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Pediatric acute hypertension

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Pediatric acute hypertension

  1. 1. Pediatric Prof .Dr. Saad S Al Ani Senior Pediatric ConsultantAcute Head of Pediatric Department Khorfakkan HospitalHypertension Sharjah ,UAE saadsalani@yahoo.com
  2. 2. Background In infants and younger children, systemic hypertension is uncommon, but when present, it is usually indicative of an underlying disease process (secondary hypertension). Adolescents may acquire primary or essential hypertension Pediatric Acute hypertension Prof. Dr. Saad S Al Ani03/20/2012 Khorfakkan Hospital ,Sharjah ,UAE 2
  3. 3. Cont. Accurate blood pressure measurements should be part of the routine annual physical examination of all children 3 yr or older. A complete family history of hypertension should be elicited Use appropriate cuff size for blood pressure (BP) measurement. Correlate with BP tables for age, height, and weight Pediatric Acute hypertension Prof. Dr. Saad S Al Ani03/20/2012 3 Khorfakkan Hospital ,Sharjah ,UAE
  4. 4. Etiology and Pathophysiology Secondary hypertension is most common in infants and younger children Many childhood diseases may be responsible for both acute and chronic elevation of blood pressure Pediatric Acute hypertension Prof. Dr. Saad S Al Ani03/20/2012 4 Khorfakkan Hospital ,Sharjah ,UAE
  5. 5. Hypertension in the newbornCont. is most often associated with: 1. umbilical artery catheterization and 2. renal artery thrombosis Pediatric Acute hypertension Prof. Dr. Saad S Al Ani 03/20/2012 5 Khorfakkan Hospital ,Sharjah ,UAE
  6. 6. Hypertension during early childhood may be due to :Cont. 1.renal disease 2.coarctation of the aorta 3. endocrine disorders 4.medications. Pediatric Acute hypertension Prof. Dr. Saad S Al Ani 03/20/2012 6 Khorfakkan Hospital ,Sharjah ,UAE
  7. 7. In adolescentsCont. essential hypertension becomes increasingly common Pediatric Acute hypertension Prof. Dr. 03/20/2012 Saad S Al Ani 7 Khorfakkan Hospital ,Sharjah ,UAE
  8. 8. The severity of hypertension is also helpful in distinguishing secondary from primary hypertension Cont. In general, children and adolescents with essential hypertension have blood pressure values at or only slightly above the 95th percentile for age Pediatric Acute hypertension Prof. Dr.03/20/2012 Saad S Al Ani 8 Khorfakkan Hospital ,Sharjah ,UAE
  9. 9. Cont. Renal and renovascular hypertension accounts for the majority of children with secondary hypertension A history of urinary tract infection is present in 25-50% of these patients and is often related to an obstructive lesion of the urinary tract Pediatric Acute hypertension Prof. Dr.03/20/2012 Saad S Al Ani 9 Khorfakkan Hospital ,Sharjah ,UAE
  10. 10. Conditions Associated with Transient or Intermittent Hypertension in Children Pediatric Acute hypertension Prof. Dr.03/20/2012 Saad S Al Ani 10 Khorfakkan Hospital ,Sharjah ,UAE
  11. 11. Renal • Acute postinfectious glomerulonephritis • Anaphylactoid (Henoch-Schönlein) purpura with nephritis • Hemolytic-uremic syndrome • Acute tubular necrosis • After renal transplantation (immediately and during episodes of rejection) • After blood transfusion in patients with azotemia Pediatric Acute hypertension Prof. Dr. Saad S Al Ani03/20/2012 11 Khorfakkan Hospital ,Sharjah ,UAE
