htn emer

1. MANAGEMENT OF
HYPERTENSIVE EMERGENCIES
PRESENTOR:DR DEEPTI
MODERATOR-DR HRICHA

2. Introduction
• Hypertension is one of the leading causes of the global burden of disease.
• Hypertension doubles the risk of cardiovascular diseases, including
coronary heart disease (CHD), ischemic and hemorrhagic stroke, renal
failure, and peripheral arterial disease
• Worldwide, hypertension may affect as many as 1 billion people and be
responsible for ~7.1 million deaths per year
• HTN is No 1 modifiable risk factor for CVD.

3. JNC guidelines

4. Acute Hypertensive Crises
●Hypertensive emergencies, sudden increase in systolic and
diastolic blood pressure associated with end organ damage of
the CNS, heart & or kidneys.
●Hypertensive urgencies, severely elevated BP without acute
end-organ damage.

5. ●Pathophysiology:
●Abrupt ↑ in systemic vascular resistance (humoral
vasoconstrictors)
●Severe elevations of BP→endothelial injury →fibrinoid
necrosis of the arterioles →deposition of platelets and
fibrin → breakdown of the normal autoregulatory
function.
●Resulting ischemia →release of vasoactive substances

6. Hypertensive Crises
●Neurologic – Ischemic & Hmg stroke, head
trauma, HTN encephalopathy
●Cardiac- acute coronary syndrome , acute heart
failure
●Vascular – acute aortic dissection
●Renal – acute renal failure
●Pregnancy- Eclampsia
●Sympathetic overactivity- pheochromocytoma ,
withdrawal of drugs likeclonidine/b-blockers

7. Symptoms of HMOD
Headache,confusion,seizure,unresponsiveness
Blurry vision
Nausea & vomiting
Chest pain
Shortness of breath
Severe anxiety
Thirst, polyuria, nocturia, haematuria
Cold extremities

8. Examination of HMOD
• Neurological examination and cognitive status
• Fundoscopic examination for hypertensive retinopathy(hard exudates,
cotton wool spots & papilloedema is indicates severe
(grade2/3)hypertensive retinopathy)
• Palpation and auscultation of heart and carotid arteries
• Kidney palpation for renal enlargement (PCOD)
• Auscultation of heart & renal arteries for murmurs or bruits indicative
of aortic coarctation/ renovascular hypertension
• Comparison of radial with femoral pulse: to detect R-F delay in aortic
coarctation

10. Management of Hypertensive crises
●Hospital Care (urgencies), ICU care (emergencies)
●Invasive BP monitoring for emergencies
●Lower the BP + stabilize and reverse the damage to target
organs
●Sodium restriction and diuretics if fluid overload
●Parenteral anti-hypertensives (emergencies),
oral/parenteral (urgencies)

11. DRUGS DOSE ONSET
min
DOA
min
ADVERSE
EFFECT
ROLE
Clevidipine 1-2mg/hr iv infusion
Max dose-21mg/hr
or 100ml per 24hr
d/t lipid load
Delivered in lipid
emulsion
2-4 5-15 AF, lipid
formulation
contain
allergen(egg,
soya)
HTN EMR
Enalaprilat 1.25- 5mg every 6hr
iv
15-30 6-
>12h
r
Headache,dizzin
ess,ppt fall in
pressure in high
renin states
Acute LVF
Avoid in
pregnancy,
derranged kft
Fenoldopam 0.1mcg/kg/min
Max-1.6mcg/kg/min
5-10 30-
60
Tacycardia,head
ache,flushing
HTN EMR
Avoid-glaucoma,
raised ICP
Hydralazine 10-20mg iv/im(max
im-40mg)
iv-10-
20
1-
>4hr
Sudden ppt
drop in
BP,tachycardia,a
ggravation of
angina,flushing,
headache
In general
avoided-d/t
prolong &
unpredictable
hypotension

