Enalapril IV

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namethatsmell

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I've heard about using enalapril IV to lower BP in the acute setting but I've yet to use it/see it used in my shops. Anybody using it? What kind of bang for your buck do you get and how long does it take to take effect?

Any specific pro/cons to be aware of?

Thanks!

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Nothing wrong it.

Wouldn't bother wasting money on IV version except in the setting of acute pulmonary edema as an adjunct to nitro for additional afterload reduction.
 
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Nothing wrong it.

Wouldn't bother wasting money on IV version except in the setting of acute pulmonary edema as an adjunct to nitro for additional afterload reduction.
This is the only time I've used IV enalapril.
 
I've used it twice. Once a pt had unilateral renal artery stenosis and BP 250/130, worked great. The other time was a guy who had scleroderma and was apparently in scleroderma hypertensive crisis and the nephrologist called ahead telling us that enalaprilat was the agent of choice for him.
 
I've used it twice. Once a pt had unilateral renal artery stenosis and BP 250/130, worked great. The other time was a guy who had scleroderma and was apparently in scleroderma hypertensive crisis and the nephrologist called ahead telling us that enalaprilat was the agent of choice for him.

Can you please explain why? I'd like to know.
 
If the patient has a hypertensive emergency and you really want to titrate the BP - Nicardipine.

If the patient has a hypertensive emergency and you want to give something to make it look like you tried to treat it, but don't want to put in the work of titration - labetalol.

If the patient has a really high BP number (but it isn't an emergency - no end organ dysfunction) - give their home med PO and get close follow up.

I've heard of sublingual ACE-I used in flash plumonary edema from hypertension. Seems like IVP might be similar in effect. Usually with these I begin nitroglycerin drip and add Bipap - and these 2 usually do the trick.
 
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Here's the original study that used captopril in acute pulmonary edema.
Rapid Improvement of Acute Pulmonary Edema with Sublingual Captopril
  1. Richard J. Hamilton MD1,*,
  2. Wallace A. Carter MD1 and
  3. E. John Gallagher MD
Academic Emergency Medicine
Volume 3, Issue 3, pages 205–212, March 1996


I don't have a free link that I can post.

I'm not aware of any studies that looked at Vasotec, but that's what I usually use if an additional BP agent is needed after Nitro in acute pulmonary edema.
If no IV, you can just pop some SL nitro and SL captopril.
I'm not as big a fan, but I've seen it work surprisingly well in some pretty sick looking patients.
 
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In residency my attendings joked about "a pill in each cheek" for these HTN Emerg/Pulm edema pts - captopril SL in one, and NTG SL in the other. I've not used captopril that much since because it's not in our Pyxis. But the NTG SL are useful because it's fast and readily available, meaning you can start treating the moment the pt hits the door.

As a side comment, it's been my experience that most nurses are nervous giving the doses of tridil needed to treat pulm edema and want to start with 20mcg or so. Once you point out that they've just given 20 times that dose SL, they feel more comfortable.
 
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...As a side comment, it's been my experience that most nurses are nervous giving the doses of tridil needed to treat pulm edema and want to start with 20mcg or so. Once you point out that they've just given 20 times that dose SL, they feel more comfortable.

Yep. Blows my nurse's & residents' minds when I start at 50-80mcg/min.

0.4mg SL q5min = 80mcg/min

Seems silly to go backwards on the dose when setting up IV.

-d
 
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If the patient has a hypertensive emergency and you really want to titrate the BP - Nicardipine.

If the patient has a hypertensive emergency and you want to give something to make it look like you tried to treat it, but don't want to put in the work of titration - labetalol.

If the patient has a really high BP number (but it isn't an emergency - no end organ dysfunction) - give their home med PO and get close follow up.

I've heard of sublingual ACE-I used in flash plumonary edema from hypertension. Seems like IVP might be similar in effect. Usually with these I begin nitroglycerin drip and add Bipap - and these 2 usually do the trick.

My exact practice.

Haven't given enalapril in years FWIW.

We'd treat CHF in residency acutely without an IV; bipap and nitro worked fine.
 
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Thanks for all the replies.

I asked because I've had a few hypertensive urgency patient's who I don't want to give labetalol to (ie bad asthmatics/COPDers) and who respond poorly to hydralazine. At my shops sbp greater than 180 and/or anti-hypertensive ggt=can't go to the floor.

Our step-down and ICU beds are always in tight supply and dispo can get tied up trying to secure one. Rather than go down that path, the possibility of a third option for a rapid-acting HTN med is appealing.
 