  12. 12. Cont. • Hypervolemia • After surgical procedures on the genitourinary tract • Pyelonephritis • Renal trauma • Leukemic infiltration of the kidney • Obstructive uropathy associated with Crohn disease Pediatric Acute hypertension Prof. Dr.03/20/2012 Saad S Al Ani 12 Khorfakkan Hospital ,Sharjah ,UAE
  13. 13. Drugs and Poisons• Cocaine • Cyclosporine or sirolimus treatment• Oral contraceptives post-transplantation• Sympathomimetic agents • Licorice (glycyrrhizic acid)• Amphetamines • Lead, mercury, cadmium, thallium • Antihypertensive withdrawal• Phencyclidine (clonidine, methyldopa, propranolol)• Corticosteroids and • Vitamin D intoxication adrenocorticotropic hormone Pediatric Acute hypertension Prof. Dr. Saad S Al Ani03/20/2012 13 Khorfakkan Hospital ,Sharjah ,UAE
  14. 14. Central andAutonomic nervous system • Increased intracranial pressure • Stevens-Johnson syndrome • Posterior fossa lesions • Guillain-Barré syndrome • Porphyria • Burns • Poliomyelitis • Familial dysautonomia • Encephalitis Pediatric Acute hypertension Prof. Dr. Saad S Al Ani03/20/2012 14 Khorfakkan Hospital ,Sharjah ,UAE
  15. 15. Miscellaneous• Preeclampsia• Fractures of long bones• Hypercalcemia• After coarctation repair• White cell transfusion• Extracorporeal membrane oxygenation• Chronic upper airway obstruction Pediatric Acute hypertension Prof. Dr. Saad S Al Ani03/20/2012 15 Khorfakkan Hospital ,Sharjah ,UAE
  16. 16. Conditions Associated with Chronic Hypertension in Children Pediatric Acute hypertension Prof. Dr. Saad S Al Ani03/20/2012 16 Khorfakkan Hospital ,Sharjah ,UAE
  17. 17. Renal •Chronic pyelonephritis •Chronic glomerulonephritis •Hydronephrosis •Congenital dysplastic kidney •Multicystic kidney •Solitary renal cyst •Vesicoureteral reflux nephropathy •Segmental hypoplasia (Ask- Upmark kidney) Pediatric Acute hypertension Prof. Dr. Saad S Al Ani03/20/2012 17 Khorfakkan Hospital ,Sharjah ,UAE
  18. 18. Cont.• Ureteral obstruction• Renal tumors• Renal trauma• Rejection damage following transplantation• Postirradiation damage• Systemic lupus erythematosus (other connective tissue diseases Pediatric Acute hypertension Prof. Dr. Saad S Al Ani03/20/2012 18 Khorfakkan Hospital ,Sharjah ,UAE
  19. 19. Vascular• Coarctation of thoracic or abdominal aorta• Renal artery lesions (stenosis, fibromuscular dysplasia, thrombosis, aneurysm)• Umbilical artery catheterization with thrombus formation• Neurofibromatosis (intrinsic or extrinsic narrowing of vascular lumen)• Renal vein thrombosis• Vasculitis• Arteriovenous shunt• Williams- Beuren syndrome• Moyamoya disease Pediatric Acute hypertension Prof. Dr. Saad S Al Ani03/20/2012 19 Khorfakkan Hospital ,Sharjah ,UAE
  20. 20. Endocrine • Hyperthyroidism • Hyperparathyroidism • Congenital adrenal hyperplasia (11 β- hydroxylase and 17-hydroxylase defect) • Cushing syndrome • Primary aldosteronism • Dexamethasone-suppressible hyperaldosteronism • Pheochromocytoma • Other neural crest tumors (neuroblastoma, ganglioneuroblastoma, ganglioneuroma) • Diabetic nephropathy • Liddle syndrome Pediatric Acute hypertension Prof. Dr. Saad S Al Ani 03/20/2012 20 Khorfakkan Hospital ,Sharjah ,UAE
  21. 21. Central Nervous System • Intracranial mass • Hemorrhage • Residual following brain injury • Quadriplegia Pediatric Acute hypertension Prof. Dr. Saad S Al Ani03/20/2012 21 Khorfakkan Hospital ,Sharjah ,UAE
  22. 22. Essential hypertension • Low renin • Normal renin • High renin Pediatric Acute hypertension Prof. Dr. Saad S Al Ani03/20/2012 22 Khorfakkan Hospital ,Sharjah ,UAE