12. Nicardipin
e
5-15mg/hr iv
infusion
Max-30mg/hr
5-15 1.5-
>4hr
Local
phlebitis,edema,flushi
ng headache
HTN
EMR(+pregna
ncy)
avoid in HF
NTG 5-100mcg/min iv
infusion
2-5 5-10 methHB,tolerance,
reflex tachy,hypoxemia
Adjunct drug
in ACS
Nitroprussi
de
0.25-10mcg/kg/min
iv infusion
max:10mcg/kg/min
in <10min
0.5-1 1-10 Cyanide/thiocynate
toxicity, inc.ICP,dec.
CBF/coronary blood
flow, m/s spasm
Avoid in
CAD/CVA,
kidney & liver
failure,inc.ICP
Esmolol Load-500mcg/kg in
1min
25/50mcg/kg/min
infusion
1-2 10-30 bronchospas,bradycar
dia,t1/2 inc. in anemia
Periop HTN
Avoid-
decomp. HF
Labetolol Bolus-20mg iv
f/b 20-89mgiv bolus
every 10min
Max-300mg
Inf-0.5-2mg/min
5-10 2-4hrs Bronchospasm,paresth
esia,heart block
Aovid—
decomp.HF
/reactive
airway

13. Metoprolol 1-25-5mg iv ,f/b
2.5-5mg iv every 3-
6hr
20min 5-8hr role in MI,
periop
HTN(avoid in
decomp.HF)
Phentolamine 5-15mg iv bolus
every 5-15 min
1-2min 10-30 Tachyarryth
mia,flushing
role in
adrenergic
crisis like
pheochromo
cytoma,
cocaine
overdose

16. Acute coronary syndrome
• Pref. drugs-IV beta blockers(lobet/esmolol) with
vasodilator(NTG), ACEI
• Trea if SBP>160 7/or DBP>100
• Reduce BP by 20-30% of baseline
• Thrombolytics C/I if BP>185/100

17. Acute heart failure
• Pts with acute left ventricular dysfunction & acute
pul.edema receive loop diuretics
• Vasodilator like NTG/sod.nitroprusside help reduce
afterload
• The goal of these therapies is to ameliorate vol.excess
& improve pul.edema(mostly seen with 10-15%
reduction of BP)
• Note- drugs that inc. cardiac work(hydralazine) or
acutely decrease cardiac contractility( lobet) should be
avoided

18. Acute aortic dissection
• It is of 2 types:
-Type A-sx management
-Type B- medical management
• The mgt involves rapid SBP lowering to 100-
120mmhg in 20min to reduce aortic shearing forces
• Combination of beta blocker+vasodilator to reduce
force of ventricular contraction(lobet/esmolol+ NTG)

19. Acute ischaemic stroke
• If BP is high it can cause haemorrghagic transformation
of infarct/cerebral edema, but if CPP is low it can cause
ischaemic penumbra
• So intervene if SBP>220/DBP>120/MAP>145 mm Hg
• Agent of choice: lobet, clevididpine ,nicardipine
• For thrombolysis , BP<185/110

20. Acute haemorrhagic stroke
• Drug of choice:nicardipine,esmolol,lobet.
• Avoid-SNP,hydralazine
• Intracerebral-
a)Raised ICP-maintain SBP<180 for 1st 24 hrs
b)Normal ICP-maintain SBP<160 for 1st 24hrs
• Subarachnoid-maintain SBP<160 till aneurysm
treated/cerebral vasospasm occurs.

21. Hypertensive encephalopathy
• Goal is to reduce MAP by 20% over next 8hrs
• Drug of choice:clevidipine,lobet
• Avoid drugs like SNP(raise ICP)
• Avoid drugs like reserpine ,methyldopa which
have adverse effect on CNS

22. Renal emergencies
• Pathophysiology include: increased vascular
resistance, activation of RAAS &
hyperparathyroidism
• Goal is to prevent further renal damage by
maintaining adequate blood flow
• SNP,lobet are useful
• Short term dialysis may be required

23. Adrenergic crises
• Alpha blockage-
• Prazocin:2.5 mg bd/tds-max 20mg
• Doxazocin: 1-2 mg OD
• Terazocin: 1-5 mg OD
• Beta blockage:
• Propranolol-10mg qid

24. Pheochromocytoma
• Adrenal medulla tumor causing excess secretion of
catecholamine
• Test of diagnosis:24hr urine
metanephrine/VMA/catechols,CT,MRI
• In a hypertensive crisis with a pheochromocytoma,
intravenous phentolamine provides the optimal blockade of
catecholamine-induced vasoconstriction as a non-selective
alpha-receptor blocker which may be given as an initial test
dose of 1 mg followed by repeat 5 mg boluses or
continuous infusion at 0.5-1 mg/minute f/b beta blockade-
propanolol/lobet/esmolol

