/min Side effects : Bradycardia Bronchospasm Hyperkalemia,masking response to hypoglycemia Dirct vasodilators Sodium Nitro Prusside 44% cyanide by weight- cyanide toxicity Nonselective vasodilator 50mg/250ml 5%D 3-40ml/hr Glyceryl trinitrate 30mg/100ml5%D 2-25ml/hr Hydralazine 10-20mg I.v. bolus, 20-40 mg 6-8 hrly Diazoxide 50-100mg I.v. boluses, 15-30mg/min infusion ACE inhibitors Captopril-6.25-50mg QDS ,in acute hypertension 12.5-25sl Enalapril-5-20mg QDS Enalaprilat –0.625-5mg boluses(parenteral) Caution in renal impairment, hypotension Losartan – 25-100mg daily Caution in renal failure Diuretics Salt &water excretion Inhibition of aldosterone Direct vasodilatory effects Eg: frusemide, thiazides Caution in hypovolemia,renal dysfunction Acute treatment In hypertensive encephalopathy Heart failure Eclampsia Acute dissecting aortic aneurysm In c/c hypertension or a/c neurological events A precipitate reduction- worsens CPP-further deterioration Target CPP>70mm Hg Hypertensive crisis Symptomatic Increased drowsiness,seizures,papilloedema,retinopathy In presence of elevated systemic pressures Diastolic BP>120-130 mm Hg Mean BP>140-150 mm Hg Encephalopathy can occur at lower pressures Principles of management Adequate monitoring-invasive BP,ECG,CVP,CO,U/O Consider pain,hypovolemia,hypothermia,agitation Consider specific treatment-phaeo,thyroid crisis,dissection Slow iv infusion-GTN,SNP,others Aim to reduce to mildly hypertensive levels Longer term treatment –started at low doses Drug doses GTN 0.5-20mg/hr SNP 0.5-1.5mic/kg/min0.58mic/kg/min Labetolol 50mg iv over 1 min repeated every 5min to max 200mg Esmolol 50-200 mic/min Hydralazine 5-10mg slow I.v. followed by 50-150mic/min Thank you