I like titratable drugs, especially if it is a true emergency. Nurses are sometimes weary of giving high dose NTG or nipride, but usually i pull 1 cc of nipride (50mg/250cc) + 9 cc of saline = 20 mcg/ml. I bolus 1cc at a time and get their map where i want it, and then start a drip to maintain it.
 
If the patient has a hypertensive emergency and you really want to titrate the BP - Nicardipine.

If the patient has a hypertensive emergency and you want to give something to make it look like you tried to treat it, but don't want to put in the work of titration - labetalol.

If the patient has a really high BP number (but it isn't an emergency - no end organ dysfunction) - give their home med PO and get close follow up
I just saw this. For a pt with ICH secondary to uncontrolled HTN, acute HTN encephalopathy, or ischemic stroke, I will reach for nicardipine. Sort of my BP-lowering-med-NOS. Pulm edema - NTG. ACOG still recommends labetalol or hydralazine for HTN in pregnancy. Esmolol followed by nicardipine or nitroprussie as needed for dissection/pseudoaneurysm
 
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Our step-down and ICU beds are always in tight supply and dispo can get tied up trying to secure one. Rather than go down that path, the possibility of a third option for a rapid-acting HTN med is appealing.
I would be cautious in emergently lowering someone's BP without evidence of end-organ damage. Brains that have trained to live at 220/110 can infarct if their SBP is lowered too much and too quickly. Giving someone 10 mg of norvasc or 20 mg of lisinopril, depending on their risk factors, is usually a good start. The hospitalist can add more as an inpatient.
 
Pointless delaying tactic. If I can send a patient home with a SBP > 180, how is it too dangerous to go to the floor?

Dc'ing someone home with that critically high of a blood pressure is irresponsible. Bragging about it on a forum intended for education is doubly so. Think of the students...
 
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Dc'ing someone home with that critically high of a blood pressure is irresponsible. Bragging about it on a forum intended for education is doubly so. Think of the students...

You're joking, right?
 
Pointless delaying tactic. If I can send a patient home with a SBP > 180, how is it too dangerous to go to the floor?
Do your inpatient floors have nursing protocols such that they cannot accept patients with certain vital signs, must "call MD" on such patients, or transfer patients with vitals outside of certain vital sign parameters?
 
Do your inpatient floors have nursing protocols such that they cannot accept patients with certain vital signs, must "call MD" on such patients, or transfer patients with vitals outside of certain vital sign parameters?
This is, sadly, the rule & not the exception.
 
This is, sadly, the rule & not the exception.
Right. So you have the perfect storm of #1 Nursing floor protocols that treat abnormal vitals inflexibly (probably necessarily so) #2 Patients who think elevated BP is a seconds-to-minutes emergency (because it's been pounded in their head that it's important and causes strokes and MIs) combined with #3 The fact that when you try to convince someone (patient or floor staff) elevated BP by itself is not necessarily an emergency and that means the patient doesn't need to be in the emergency dept, you're looked at like you have a [insert favorite human appendage] sticking out of your forehead by suggesting that having an "emergency" is even remotely connected in any way to any legitimate need to occupy space and time in an ED.

I don't know how you fix that without fixing the "number," which then reinforces the original patient and nursing perception that the BP needs to be acutely lowered, which is exactly what everyone tells you don't need to, and shouldn't always, do in the first place.

It's a little bit of a "no win."

Choose one:

A-Treat the asymptomatic BP number to make the nurse and patient happy and your shift slightly easier (knowing the Gods of ABEM General Hospital kill a kitten every time you do so), or

B- Don't treat the number and give the canned "Asymptomatic Elevated BP " speech against patient and nurse pushback, making your day a little harder (knowing you'll only hear the sound of *crickets* from the Gods of ABEM General Hosp) but that you'll be right.
 
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Agree with giving it in pulmonary edema. In the hundreds of dollars per IV dose, so in a non emergent case I'll choose a cheaper option.
 
Can you please explain why? I'd like to know.
In a scleroderma renal crisis, The scar tissue that normally gets deposited everywhere and scleroderma ends up in the renal arteries. What sometimes happens in these patients is for whatever reason, they get a decrease in perfusion to the kidney, so the kidneys activate the RAAS because they think it's a decreased perfusion state, which causes the vasculature to clamp down more, which decreases perfusion further, which causes more RAAS... And on and on. Shoots their BP up into the crazy range and your BUN/Cr will elevate as well. ACEIs, while obviously you would avoid in most other acute kidney injury are actually specifically indicated in this situation because you are directly targeting the source of the problem.
 
