Hypertension Treatment Question

[QofQuimica]

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So, I'm on an ICU rotation. I'm the intern on the team, along with a senior resident and a fellow. We were going over a practice case that asked how to treat hypertension in a patient with an intracranial hemorrhage, and I suggested using a hydralazine drip. They both looked at me like I was insane and said you can't do hydralazine gtt. I said, "of course you can, the OBs do it all the time." But they're both still skeptical. The right answer to the case was to give the patient a nitroprusside drip, but I think that my answer should be right, too. So, you all are the experts; would it work? If not, why not? Any good references on this topic?

Thanks in advance to anyone who can help, especially if you can help me prove them wrong. 😛

 

[ShyRem]

Wonder why they didn't say cardene?

 

[QofQuimica]

Wonder why they didn't say cardene?

Good question. I'm guessing it's because these cases are kind of old. I actually found a reference that says *not* to use nitroprusside in ICH patients because it's not as selective for systemic vascular smooth muscle as nicardipine is, and there's a chance you could raise ICP due to dilating cerebral blood vessels. These authors recommend using nicardipine, esmolol, labetalol, or enalapril. They don't comment one way or the other on hydralazine.

 

[Ackj]

Is the ICH secondary to the htn? Looking at like 180+ systolic? Nicardipine or labetolol are a better bet than hydralazine since that can increase ICP just like the nitroprusside. Hydralazine drops the BP pretty drastically, and is much longer acting, which could be a drawback since you want to lower their BP slowly. The other agents both peak in about 15 minutes and last only a few hours.

 

[group_theory]

Hydralazine can drop the blood pressure too quickly, which is also bad. I've seen it go from "not working, not working, not working, oh **** too low, quick, turn it off and start pressors"

I don't like nipride drip because prolong use can lead to cyanide toxicity

I usually go with either nicardipine or labetolol drip. I have seen others use nitroglycerin drip for blood pressure control.

 

[pharm B]

Apparently all of our pharmacists are off SDN for the holidays.

 

[typhoonegator]

Hey, neurointensivist here and came across this thread.

Nicardipine is the first-line agent for us, as a gtt, because it is relatively non-cardioselective, rapid-acting, easily titratable, and won't affect ICP. Downside is that a significant percentage of patients will develop pulmonary shunting due to V/Q redistribution, which can drop their O2 sats. Usually not a severe issue though.

Labetalol is a great second line agent, but many of our patients with hypertensive ICHs are already on beta-blockers, and they can get bradycardic on labetalol. Great as a push, though, when you need rapid control. Also won't affect ICP.

Nitroprusside is a pretty significant cerebral vasodilator and definitely can increase ICP. Now, in most people that isn't a big deal, but in people with global cerebral edema or focal space-occupying lesions, it can ruin your patient's day. Hydralazine can also cause venodilation in the CNS beds and increase ICP, although I think this side effect is fairly oversold.

I never use nitroglycerin for anything other than coronary ischemia.

Now if you're talking about aneurysmal SAH instead of primary lobar or deep ICH, the meds are different. If they're still unsecured, then the above agents are used. Once they are secured and in vasospasm, sometimes we'll use things like milrinone/dobutamine in concert with a peripheral vasoconstrictor like phenylephrine, particularly if they have a takotsubo cardiomyopathy and you need to keep their cardiac index and MAP up, but we usually have a a PA catheter in place for those peeps to guide therapy.

 

[lorain]

Hey, neurointensivist here and came across this thread.

Nicardipine is the first-line agent for us, as a gtt, because it is relatively non-cardioselective, rapid-acting, easily titratable, and won't affect ICP. Downside is that a significant percentage of patients will develop pulmonary shunting due to V/Q redistribution, which can drop their O2 sats. Usually not a severe issue though.

Labetalol is a great second line agent, but many of our patients with hypertensive ICHs are already on beta-blockers, and they can get bradycardic on labetalol. Great as a push, though, when you need rapid control. Also won't affect ICP.

Nitroprusside is a pretty significant cerebral vasodilator and definitely can increase ICP. Now, in most people that isn't a big deal, but in people with global cerebral edema or focal space-occupying lesions, it can ruin your patient's day. Hydralazine can also cause venodilation in the CNS beds and increase ICP, although I think this side effect is fairly oversold.