  23. 23. AcuteHypertension • Hypertensive urgency: Significant elevation in BP without accompanying end-organ damage; more common in children.  Symptoms include headache, blurred vision, and nausea • Hypertensive emergency: Elevation of both systolic and diastolic BP with acute end-organ damage (e.g., cerebral infarction or hemorrhage, pulmonary edema, renal failure, hypertensive encephalopathy, or seizures) Pediatric Acute hypertension Prof. Dr. Saad S Al Ani03/20/2012 23 Khorfakkan Hospital ,Sharjah ,UAE
  24. 24. Physicalexamination• Four-extremity BP• Funduscopy (papilledema, hemorrhage, exudate)• Visual acuity• Thyroid examination• Evidence for congestive heart failure (tachycardia, gallop rhythm, hepatomegaly, edema)• Abdominal examination (mass, bruit)• Thorough neurologic examination• Evidence of virilization, cushingoid effect Pediatric Acute hypertension Prof. Dr.03/20/2012 Saad S Al Ani 24 Khorfakkan Hospital ,Sharjah ,UAE
  25. 25. Initial diagnostic evaluation • Urinalysis • Blood urea nitrogen • Creatinine, • Electrolytes • Chest radiograph • Electrocardiogram Pediatric Acute hypertension Prof. Dr.03/20/2012 Saad S Al Ani 25 Khorfakkan Hospital ,Sharjah ,UAE
  26. 26. Consider • Renin level • Toxicology screen • Thyroid and adrenal testing • Urine catecholamines • Abdominal ultrasound • Renal Doppler ultrasound • Head CT Pediatric Acute hypertension Prof. Dr.03/20/2012 Saad S Al Ani 26 Khorfakkan Hospital ,Sharjah ,UAE
  27. 27. Management Hypertensive emergency: Goal: Lower BP promptly but gradually to preserve cerebral autoregulation (a) Mean arterial pressure (MAP) = 1/3 systolic + 2/3 diastolic BP (b) Lower by 1/3 of planned MAP reduction over first 6 hours, then (c) Lower by additional 1/3 over next 24–36 hours, then (d) Lower final 1/3 over next 48 hours After elevated ICP is ruled out, do not delay treatment because of further diagnostic workup Pediatric Acute hypertension Prof. Dr.03/20/2012 Saad S Al Ani 27 Khorfakkan Hospital ,Sharjah ,UAE
  28. 28. Pediatric Acute hypertension Prof. Dr. Saad S Al Ani03/20/2012 28 Khorfakkan Hospital ,Sharjah ,UAE
  29. 29. Hypertensive urgency: Goal: To lower MAP by 20% over 1 hour and return to baseline levels over 24 to 48 hours An oral route may be adequate. (Use of sublingual nifedipine is not recommended, as a precipitous, uncontrolled fall in BP may result.) Pediatric Acute hypertension Prof. Dr. Saad S Al Ani03/20/2012 29 Khorfakkan Hospital ,Sharjah ,UAE
  30. 30. Pediatric Acute hypertension Prof. Dr. Saad S Al Ani03/20/2012 30 Khorfakkan Hospital ,Sharjah ,UAE
  31. 31. Algorithm for identifying children with high blood pressure (BP) Pediatric Acute hypertension Prof. Dr. Saad S Al Ani03/20/2012 31 Khorfakkan Hospital ,Sharjah ,UAE
  32. 32. References• Flynn JT: Whats new in pediatric hypertension? Curr Hypertens Rep 2001;3: 503-10.• Kay JD, Sinaiko AR, Daniels SR: Pediatric hypertension. Am Heart J 2001;142:422-32.• Blaszak RT, Savage JA, Ellis EN: The use of short-acting nifedipine in pediatric patients with hypertension. J Pediatr 2001;139:34-7.• Katherine M. Steffen. Trauma, Burns, and Common Critical Care Emergencies(in) The Harriet Lane handbook. 19th ed. Philadelphia 2012 Ch.4 p:113-115 Pediatric Acute hypertension Prof. Dr. Saad S Al Ani03/20/2012 32 Khorfakkan Hospital ,Sharjah ,UAE
  33. 33. Thank you Pediatric Acute hypertension Prof. Dr. Saad S Al Ani03/20/2012 33 Khorfakkan Hospital ,Sharjah ,UAE

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