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Quick question from a know-nothing med student. Why bother with IV enalapril for acute pulmonary edema when you could just titrate up nitro to ~100-150 mcg/min and get the same afterload reduction without having to add another med and reduce the total cost of the intervention (as I assume IV enalapril is much more expensive than IV nitro)?
 
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Quick question from a know-nothing med student. Why bother with IV enalapril for acute pulmonary edema when you could just titrate up nitro to ~100-150 mcg/min and get the same afterload reduction without having to add another med and reduce the total cost of the intervention (as I assume IV enalapril is much more expensive than IV nitro)?
Good question.
 
Yep. Blows my nurse's & residents' minds when I start at 50-80mcg/min.

0.4mg SL q5min = 80mcg/min

Seems silly to go backwards on the dose when setting up IV.

-d
Yep. Blows my nurse's & residents' minds when I start at 50-80mcg/min.

0.4mg SL q5min = 80mcg/min

Seems silly to go backwards on the dose when setting up IV.

-d

Agree with this, the nurses think I'm bat **** crazy when I don't want to start my ntg drip at 10mcg. EMRAP had a talk about treating acute pulm edema not too long ago and they went on at length about how we tend to underdose our nitro gtts
 
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Yep. Blows my nurse's & residents' minds when I start at 50-80mcg/min.

0.4mg SL q5min = 80mcg/min

Seems silly to go backwards on the dose when setting up IV.

-d

Not to be pedantic, but I think sublingual nitro has a 40% bioavailability, so the equivalent IV dose is more like 30-40ish mcg/min. Still agree with the larger point that we shouldn't fear the IV nitro.
 
Quick question from a know-nothing med student. Why bother with IV enalapril for acute pulmonary edema when you could just titrate up nitro to ~100-150 mcg/min and get the same afterload reduction without having to add another med and reduce the total cost of the intervention (as I assume IV enalapril is much more expensive than IV nitro)?

nitroglycerin is more preload reduction than active afterload reduction which arguably enalapril is

plus the headache you can get from the nitro at that level

though the kind of pulmonary edema that would require that level of nitro or the addition of enalapril isn't going home and discussing the difference in prices at that point probably isn't terribly meaningful
 
nitroglycerin is more preload reduction than active afterload reduction which arguably enalapril is

plus the headache you can get from the nitro at that level

though the kind of pulmonary edema that would require that level of nitro or the addition of enalapril isn't going home and discussing the difference in prices at that point probably isn't terribly meaningful
And don't forget the most important reason:

Nitro is in my Pyxis & overridable. Vasotec (enalaprilat) is neither.

The readily available intervention will always trump.
 
plus the headache you can get from the nitro at that level

Seems like its only ever the non-specific chest pain/fibromyalgia patients who complain about the headache from nitroglycerin, certainly not my hypertensive emergency/pulmonary edema folks ....

Regardless, in summary response, enalaprilat is an excellent drug. When you have massive doses of nitroglycerin hanging, does it have much additive value? Yes, but infrequently.
 
Seems like its only ever the non-specific chest pain/fibromyalgia patients who complain about the headache from nitroglycerin, certainly not my hypertensive emergency/pulmonary edema folks ....

I wonder if it takes some time to set in and how long you normally need to watch these folks after calling for the admit. I've seen it often enough with high doses of nitro, have since residency. It's why we kind of giggle when you guys send up the hypertensive "emergencies" on big nitro doses and then switch to something more appropriate.

I don't know whose anecdote gets to win. Nor am I telling anyone what they "have to" do. Do what you want.

My main point though was that nitroglycerin isn't really an after load reducer. If you really want to or need to reduce afterload then use something that will, like an ace, or oral hydralizine, or nipride.
 
I wonder if it takes some time to set in and how long you normally need to watch these folks after calling for the admit. I've seen it often enough with high doses of nitro, have since residency. It's why we kind of giggle when you guys send up the hypertensive "emergencies" on big nitro doses and then switch to something more appropriate.
We giggle at them too. At least, those of us who read do. Just like we giggle at the inpatient services that continue to demand NPO status for pancreatitis, or other non-EBM treatments. Try and teach, then move on.
 
It's why we kind of giggle when you guys send up the hypertensive "emergencies" on big nitro doses and then switch to something more appropriate.

You mean, the hypertensive "emergencies" sent from clinic/pre-op/etc. for admission?

Can't recall where I saw it, but there was a nice succinct article describing the fallacy of describing folks as "hypertensive emergency". The pressure is just a symptom of the underlying medical problem – which either requires emergent management (heart failure, dissection, SAH, etc.) or doesn't (chronic hypertension, headache, non-specific dizziness).
 