25. Hypertension in Pregnancy
HTN in pregnancy is defined as BP measurements of SBP ≥ 140 &/ DBP ≥ 90 mmHg.
It includes :
1.Pre-existing/Chronic HTN: precedes pregnancy / develops before 20 wks of
gestation, & persists for >6 weeks post-partum
2.Gestational HTN: develops >20 wks of gestation, without significant proteinuria &
usually resolves within 6 wks postpartum.
3.Preeclampsia is gestational HTN with significant proteinuria (>0.3 g/24 h or ≥30
mg/mmol). It is usually accompanied by headache, visual disturbances, abdominal pain.
4.Eclampsia is occurrence of seizures in a patient with preeclampsia.
5.Preeclampsia superimposed on Pre-existing HTN
Investigations include –urine analysis , a urine protein dipstick test showing >1+
warrants evaluation of ACR with values of ≥30mg/mmol being abnormal.
-CBC, hematocrit, liver enzymes, serum creat./urea
-Additional tests - USG of the kidneys and adrenals and USG-doppler of the uterine
arteries.

26. Management of PIH
1.Methyldopa is recommended for women whose HTN is 1st diagnosed during
pregnancy , CCBs (nifedipine), Labetalol can also be used.
2.In Mild HTN, T/t initiated if the BP is ≥ 140/90 mmHg along with gestational HTN or
subclinical HMOD or in any patient with BP≥150/95mmHg. ABP target of<140/90mmHg
has been suggested.
3. Severe HTN i.e BP ≥160/110 mmHg is a medical emergency. It needs immediate
hospitalization and T/t initiated with IV labetolol, CCB or oral methyldopa.
- IV NTG is the DOC in severe HTN with pulmonary edema.
- IV MgSO4 is the DOC both for prevention and treatment of seizures (eclampsia).
- IV hydralazine can be used but is not currently available in India.
- In some cases of eclampsia, anti-HTN treatment fails to control HTN and the only
means of controlling HTN would be to induce delivery.
4.CI drugs in pregnancy - ACEIs, ARBs & sodium nitroprusside (d/t risk of fetal cyanide
toxicity).
- Use of low dose diuretics is discouraged, since pre-eclampsia is a volume-depleted
state.

28. PERIOPERATIVE HYPERTENSION
• It occurs in 25% of hypertensive patient’s that
undergo sx.
• Most important cause of periop HTN is cessation of
antihypertensive on arrival to hospital in a known
HTN
• Common predictors of perioperative hypertension
are previous history of hypertension, especially a
DBP>110 mm Hg, and the type of surgery
• Importance:
– Increased risk of cardiovascular events
– Increased post-operative morbidity and mortality
– Association with end-organ damage

29. Effects of Peri-operative hypertension
●CVS effects:
●Increased BP→ ↑ afterload & myocardial O2 demand →
myocardial O2 supply and demand imbalance.
●Hypertrophied myocardium → decreased compliance →
Abn. diastolic filling.Diastolic dysfunction esp. apparent during stress,
important during surgery & acute recovery interval
● CNS effects:
●Increased risk of stroke
●Impaired cerebral autoregulation(imp. in neuro SX pt.)
● Effects on renal function
●Effective control of BP prevents renal dysfunction
●Intraop.urine output monitoring for assessment of
perioperative renal function

30. Preoperative evaluation
❖Determine adequacy of blood pressure control
❖Review pharmacology of drugs being administered
❖Evaluate for evidence of end organ damage
❖Continue drugs used for control of blood pressure
•The magnitude of blood pressure decreases during
anesthesia is greater in hypertensive than in
normotensive patients.

31. ●Preoperative history and examination
●End-organ damage
●Associated cardiovascular pathology
●Current anti hypertensive medications
● To be continued during perioperative period
● Special care regarding β-blockers and
clonidine(rebound HTN)
●Patients with preoperative HTN, more likely to
develop intra-operative hypotension. (ACE
inhibitors)

32. ●Preoperative ACE inhibitors & AT-1 antagonists:
●Refractory /exaggerated hypotension
●As long as euvolumia, no hypotension
●Pts. with preoperative BP elevations; exaggerated
intraoperative BP fluctuations & ECG evidence of
ischemia.
●Preop. Control of BP; ↓tendency to perioperative
ischemia.

