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Hypertensive Crisis in PICU

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Dr Anil Sachdev, New Delhi    19 January 2018

  1. Causes of hypertensive crisis - Essential hypertension, primary CNS disease, spinal cord injury, renal parenchymal disorders, renovascular disorders, systemic lupus erythematosus and vasculitides.
  2. Hypertensive crisis should be managed in high dependency unit (HDU) or pediatric intensive care unit (PICU) settings.
  3. Definition of hypertension - Systolic BP and/or diastolic BP ≥95th percentile for age, gender and height. Prevalence of hypertension in pediatric population is increasing.
  4. Gold standard for BP measurement is intra-arterial monitoring. Oscillometric monitoring is the most common screening method.
  5. Clinical manifestations may be divided into features related to hypertension and those related to target organ injury. In infants, symptoms related to hypertension are lethargy and irritability, whereas in older children, they include severe headache, dizziness, blurred vision and epistaxis. Physical examination findings such as altered mental status, papilledema and pulmonary edema are related to the organs involved.
  6. Hypertensive crisis requires prompt therapy to prevent or ameliorate further target organ damage. Rapidly acting, short half-life drugs are preferred for easy titration.
  7. Primary goal of therapy is to prevent and/or reverse end-organ injury, and not solely to restore BP to normal level. Immediate assessment of airway, breathing, circulation and disability is necessary.
  8. Predetermine the target reduction in BP. Rapid fall in BP can be detrimental with neurological sequelae.
  9. Ascertain the cause of hypertension and select antihypertensive drugs accordingly.
  10. Sodium nitroprusside has a rapid onset of action (30 seconds), peak effect at 2 minutes.
  11. Labetolol lowers systemic vascular resistance with minimal effect on CO. Onset of action is in 2-5 minutes, with peak effect at 5-15 minutes. Duration of action is up to 4 hours.

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