I never use nitroglycerin for anything other than coronary ischemia.

Now if you're talking about aneurysmal SAH instead of primary lobar or deep ICH, the meds are different. If they're still unsecured, then the above agents are used. Once they are secured and in vasospasm, sometimes we'll use things like milrinone/dobutamine in concert with a peripheral vasoconstrictor like phenylephrine, particularly if they have a takotsubo cardiomyopathy and you need to keep their cardiac index and MAP up, but we usually have a a PA catheter in place for those peeps to guide therapy.

damn this dude knows what hes talking about

wish you wouldve taught me in pharm school

 

[QofQuimica]

Thanks, guys.

Well, at least I can take solace in the fact that even though I wasn't right, neither were they. And neither was whoever wrote the answer to the case.

 

[taken2]

Hey, neurointensivist here and came across this thread.

Nicardipine is the first-line agent for us, as a gtt, because it is relatively non-cardioselective, rapid-acting, easily titratable, and won't affect ICP. Downside is that a significant percentage of patients will develop pulmonary shunting due to V/Q redistribution, which can drop their O2 sats. Usually not a severe issue though.

Labetalol is a great second line agent, but many of our patients with hypertensive ICHs are already on beta-blockers, and they can get bradycardic on labetalol. Great as a push, though, when you need rapid control. Also won't affect ICP.

Nitroprusside is a pretty significant cerebral vasodilator and definitely can increase ICP. Now, in most people that isn't a big deal, but in people with global cerebral edema or focal space-occupying lesions, it can ruin your patient's day. Hydralazine can also cause venodilation in the CNS beds and increase ICP, although I think this side effect is fairly oversold.

I never use nitroglycerin for anything other than coronary ischemia.

Now if you're talking about aneurysmal SAH instead of primary lobar or deep ICH, the meds are different. If they're still unsecured, then the above agents are used. Once they are secured and in vasospasm, sometimes we'll use things like milrinone/dobutamine in concert with a peripheral vasoconstrictor like phenylephrine, particularly if they have a takotsubo cardiomyopathy and you need to keep their cardiac index and MAP up, but we usually have a a PA catheter in place for those peeps to guide therapy.

PGY-7

 

[Pharmgrlnxdor]

Wow, that response was like a verbal work of art. Impressive.

 

[GreyFox2002]

Hey, neurointensivist here and came across this thread.

Nicardipine is the first-line agent for us, as a gtt, because it is relatively non-cardioselective, rapid-acting, easily titratable, and won't affect ICP. Downside is that a significant percentage of patients will develop pulmonary shunting due to V/Q redistribution, which can drop their O2 sats. Usually not a severe issue though.

Labetalol is a great second line agent, but many of our patients with hypertensive ICHs are already on beta-blockers, and they can get bradycardic on labetalol. Great as a push, though, when you need rapid control. Also won't affect ICP.

Nitroprusside is a pretty significant cerebral vasodilator and definitely can increase ICP. Now, in most people that isn't a big deal, but in people with global cerebral edema or focal space-occupying lesions, it can ruin your patient's day. Hydralazine can also cause venodilation in the CNS beds and increase ICP, although I think this side effect is fairly oversold.

I never use nitroglycerin for anything other than coronary ischemia.

Now if you're talking about aneurysmal SAH instead of primary lobar or deep ICH, the meds are different. If they're still unsecured, then the above agents are used. Once they are secured and in vasospasm, sometimes we'll use things like milrinone/dobutamine in concert with a peripheral vasoconstrictor like phenylephrine, particularly if they have a takotsubo cardiomyopathy and you need to keep their cardiac index and MAP up, but we usually have a a PA catheter in place for those peeps to guide therapy.

^^^^^ This Guy ^^^^^ 👍

I've spent some time in the Neuro ICU and this is exactly the game plan. The problem with nicardipine though is that it's ridiculously expensive. The urban, academic hospital I spent time at generally used labetalol whenever it could because of the price. If labetalol wasn't enough to maintain lower pressures, they'd switch to nicardipine.

Any of your vasodilators like nitroprusside or hydralazine should generally be avoided because of elevated ICPs, that's what I learned/observed anyways. Enalaprilat is too difficult to titrate to really be useful.