33. Management of perioperative
hypertensive crisis
• The ideal drug for management of hypertensive emergency: rapid
onset of action, a short DOA, rapidly titratable, allow dose
adjustment, have a low incidence of toxicity, be well tolerated &
have few C/I( parenteral antihypertensive agent )
• The goal of therapy is to halt the vascular damage & reverse the
pathological process
• Guidelines by JNC for treating HTN emergencies include reducing
SBP by 10 -15%, up to 25% within 1st hr ,f/b gradual reduction of
BP to 160/110 mmHg over the following 2-6 hours.
• HTN that occurs with tracheal intubation, surgical incision &
emergence from anaesthesia is best treated with CCB,short-acting β-
blockers, vasodilators or ACE inhibitors.
• Postop.hypertension is best managed by correction of precipitating
factors (pain, hypothermia, hypervolemia, hypoxia and hypercarbia).

34. • Unintentional hypotension & associated organ hypoperfusion
can happen with aggressive attempts to lower BP since the
homeostatic mechanisms depend on higher BP for adequate
organ perfusion.
• The alteration b/w overshooting BP & severe hypotensive states
& using vasopressors to get the normotensive levels may
damage end-organs & the vasculature - precise control of BP in
a hypertensive crisis is a challenge
• Chronic HTN shifts cerebral & renal perfusion autoregulation to
a higher level, the brain & kidneys are prone to hypoperfusion
with rapid decrease in blood pressure. So control of blood
pressure to baseline levels should take 24 to 48 hours

35. Intraoperative concerns
●Maintain BP within 20% of the preoperative level
●Stressful intraoperative events:
●Intubation
●Surgical incision
●Emergence from GA and extubation

36. ●Other causes of intra-operative hypertension:
●Inadequate depth of anesthesia
●Pain
●Hypercarbia
●Hypoxemia
●Bladder distension
●Hypervolumia
●Exaggerated response in hypertensive patients
●Increased sympathetic tone
●Decreased intravascularvolume

37. ●Methods to blunt the sympathetic response:
●IV Esmolol (1-2mg/kg, studies with lesser dose
0.4mg/kg)
●IV Lignocaine( 1.5 mg/kg, 90 sec before
intubation/extubation)
●Short acting narcotics (Fentanyl 2-3µg/kg, sufentanil
0.3-0.5µg/kg)
●Increased concentration of inhalational agents
●IV Labetalol (5-20 mg boluses)

38. ●Choice of anesthetic techniques and medications
on the basis of presence of comorbid disease and
type of surgery.
●Hypertensive patients treated with diuretics or
having LVH more susceptible to vasodilatory
effects of inhaled anesthetics & neuraxial blockade

39. Monitoring
●Monitoring in patients with essential hypertension is
influenced by the complexity of the surgery.
●ECG is particularly useful in recognizing the occurrence
of myocardial ischemia during periods of intense painful
stimulation such as laryngoscopy and tracheal
intubation.
●Invasive monitoring with an intra-arterial catheter & a
central venous or pulmonary artery catheter may be useful
if extensive surgery is planned and there is evidence of left
ventricular dysfunction or other significant end-organ
damage.
●TEE is an excellent monitorof left ventricular
function and adequacy of intravascularvolume
replacement

40. Postoperative concerns
●Defined as SBP>190 mm Hg and/or DBP≥100 mm
Hg on two consecutive readings following surgery
●Implications:
●Risk of hemorrhage
●Disruption of vascular or cardiac suture lines
●Cerebral edema
●↑ myocardial wall stress and oxygen consumption→
myocardial ischemia

41. Causes
●Preoperative hypertension
●Withdrawal of antihypertensive medications
●Pain
●Emergence delerium
●Hypoxia
●Hypercarbia
●Hypothermia
●Hypervolumia
●Typeof surgery

42. ●Management:
●Aggressive pain management
●Correction of previously mentioned
causes
●Antihypertensive medications
●Parenteral
●Rapid onset
●Labetalol, hydralazine
●Refractory or profound hypertension
●SNP or NTG