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We giggle at them too. At least, those of us who read do. Just like we giggle at the inpatient services that continue to demand NPO status for pancreatitis, or other non-EBM treatments. Try and teach, then move on.

EBM is largely nonsense and really only used as a weapon to beat people that one disagrees with, when the EBM happens to support ones point, of course.

I don't know if EVERY pancreatitis patients needs to be NPO, but plenty of them flare up again when fed and fed too early from a pain perspective. I'm actually somewhat sympathetic to the arguments of the "never feed" crowd to be honest. Two things you really should never mess with in the hospital 1) married nurses and 2) the pancreas. Bad flare pancreatitis can easily become the sickest patient in any ICU and it's rather unsatisfactory because there isn't a damn thing you can do about except treat numbers and wait.
 
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You mean, the hypertensive "emergencies" sent from clinic/pre-op/etc. for admission?

Can't recall where I saw it, but there was a nice succinct article describing the fallacy of describing folks as "hypertensive emergency". The pressure is just a symptom of the underlying medical problem – which either requires emergent management (heart failure, dissection, SAH, etc.) or doesn't (chronic hypertension, headache, non-specific dizziness).

Word. I get at least one a month. Transfer in from st elsewhere on a drip that just MUST come to the tertiary MICU.
 
Dc'ing someone home with that critically high of a blood pressure is irresponsible. Bragging about it on a forum intended for education is doubly so. Think of the students...

Wow on your high horse i see. This isn't critically high BP for the average hypertensive. This is , outpatient blood pressure management. Start them on a med and have them see their PCP.

Quick question from a know-nothing med student. Why bother with IV enalapril for acute pulmonary edema when you could just titrate up nitro to ~100-150 mcg/min and get the same afterload reduction without having to add another med and reduce the total cost of the intervention (as I assume IV enalapril is much more expensive than IV nitro)?

Personally I feel there are no reasonable uses for enalaprilat with the exception of scleroderma renal crisis in someone unable to take PO. Similar to IV hydralazine, it has variable action and I have seen a lot of hypotension with its use. There are so many better options.
 
I wonder if it takes some time to set in and how long you normally need to watch these folks after calling for the admit. I've seen it often enough with high doses of nitro, have since residency. It's why we kind of giggle when you guys send up the hypertensive "emergencies" on big nitro doses and then switch to something more appropriate.

I don't know whose anecdote gets to win. Nor am I telling anyone what they "have to" do. Do what you want.

My main point though was that nitroglycerin isn't really an after load reducer. If you really want to or need to reduce afterload then use something that will, like an ace, or oral hydralizine, or nipride.

Agree. We very frequently deal with nitro given our pt population and I see a lot of headaches. It's really common when you get up above 100 mcg/min.
 
Wow on your high horse i see. This isn't critically high BP for the average hypertensive. This is , outpatient blood pressure management. Start them on a med and have them see their PCP.
I'm pretty sure he was being sarcastic/joking.
 
Wow on your high horse i see. This isn't critically high BP for the average hypertensive. This is , outpatient blood pressure management. Start them on a med and have them see their PCP.

Maybe you're ok with their heads exploding in the parking lot. I actually care about my patients ;)
 
Maybe you're ok with their heads exploding in the parking lot. I actually care about my patients ;)
I haven't seen it, but I heard that's why N. Korea was so angry about The Interview movie. Rumor has it, that in the movie, the Kim Jong-Un character was discharged from the ED with asymptomatic hypertension causing SCE (spontaneous cranial explosion) upsetting the N. Korean leader, which led to a cyber-terror attack on Sony Corp. If true, the refusal to use IV Enalapril could in fact trigger a chain of events that could start WWIII, and more importantly, possibly a poor PG score from Kim Jong-Un. Just sayin'.
 
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I used vasotec IV in residency (early residency), because where I trained it was the only IV medication for lowering blood pressure that could be used on the floor. It was standard practice there. It was a way of keeping people who really didn't need to be in the unit out of the unit (again, via stupid BP cut off for floor patients.) A number of years and a few thousand pages of reading later, it probably wasn't appropriate - but my guess is the protocol is still in place.
 
By the way - I'm loving the 'Tis and 'Twas... very festive.
 
I start nitro drips at the highest dose the nurse is willing to give. I give enaliprilat when I'm admitting a patient for CHF but they don't really need a nitro drip.

And it is common practice where I work to discharge people with SBP in the 200mmHg range if they are asymptomatic. I usually troll the "to be triaged" list for people sent from our outpatient clinics with asymptomatic hypertension so I can discharge them immediately and send them back to the clinic while it's still open.
 
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